Preparing Nursing Students to Manage Acculturative Stress Experienced During Study Abroad Experiences: Novel Use of Immersive Simulation and Cognitive Behavioral Strategies


  • Theresa G. Schnable College of Nursing, Marquette University
  • Christine A. Schindler College of Nursing, Marquette University and Medical College of WI, Department of Pediatrics
  • Jeffrey D. Roche Counseling Center, University of Northern Colorado
  • Karli Webster Office of International Education, Marquette University
  • Chris Larkee Opus College of Engineering, Marquette University
  • Maharaj Singh College of Nursing, Marquette University
  • John F. LaDisa Medical College of Wisconsin



Anxiety, immersive simulation, mixed reality, nursing education, virtual reality


This pilot study adds to the understanding of interventions to manage acculturative stress experienced during undergraduate study abroad programs. It was designed to evaluate the impact of cognitive behavioral strategy training combined with intentional practice during mixed reality (MR) simulations on acculturative stress. Participants included a convenience sample of undergraduate nursing students enrolled in a faculty-led study abroad course. Students participated in two MR simulations within a virtual environment over back-to-back days. Simulations were written by nursing faculty experts to reproduce realistic clinical situations students may encounter while studying in Peru. The Generalized Self-Efficacy Scale, State-Trait Anxiety Inventory, and Slater-Usoh-Steed questionnaire were administered. Quantitative biometric indices assessed during simulations included estimates of heart rate, blood pressure, respiratory rate, oxygen saturation and alterations in sweat gland activity reflective of changes in emotional state (galvanic skin response). There were changes in biometric indices within each simulation, but indices were not different between pre- and post- cognitive behavioral strategy training. Intentional reflective writing before, during, and after the study abroad program demonstrated an iterative cycle of reflection on action and mindfulness. These qualitative data suggest that pre-departure cognitive based behavior stress management strategies paired with simulated practice prior to departure may be one way to help nursing students deal with acculturative stress during study abroad experiences.


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Author Biographies

Theresa G. Schnable, College of Nursing, Marquette University

Theresa G. Schnable, PhD, RN, CNE, is a clinical instructor in the College of Nursing at Marquette University. Her nursing education expertise includes healthcare simulation, population health, and global health study abroad. She leads several global health faculty-led study abroad programs, and her research investigates how nursing students incorporate the social determinants of health into their patient plan of care.

Christine A. Schindler, College of Nursing, Marquette University and Medical College of WI, Department of Pediatrics

Christine A. Schindler, PhD, RN, CPNP-AC/PC, has a joint appointment between Marquette University and the Medical College of WI where she serves as a member of the nursing faculty and practices as a pediatric nurse practitioner in the pediatric intensive care unit at Children’s WI. She leads several global health faculty-led study abroad programs and her research is focused on patient safety and leadership.

Jeffrey D. Roche, Counseling Center, University of Northern Colorado

Jeffrey Roche, PhD, L.P., is a licensed psychologist who currently serves as the Director of Training for the Counseling Center at the University of Northern Colorado. He has worked in five different university counseling centers, supporting the mental health needs of students for over ten years. As a university-based psychologist, Dr. Roche serves others in a variety of capacities, be it through direct clinical care, supervision and training, outreach, or collaborative projects and interventions such as this.

Karli Webster, Office of International Education, Marquette University

Karli Webster, MS, has been an international education professional since 2004. She became the Manager of Education Abroad at Marquette in 2014 and the Director of the Office of International Education in 2022. Her main responsibilities focus on emergency response and risk management, as well as management of the Sibanye Cape Town program and oversight of Marquette's various education abroad options. She also oversees exchange student mobility and serves as an ARO.

Chris Larkee, Opus College of Engineering, Marquette University

Chris Larkee, BFA, is the technology specialist for the Visualization Laboratory at Marquette University. He has 15 years of experience in computer animation, media production, and broadcast engineering. Since 2014, he has served a lead role in Marquette University's Visualization Laboratory, working with faculty and graduate students in the development of customized immersive environment software to implement their concepts for research and learning. Chris's skills include programming, 3-D modelling, and interactive user experience design.

Maharaj Singh, College of Nursing, Marquette University

Maharaj Singh, PhD, serves as an Associate Professor at the College of Nursing, Marquette University. With a rich background spanning over two decades, he specializes in teaching applied statistics courses and offering statistical consultation in biomedical research. His expertise benefits a diverse range of clients, including faculty, students, physicians, and research scientists.

John F. LaDisa, Medical College of Wisconsin

John LaDisa, PhD, was a postdoc at Stanford University for 2.5 years after earning his PhD in Biomedical Engineering. He previously directed the Visualization Laboratory and Laboratory for Translational, Experimental and Computational Cardiovascular Research at Marquette University. He now serves as Director of the Computational Engineering and Visualization Program for the Section of Cardiology in the Department of Pediatrics at the Medical College of Wisconsin.


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How to Cite

Schnable, T. G., Schindler, C. A., Roche, J. D. ., Webster, K., Larkee, C., Singh, M., & LaDisa, J. F. (2024). Preparing Nursing Students to Manage Acculturative Stress Experienced During Study Abroad Experiences: Novel Use of Immersive Simulation and Cognitive Behavioral Strategies. Frontiers: The Interdisciplinary Journal of Study Abroad, 36(1), 229–253.



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