Increasing Cultural Competence: Implementation of Study Away/ Abroad in an Athletic Training Program

Background: Cultural competence (CC) became a component of the Commission on Accreditation of Athletic Training Education 5 years ago in the fifth edition competencies. The Commission on Accreditation of Athletic Training Educationaccredited ATPs, however, struggle to teach this concept effectively to students. The implementation of study away/abroad models in the athletic training curriculum may maximize students’ exposure to other cultures.


INTRODUCTION
An athletic training program (ATP) in the United States traditionally employs the cohort model in which students are required to progress through the curriculum in a highly structured sequence. Students who miss a course in the sequence or need to retake coursework are typically faced with an additional semester(s) to complete the program. Therefore, students who wish to participate in an external activity, such as a semester-long study away/abroad program, are often relegated to a leave of absence, extending their studies, and increasing debt. In a cohort model, students may be unable to explore such options and thus unable to expand experience and knowledge beyond the traditional athletic training curriculum didactic coursework due to curricular time constraints. However, minor modifications in the athletic training curriculum combined with recent advancements in technology potentially minimize negative consequences and allow students to benefit from study away/abroad experiences. [1][2][3] Athletic training students may become more culturally competent athletic trainers (ATs) equipped to handle changing demographics through study away/abroad experiences.
Globalization and diversity continues to increase in the United States. Currently 37.9% of the US population is classified as nonwhite (Table). 4 However, the population demographics may not directly reflect an AT's patient population since levels of diversity vary among different clinical settings. For example, the National Collegiate Athletic Association Sport Sponsorship, Participation and Demographics Database 5 exhibits less diversity than Division I to III athletes from the 2014-2015 academic year (Table). 6 When examined chronologically, however, the nonwhite categories have rapidly transitioned from 116 247 student-athletes in the 2009-2010 year to 161 452 in the 2014-2015 year, equaling approximately 38.89% during that 5-year period. 5 The population of ATs is approximately 80% white, consistently less diverse than the patient population (Table). A health care provider-to-patient population diversity gap has potential to impede patient care due to a lack of cultural understanding, unintended cultural biases, and ineffective communication. 7 Educational curricula should include, as a component of clinical experience, interaction with a diverse population. Educational clinical experiences with a mostly ethnically homogenous group may diminish the opportunity to integrate culturally diverse individual needs into clinical practice.
Culturally competent health care providers are capable of willingly assessing, appreciating, and respecting an individual's unique backgrounds (ie, race, ethnicity, sex, sexual orientation, religion, beliefs, age, socioeconomic status) to make medical decisions and minimize disparities in health care. 8 Literature suggests that athletic training students and ATs lack an ability to transition cultural competence (CC) from didactic education into practice. 9,10 Despite efforts to nurture culturally competent ATs, limited evidence exists that current practice is effective. The outcomes of current didactic CC education and transition to clinical practice are not encouraging. [9][10][11] Both athletic training students 7 and certified ATs 10 tend to perceive they possess a high level of CC, although actual ability to deliver culturally competent care remains lower than self-perception. Athletic training students and ATs indicate they understand that cultural differences exists (culturally aware), but do not apply the awareness through behaviors (culturally proficient or competent). 9,10 For the past 16 years, CC has become increasingly integrated into the athletic training didactic curriculum, yet application of knowledge into professional practice is lagging. 8,12 A change from a traditional didactic learning of CC to impactful learning experiences is necessary to improve the transition of experiences to clinical practice, 9,10,[13][14][15] and therefore expanded clinical experience integration in athletic training educational curriculum is suggested.
The most consistent and perhaps the most significant factor that influences CC is an individual's minority background. 9,10,13 Athletic training students and ATs of color 9,10 exhibit a significantly higher level of CC compared with whites. 13 Likewise, non-US country of origin and the ability to speak 2 or more languages have also been recognized as major characteristics contributing to greater CC. 13 Although these factors may be viewed as nonmodifiable, an experience such as an exchange student with opportunities to interact with people from different cultures (clinically and/or on leisure time) may create a minority experience affecting CC. 13 Experiences whereby athletic training students are placed in a minority position in another country or culturally different area of the United States enhance maturity and sensitivity to cultural differences and thus minimize barriers to patient care. 13 The lack of congruity between CC awareness, primarily provided through didactic education, and CC application is not limited to ATs; nurses, 13,14 physicians, 15,16 dentists, 17 and pharmacists 18 reported similar findings. The majority (74%) of nursing students demonstrate a low level of CC despite formal classroom education, 13 with students indicating that didactic training alone is not enough to develop the appropriate level of competence. 14 Clinical educators in medical schools identified cultural incompetence among students originated from a low level of emphasis in didactic curriculum, curriculum overload, and low expectation from clinical educators, which further implies a lack of common goals regarding CC exists in clinical settings among educators and students. 15 Interestingly, low CC appears to be a mutual perception whereby students do not perceive their faculty as demonstrating CC, 16 which in turn signifies the possibility that educators may not be prepared enough to effectively teach application. 15 Overall, the literature suggests a disconnect between the didactic and clinical education and a strong need for more structured profession-wide education. 9,10,[13][14][15] The creation of nontraditional, yet innovative cultural education external to the regular AT curriculum offered parallel to didactic education that offers authentic cultural experiences is a curricular option to bridge the gap between what educators teach and what students extrapolate from the curriculum. Students in ATPs indicate the desire for more exposures to cultural diversity and opportunities to actually encounter and interact with diverse populations through travel, work, and experience. 11 One approach to providing cross-cultural experiences would be through a study away/abroad program, which may provide the opportunity within an athletic training curriculum to integrate all 3 components, travel, work, and experience. A study away/ abroad program offers immersed cultural experiences and creates a unique opportunity for students to experience different cultures and values. 14,19,20 Changing or modifying the traditional curriculum to include culturally different and/or global experiences may enhance CC by placing individuals into cultural minority situations, increasing cultural sensitivity and perspective. The purpose of this article is to review the current literature on study abroad programs across various health care professions, to identify the benefits and key characteristics of a successful program, and to propose a model of study abroad and international opportunities embedded within the current athletic training curriculum.

BENEFITS OF A STUDY AWAY/ABROAD PROGRAM
A systematic review 21 of 13 studies suggested consistent benefits across various study away/abroad programs. Students described their experiences as ''enriching and enlightening,'' ''eye opening,'' and ''the best thing I have ever done.'' 21 Likewise, implementation of the program added more depth to the cultural competency education in the athletic training curriculum. 21 Curricular integration of study away/abroad within the athletic training curriculum with didactic and clinical experience requirements allows for a more beneficial experience.
Athletic training students can develop the ability to provide culturally sensitive patient care through the cultural exchange that occurs at both personal and professional levels within a study away/abroad program. 21 Likewise, students placed in the position of a foreigner begin to view their surroundings through a different set of cultural expectation lenses. 10,19,20 In a new setting, what was the norm is no longer familiar, and students become somewhat detached from their familiar world, which helps objectify the environment. The feeling of uncertainty is crucial to rediscover and reappreciate their own ethnical and cultural identity. 19,20,22 Students thus learn about their values, beliefs, likes and dislikes, even prejudice and biases they may be unaware that they hold. The experience is described as ''shaking students' belief system'' and assists individuals to recognize differences and similarities among others. 19 In addition, students gradually become familiar with a new culture by engaging in and accepting cultural differences 14,19,21,22 and build new personal and professional relationships. 19,21,22 Study away/abroad fosters the sense of achievement, greater sensitivity and willingness to embrace differing cultural practices, which leads to new levels of confidence to work with colleagues and patients who may not share personal beliefs or expectations [19][20][21][22] and personal traits essential for effective clinicians with CC.
Students in study abroad programs in nursing indicated a broader knowledge by learning new types of health care systems, different levels of recourses and service availabilities, and untraditional practice and techniques. 14,20-22 Although direct patient care and the type of facilities may vary between nursing students and athletic training students, the overall outcome may be similar. Students who are exposed to different cultures are more likely to reflect on learning and more willing to change and improve their practice. 14,[20][21][22][23] Likewise, the health care provided may be more effective, culturally sensitive, and patient centered from individuals who have experienced a different culture. [21][22][23] Some students reported they developed new insight into possibilities of multidisciplinary working. 22 Students believe that specifically study away/abroad provides an advantage in expanding employment options. 22,24 Many organizations and institutions associate global experiences with increased employability. 24 In addition to student experience away/abroad, host universities and institutions can also learn from the visiting students' cultures and expand professional relationships by providing an avenue for the student to share their learning experiences with educators and peers upon return. 23 Clinical or didactic education in a traditional athletic training curriculum can then augment the level of immersion and the profession-wide learning experiences beyond the borders.

Curriculum Designs
Embedding a study away/abroad component into the curriculum requires that CC, diversity, and international experiences constitute a programmatic goal. A programmatic study away/abroad curricular goal, much like any desired curriculum outcome, obligates programs to integrate culturally expansive experiences and/or international opportunities beyond isolated experiences. A curriculum that meets study away/abroad goals should have several components including a curricular theme, prestudy away/abroad content, and specific didactic coursework on CC.
Embedding CC into each course for a thematic curriculum requires that students are provided with initial didactic foundational information in an entry course so that application can be integrated into future coursework and experiences. Clinical competence objectives integrated into each course may take the form of activities such as case studies, simulations, epidemiology information and testing, practical skill application, and real patient population clinical experiences. A sprinkling of CC activities and engagements throughout the curriculum provides a thematic construct for transferring knowledge into practice. Before the study away/ abroad experience, a prestudy away/abroad CC course/course content integration is recommended to provide translational information for students on advanced practice of CC and expectations of the experience. In addition to a study away/ abroad experience, the athletic training curriculum may also incorporate smaller service clinical experiences with diverse patient population to practice CC. Short-term clinical service experience may include a free clinic serving low-income patients, urban or rural area clinics, low-income and minority patients, or a clinic with an underserved population. The curriculum sequence for CC builds on foundational knowledge to more complex integration, until the skills are applied in a culturally foreign or international environment.

Important Characteristics of a Study Away/Abroad Program
Timing. The timing and duration of a study away/abroad program in an athletic training curriculum must be carefully examined to meet outcome expectations based on the demographics of the study-body. The duration of the program (positively, the longer, the greater) and the students' age (negatively, the younger, the less) influences the degree of experience impact. 25 Students' maturity may play a larger role than the chronological age, as well as open-mindedness and willingness to accept different views. 26 Athletic training students, on the other hand, believe that cultural education must occur early in the curriculum and be repeated throughout the entire length of the curriculum. 11 Thus, placement of a study away/abroad experience in the curriculum is a programmatic decision based on the student characteristics. For example, considering that most of the master's professional ATPs are 2 years in duration (ie, Summer 1, Fall 1, Spring 2 and Summer 2, Fall 2 and Spring 2), an ATP can implement a study abroad program in the second summer semester. The timing would allow athletic training students to garner a maturity with the cultural competency content and build a base of current practice knowledge in their home country, which is needed to appreciate the differences to which they will be exposed in a culturally different/diverse experience or in another country. A poststudy away/abroad dialogue should also be a component of the curriculum to debrief, provide peer mentoring, and enhance meaningful conversation such as racism, inequalities, and health needs. 15 Best practice components of a study away/abroad experience includes a predeparture briefing and postreturn debriefing with the contact instructor. 27 An instructor should spend a few days before departure to prepare students for potential experiences and cultural expectations, and a few days to reflect after return. Instructor involvement ranges from away/ abroad attendance with the students to home-based guidance through telepresence. Experiences tend to be greater for students who experience away/abroad education with reduced onsite guidance from instructors. 27 Regardless of length of time and instructor onsite integration, planning ''a break'' approximately every 7 days is suggested as it creates opportunities to explore the area on the students' own. 27 Students appreciate occasional ''time-outs'' from one another returning to didactic and clinical learning the next day, feeling refreshed and motivated. 18 Although the duration of study away/abroad programs in the literature varies from 1 to 20 weeks, 21 some ATPs offer a 1-to 3-week program during winter, spring break, and summer. 27 Summer sessions vary from 4 to 11 weeks. The literature suggests that the longer an away/abroad experience, the more impactful. 21 Clinical Experiences. Study away/abroad internships embedded in the athletic training curriculum should be placed no earlier than the end of the first year of the programing to allow for foundational CC and reflection on advanced competencies in poststudy away/abroad courses. Reassigning the typical internship into a study away/abroad experience allows athletic training students to gather the cultural competent skills necessary to work respectfully and effectively with different/diverse populations internal or external to the United States. Desired goals for the implementation of a study away/abroad and international opportunities include enhancing a student's intellectual growth, increasing professional development and personal growth, developing skills needed to relate to a diverse population, and enhancing student selfawareness. However, to ensure learning outcomes are met, there should be a clear delineation of clinical expectations, preceptor/supervisor roles, safety, and special institutional considerations. The criteria for acceptable experiences must be a component of the student's preparation. The sample study away/abroad program (Figure) suggests placement in the Summer 2 semester, but the placement may fluctuate depending on the time the study away/abroad is offered, the length of the study away/abroad, the availability of course instructors, and the type of resources that are accessible internationally.
Establishing relationships with the study away/abroad community and partnering institutions aids in creating clinical experiences. Specifically, for international experiences, relationships with entities that have a mutual recognition agreement, such as the Board of Certification (US), Canadian Athletic Therapists Association, and the Athletic Therapy Rehabilitation Ireland, may be of benefit. 28 The aforementioned countries, as well as others that have strong sports medicine programs, may collaborate through a variety of valuable clinical experiences. Culturally diverse and international experiences allow athletic training students to gather an alternative perspective into the health and safety of the active population. Techniques, protocol, and patient population may differ in other areas of the United States and countries allowing for additional opportunities to enhance CC. Mission trips and service learning opportunities in culturally diverse areas or developing countries also allow for clinical experience opportunities that can enhance clinical practice and CC. Volunteer opportunities are easily identified through a variety of volunteer or service learning programs, including Athletes in Action, Council on International Educational Exchange, and Institute for Collegiate Sports Medicine. 29 Technology. Current technology (eg, Skype, Google Hangouts, Facetime) allows easy communication and monitoring with remote students with the ability to maintain congruency with course outcomes and student engagement. Likewise, students have the opportunity to travel internationally and still take required coursework online without the need to extend the educational timeline. The athletic training curriculum may need modifications to ensure that didactic online courses are available for the study away/abroad period, for example sport nutrition, sport psychology, research methods, and pharmacology. For example, students and an instructor for an online course can ''check in'' via an online meeting platform to discuss the course progress while students are enrolled in a study away/abroad program. Recorded lectures can be used to disseminate the materials, and students can, in turn, create video responses to have an ongoing conversation about course topics. If the time difference between 2 countries prohibits real-time communication, active discussion through forums still allows the exchange of opinions. Shaping the course sequence so that coursework that can easily be instructed in online format allows for study abroad opportunities. Study away/abroad opportunities can be subsidized by student federal loans if students maintain full-time student status, thereby reducing student financial barriers. 30 Staffing. The optimal scenario is to have a study away/ abroad liaison linked to an institution who provides the framework for the courses and international experience. Most universities have or create these relationships through the study away/abroad office, minimizing the demands on faculty. If the ATP chooses to conduct a faculty-led study away/ abroad program, staffing may become an issue as demands are placed on current faculty members. One suggestion is to use alumni, both who have developed expertise in CC from clinical practice and who have a desire to focus on CC, as a faculty resource. 31 For example, alumni may be asked if they are interested in participating as affiliate faculty. Engaging alumni may benefit these constituents with the ability to practice leadership skills, improve CC/sensitivity, learn a different health care model, and even expand international networking. 31 Alumni may also be integrated with graduate students into the research component of the program through conference presentations, publication submissions, program/ alumni newsletters, and developed research projects based on study away/abroad experiences. 31 Regardless of internal partnerships of faculty-led programs, instructors should be carefully interviewed and selected based on their ability to speak the language and/or knowledge about the area and people in the country. 31 To ensure effective educators, it is critical that expectations and roles are clearly explained before the travel (eg, immunizations), and formal CC training for the instructors must be provided by the stateside faculty members. 31 Cost and Logistics. Study away/abroad opportunities are available to the students in a variety of periods, including spring break, Christmas break, Maymester, January terms, and summer terms. Popular destinations for study abroad programs include Belize, Prague, Ireland, Italy, Costa Rica, Japan, Australia, and Greece. 22 Current economic and political stability of potential destinations should be assessed to allow for student safety and focus on learning. 22 Trip expenses range from $1400 to $5300 depending on location and the number of course offerings available during the study away/abroad period. Tuition, financial aid, small grants, institutional reciprocity, and scholarships can all help offset some of the costs associated with these trips. Financial aid and student loans are available for study away/abroad opportunities when embedded as a component of coursework through the institution; however, individual institutions handle travel and housing differently and should be clearly identified for students. 30 Relationships with institutions and entities may offset housing costs through embedding course fees or sponsored housing onsite. The study away/abroad department generally assists in creating these relationships. Programs that are instituted through a study away/abroad institutional office with interinstitutional agreements may be facilitated through the institution with optimal financial aid benefits.
Before, During, and After the Travel. Detailed planning and close communication before the trip remain major determinants of programs success. 22,23,25 A prescreening of the clinical site should have been conducted before any placement to ensure safety and supervision consistent with accreditation standards. Although students are realistic that a study away/abroad facility is different and usually anticipate the unknown and challenges, 22 homesickness and loneliness are commonly the first challenges facing students. 20 Assuring planned assistance and social support from local institutional staff, local students, local clinical staff, and the host family can alleviate emotional distress that students may encounter. 20,22 The host and partner institutions should have a clear understanding of their responsibilities and the objectives before the trip. 22,23 Both written and verbal forms of communication are encouraged in order to minimize the risk of miscommunication. 22 Mentors must support, monitor, and engage throughout the actual experience to ensure the high quality of learning. 22 Proficiency in the language is a major facilitator, as inadequate communication skills create social barriers and can further lead to isolation. 22 Both faculty and students participating in self-guided study abroad experiences whereby students are placed in a nonnative language should expect the student is conversationally and medical-terminology capable before the experience. The athletic training stateside institution must confirm that student languages are a competent match for the country of placement and, if needed, translators are available through the study away/ abroad program for students and/or faculty who have difficulty speaking the country's language.
Assignments before, during, and after the trip should include some form of reflective writing such as daily journaling. 13,21,23,25 Daily blogging in particular is deemed in the literature as a successful communication and reflective journal technique to create a debriefing dialogue and enhance the student experience. 25 After returning to the home country, evaluation of study away/abroad program must be obtained, shared, and applied to improve the program by all stakeholders (students, lecturers, universities, and funding organizations). 19 A New, Repeated Continuum Model. Berger and Peerson 32 proposed the continuum model of CC training in which a 3-step ''tree'' approach is used: roots of knowledge, students explore different cultures and build understanding; leaves for change, students analyze how certain values can influence health belief and philosophy; and fruits of wisdom, students formulate strategies to maximize the patient's outcomes across various cultures. Because athletic training students want repeated learning experiences, we can expand this concept and formulate a new, repeated continuum model. Athletic training students can spend their first year in the athletic training curriculum learning and experiencing the 3 steps through didactic education (eg, in-class discussion, reading, writing, activities). Before the study away/abroad, students may engage in another opportunity to grow ''the roots'' by learning about the specific culture in which they are about to become immersed through pretrip assignments and activities. Students then explore ''the leaves'' during the program to selfreflect and self-debrief and make connections between new CC experiences and professional practice. After the study away/abroad experience, students should examine ''the fruits'' by taking time to revisit the learning experience and reflecting upon the impact to their clinical practice in order to maximize the patient outcomes. Cultural competency is never a destination, rather a way of living, and is an ongoing process of learning the unfamiliar and making adjustments. 33 Students should be guided to understand the true meaning of the repeated process.

CONCLUSION
Contrasting some similar health care professions requiring clinical experience at the end of the educational curriculum, athletic training education incorporates basic science and clinical science simultaneously. 34 Athletic training students have the opportunity to learn the knowledge, practice the clinical skills, and apply the skills in a clinical setting within a short duration of time. The same approach should be taken when teaching cultural competency. Students must learn, practice, and provide culturally competent patient care in an environment in which students can safely explore different cultures and values. Studying away/abroad creates the opportunity to culturally challenge students and expand their perspectives. Implementation of study away/abroad programs within the athletic training curriculum is practical and realistic as technology now allows distance learning and real-time communication beyond borders. Students can travel overseas and become immersed in a different culture while continuing to take online classes with the institution in the home country to mitigate potential impact of a study away/ abroad experience that may extend the program and graduation date. Further evaluation of the current international opportunity landscape in athletic training education needs to be conducted to provide additional details on programmatic differences, benefits, and detriments. The benefit of study away/abroad opportunities is that the student experience, as a minority, provides a new lens to augment cultural sensitivity, enhance CC, and support application into clinical practice.