NURSING PRACTICE AND HEALTH CARE

The topics of collaborative learning and community of learners have been discussed in the literature for more than three decades. Educational literature highlights group work as a purposeful and relevant approach to facilitate learning and teaching. The premise of this study was that communities of learners can be fostered by learning environments that offer the opportunity and stimulus for students to form such a community. Several studies have documented the importance of the academic environment in promoting positive outcomes among nursing students. However, studies to identify strategies by which a nurturing learning environment can be created are scarce. Students learn best when they are actively involved in the process. Many researchers report that students working in small groups tend to learn more and retain the information longer, regardless of subject matter. This form of teaching has been called cooperative learning, collaborative learning, collective learning, etc. The purpose of this qualitative evaluation study is to explore the role of socialization in academic success of first-year nursing students. Participants are first-year nursing students from two classes, morning and evening. Students are randomly assigned by the instructor to groups to maximize their heterogeneity. There are five members in each group (four members and one group leader).

Community of learners; Collaborative learning; Caring; Accelerated 2nd-degree nursing student

Many nursing responsibilities are accomplished in groups. Nursing curricula need to prepare students in the skills required to function effectively in groups. Caring and healing have been rooted strongly in nursing’s tradition since Florence Nightingale. Development of caring behaviors can be enhanced through the relationships that students experience with their peers. There is a growing support for integration of healing and caring in nursing education as informal curriculum that students experience as part of the educational process [1,2]. Peers can play an important role in students’ ability to develop caring behaviors [3]. Enhanced awareness of the meaning and importance of caring, greater acceptance of peers, and a desire to transfer caring to nursing practice have been reported [4]. Students who experience a nurturing learning environment have the potential to transfer an attitude of caring to their practice [5].

Although collaborative and cooperative learning are used interchangeably in the literature, for the purpose of this study , the definitions offered by Bruffee [6,7]are used in that collaborative learning refers to specific type of active learning in which students are intentionally grouped for synchronous intellectual effort to primarily co-construct nonfoundational knowledge. Authority is distributed, and responsibility is shared by faculty and students. Collective decision-making is reached in open-ended tasks assigned by the instructor or mutually determined. The process will evidence a sophisticated level of: (a) agreement and disagreement, (b) intellectual negotiation, and (c) collective decision making. In designing learning tasks and student evaluation, collective or self-governance (i.e. independent of the instructor) is more valued than teacher-directed accountability [6]. Cooperative learning refers to a form of active learning in which students are intentionally grouped to work together to learn primarily what is known (e.g. basic, indisputable facts).

Educational literature highlights group work as a purposeful and relevant approach to facilitate learning and teaching. Cooperative/collaborative, small group work can advance student’s achievement, critical thinking, social interactions, communicative behaviors, self-esteem and motivation [8,9]. The concept of collaborative learning, the grouping and pairing of students for the purpose of achieving an academic goal, has been widely researched and advocated throughout the professional literature. The term “collaborative learning” as defined earlier, refers to an instruction method in which students at various performance levels work together in small groups toward a common goal. The students are responsible for one another’s learning as well as their own. Thus, the success of one student helps other students to be successful. The opportunity for self-governance is considered to be one aspect of adult collaborative learning that must be in place to be successful [7]. Self- governance may occur when the educator has given the assignment, and then steps back to let the students work together. Self-governance is difficult to achieve in many classroom settings, where students may be unlikely to choose their own work groups, topic, or goals; these are more typically established by the instructor.

In spite of these advantages, most of the research studies on collaborative learning have been done at the primary and secondary levels. As yet, there is little empirical evidence on its effectiveness at the college level. However, the need for noncompetitive, collaborative group work is emphasized in much of the higher education literature. 

Literature Review

A systematic study and analysis of the literature revealed empirical and theoretical findings which resulted in a summary of the current state of the community of learners and collaborative learning in higher education. Primary sources included peer-reviewed journals, integrative reviews, and dissertations. To study the broad range of experiences with this topic, the researcher conducted a computer-assisted search using ERIC, CINAHL, PubMed, PsycINFO, and ProQuest Central. Entry of the key terms Community of learners along with secondary terms of higher education and nursing students launched the initial search process. Retrieval of database articles, an ancestral review of included references allowed identification and location of additional relevant sources. To narrow down the search, term collaborative learning was added. All the articles in English in which qualitative, quantitative, and mixed-method methodologies were used to explore the topic in nursing and allied health fields were included. Data were synthesized narratively to address the study aims. Since the 1980s, the literature reveals a growing interest in collaborative learning as an instructional strategy yet a minimal application of this pedagogy exists within the college classroom. Documented by several, Gamson [10] succinctly depicted this disparity, “while the evidence for the impact of collaborative learning is growing, it is still quite sparse”.

Collaborative and cooperative learning has been explored at length in educational and developmental research, beginning with early concepts of social learning. Dewey [11], is most notable for his concept of learning and doing, and his emphasis on the importance of social learning. Dewey suggested that students should work with other students to solve problems through a hands-on approach, and advanced the concept of learning communities [12]. Learning communities, as conceptualized by Dewey, were based on principles of democracy, respect of others, and productive work as a method to encourage collaborative learning [12]. Vygotsky [13] also contributed to the research on the social impact of learning. He proposed that the intellect of humans was affected by their culture and environment, and particularly by their interaction with other humans [12]. He noted that individuals interpreted their world from their own perspective, and in a group learning environment [14,15], had a greater ability to learn due to the exchange of ideas with others [16]. This exchange led to diversity of ideas and a broader perspective.

The study was guided by the following theoretical framework and assumptions:

Cooperative/Collaborative learning

Cooperative Learning (CL) is defined by Johnson, Johnson and Smith [17] as “an instructional paradigm in which teams of students work on structured tasks under conditions that meets five criteria:

   –    Positive interdependence

   –    Individual accountability

   –    Face-to-face interaction

   –    Appropriate use of collaborative skills, and

   –    Regular self-assessment of team functioning.”

-The behavioral learning theory: assumes that cooperative efforts are based on extrinsic motivation and rewards, and

-Cognitive-developmental theory: views cooperation as essential prerequisite for cognitive growth and focuses on what happens within a single person [18].

Alderman [19] and Gokhale [20] consider collaborative learning as the type of learning which takes place in a small group, with an interactive social environment, for common academic purpose, and shared learning tasks. Several studies have investigated the effects of learning styles on the outcome of the group works as well as effectiveness of homogeneous versus heterogeneous teams. Although it is still unclear, it appears that heterogeneous teams, taking into consideration their learning styles, may perform better overall [21]. However, some research contradicts these assertions [22,23]. Collaborative work for learning is also known as “social scholarship” [24]. Learning communities are amongst the oldest and most used models of education [25].

Freire’s Model of Oppression

Roberts [26] applied Freire’s model of oppression and argued that some nurses exhibit oppressed group behaviors. She asserted that such dependent and submissive behaviors have evolved throughout history in response to hospital administrators and physicians. Recently, few studies have supported such an assertion [27-30]. The main tenets of Paulo Freire’s Oppression model (1976) are: 1) education as an important tool to overcome oppression and 2) paving the way toward emancipation through education.

Caring

Nursing is grounded in caring. Jean Watson’s Caring Theory allows the nurse to practice the art of caring, to provide compassion to ease patients’ and families’ suffering, and to promote their healing and dignity. This theory can also contribute to expand the nurse’s own actualization [31]. Caring relationships with teachers and other students increase students’ desire to learn, and those who are more confident in their abilities try harder. In addition, social and emotional learning (SEL) facilitates academic learning [32].

Food and social relations

Eating together was one of the components of this project. Food serves both biological and social purposes in human societies Watson J [33]. The process of eating together reinforces social relations and group memberships [34]. The process of eating together or giving and receiving food, reinforces social relations and group memberships [35]. Food acts as “social glue” [36,37].

Reflection

Reflection plays a crucial role in the learning process [38]. Reflection involves both self-reflection on oneself as a person and a professional, and team reflection on the group process [39]. As part of a learning and evaluation process, the participants were required to submit reflective journals on a weekly basis.

Characteristics of the Second-degree Students

Participants in this study were second-degree nursing students. The second-degree nursing program is also called the accelerated nursing program. Second-degree students are highly motivated, tend to excel academically, and have already obtained a college degree in another field. They are highly motivated; however, their training and socialization to the nursing profession present several challenges. Shane [40], using “reality shock” construct presented by Kramer [41], divides the process of “returning to school syndrome” into four stages: honeymoon, shock or rejection, recovery, and resolution. Accelerated second-degree students differ from traditional students in that they are more highly focused on the outcome of their nursing education, have a stronger history of academic performance, bring more life experiences and are generally older.

Needs assessment

Several studies have documented the importance of the academic environment in promoting positive outcomes among nursing students. However, studies to identify strategies by which a nurturing learning environment can be created are scarce. Students learn best when they are actively involved in the process. Many researchers report that students working in small groups tend to learn more and retain the information longer, regardless of subject matter.

Purposes of the study

The objectives of the project entitled “The Role of Socialization in Promoting Academic Wellness” were to assess:

1) the effectiveness of the socialization in overall academic success of first-year nursing students, and

Research design and process

This is a qualitative Evaluation/Action research study. The university IRB granted permission to conduct the study. After receiving detailed information about the research, the participants gave written informed consent prior to the interviews. All students were invited to participate in this extra-curricular project. Also, students were given the choice not to participate and the option to withdraw their consent at any time during the study. The participants were assured that interview data would be kept confidential, and that participation in this study was voluntary and would not affect their status in school in any way. Semi-structured, in-depth interviews were conducted. Anonymity was assured by code-numbering the interviews. The interviews were audio-recorded and transcribed verbatim. Field notes were taken during and after each interview. The students’ reflective journals for this particular topic were used as another source of data. A purposive sample of fifty seven junior student nurses was selected to participate in this study (N=57; female n=39, and male n=18). Participants ranged in age from 21-44 years. Purposeful sampling allows persons or activities to be deliberately selected to provide relevant information to the researcher’s questions, since selecting participants in qualitative research is neither probability nor convenience sampling

This study used a qualitative research methodology, which focused on the experiences of people and the meanings of those experiences [42,43]. Qualitative research attempts to explore issues in depth, and to identify the ways that people behave and the motivation behind those behaviors. Researchers attempt to make sense of participants’ perceptions and experiences, and gain knowledge by identifying common themes in the data. Qualitative research is descriptive and helps to explain the meaning or processes related to a specific event, phenomenon, or interaction among people [42].

The purpose of this qualitative action research study was to explore how participating in “Caring Bunch Project” influences the undergraduate nursing students’ socialization and practice of “caring.” The purpose of action research is to change practices during the research process to bridge the theory practice gap [44]. CochranSmith and Donnell [45] discussed the problems and issues occurring from practice, and gaps between what is intended and what occurs are the focus of this type of research. Munn-Giddings [44] contended that action research is based in practice, not separated from it. At its core, action research is context bound and addresses real-life issues. For these reasons and the purpose of this study, an action research approach was appropriate. In this study, my dual role was that of faculty and researcher. There is little distance between faculty researchers and participants in action research [46]. However, Mills [46] declared that the most complex issue in action research is protecting the rights and freedoms of students. As the researcher, protecting these rights and freedoms was my responsibility. This was accomplished partly by obtaining institutional review board (IRB) approval and participant consent. Action research is participatory and undertaken by insiders [47]. I am a nurse educator with years of experience teaching. Cochran-Smith and Donnell [45] stated that the practitioner researcher “can know through systematic inquiry into the situations in which they practice is worth knowing” . It was communicated with the students that the criterion of success is not how accurately steps were followed but whether there is an evolution in the participants practice, in the understanding of practice, and in the situations in which they practice. They were also asked to include in their weekly journals if they found this project a “fun” activity

Caring bunch project

• Purpose of Caring Bunch Project (CBP) was helping-students help-themselves.
• Seeds of caring exist in every one of us. They just need time, attention, a fertile environment, and a good gardener to help them grow and blossom. 
• The main purpose of this project is provision of the needed elements to achieve a semester full of blossoming students.
• There are four main tenets of the project that the students are: 1) intelligent, 2) hard working, 3) goal-oriented and 4) caring. 
• This was an optional class project and upon completion of the project each participating student earned 10 points and the team leader earned 14 points. (out of 225 total maximum points for the course) Participating students and team leaders had to follow the project requirements closely and completed the project successfully to receive the extra points.   

Step-by-step Criteria

• Members of each group must actively participate in at least a 1-hr weekly study (review) session.
• Members of each group must participate in at least one social gathering (eating out). We shall call this “food-for-thought” activity. Leaders must locate an eatery with reasonable price that all group members can afford, or the members can bring their food with them.
• The study session and eating out occasion cannot be on the same day.
• Each member must write a one-page reflective paper weekly, sharing her/his activities and experiences and submit it on every Tuesday (class time).
• While working in a group and as a team, the team members should come up with a creative idea to facilitate learning pathophysiology content (or teaching/learning in general).
• The following exploratory questions guided this qualitative study:
• What were your initial thoughts and feelings about the “Caring Bunch” project? What are your thoughts and feelings now? • What parts of eating out and socializing with your classmates were pressing for you? please elaborate...
• What parts of studying with your classmates were pressing for you? please elaborate...
• What part of the project was more enjoyable for you?
• What “project” or activities would you design to provide an environment for students’ caring practice?
• What have you learned by participating in this project? • Why do you think projects such as this are/are not needed?
  

Data Analysis and Results

Initially, several of the participants were not sure about the goals of the project “My initial thoughts about the “Caring Bunch” project was those filled with hope and the prospect of a highly educational outlook involving this class”, “In the beginning I was unsure if I would be able to participate as I had a job that made it hard to allow time during the week to meet in a group”, and “Where do I begin? My initial thoughts about the caring bunch project was that it was pointless and a waste of gas. I was upset because I thought I had to drive an extra day to school and waste gas to eat with a group of people I barely knew.” But some of their perceptions have changed over time “I still feel that way to a point. Ironically enough, two of the people you put me into a group with, are both wonderful friends of mine now”, “Now that it is over, I am glad I participated because I gained a lot” and “This project has helped me more than anything.”

Initially, three participants withdrew from the project for personal reasons. Remaining participants continued with their assigned activities. Personal reflective journals were submitted to Digital Drop Box on D2L platform. Group leaders met with the researcher after the first week of project activities. It seemed that there was a slight inter and intra group conflict. Apparently, some of the students preferred to combine the study session with the group social activities to save time. This created some confusion. The objectives of the project were explained to the group leaders and they were asked to clarify these for their members. In the second meeting with the leaders, they reported some inconsistencies and taking short cuts by some of the group members. At the third meeting, the leaders reported that inconsistencies and intra group conflicts escalated. At the forth meeting, due to continuations of conflicts and since no resolutions were achieved, the leaders were notified to inform their group members that the group activities were cancelled. It was announced to class that from that point on only members and groups which could get along could continue with the group activities.

One of the emerged themes was “me care, the care.” Several of the participants were more concerned about caring for self. They wanted to receive the extra points for the project but for different reasons did not want to participate in the group activities “two members of the group are no longer with the study group…it was extremely annoying to have people constantly complain about spending money each week and trying to find a happy medium”, “It was also slightly challenging because some members would not participate in the study sessions and kind of did their own thing during our group time. Honestly, if there hadn’t been points involved in the project a majority of the people would not have participated”, “I thought this project was not going to be very beneficial to me. I like to study and work independently, and I find group projects somewhat hindering to my style of learning”, and “One thing that I have learned in life is that no matter what situation you are in people are going to look out for themselves first and then if they are able they will help out their peers. I have had to learn this lesson the hard way several times in my life and I do wish that the world wasn’t this way sometimes, but it is a survival of the fittest type of life.”

Overall, participants benefited to some extent from the collaborative activities and found them caring “two of the people you put me into a group with, are both wonderful friends of mine now. We are continuing to improve our grades with each test and have instilled a study program that works well for all”, “I did not understand at first why it was imperative that we get together just to eat and socialize. I can honestly say that I enjoyed going out once a week for a meal with a group of fellow students and missed it after it stopped. I enjoyed studying with them very much. I gleaned from their different ways of studying”, “I wish my social skills were better and could be able to converse more easily with others. We helped each other understand expectations for this class as well as for other classes. I learned the sacrifices others were making in the pursuit of this nursing goal and that my troubles were relatively minor compared to what others were going through or had gone through to attend this program”, “even though this sounds corny, I believe hugging is an important aspect to show people you care. Emotional development requires some type of human contact whether it is physical or social. Hugging is something that I believe provides both”, and “This project has helped me more than anything. Being able to study with such great and intelligent people was amazing. I have been blessed to meet such great people and now I can call them good friends”, “If I had to come up with something to teach students how to practice with care, I would set up two scenarios. One would have nurses treat the patients as if they didn’t care at all about his/her needs. The other would have nurses doing everything they could to make the patient happy and comfortable. This would show the students how to practice with care for the patients.”

The data support the two other similar studies [4,50] which indicated that participation in an informal peer experience was only partially effective in promoting students’ academic and social wellbeing, and professional socialization.

There is growing support for the integration of caring in nursing education. Noddings [51]identified four process through which students experience a learning environment that nurtures “the ethical idea” of caring: modeling (faculty showing caring behaviors), dialogue (open communication and sharing thoughts and feelings), practice (opportunities for students practicing giving and receiving caring), and confirmation (evaluation of a student’s caring ability).

Findings from Hughes et al. [50], study failed to indicate that participation in an informal peer group experience was effective in promoting students’ professional socialization as caring practitioners. They included several possible reasons such as: sample size, participant attrition, etc. In addition, they asserted that effective group process takes time to develop and a single semester may not have been long enough for students to develop a cohesive group.

Collaborative learning emerged as an important pedagogy in the higher education during the late 1980s. Unlike the traditional lecture method, this approach allows intensive interaction between students-students and students and the faculty member. Much has been written about the benefits of collaborative learning, however, the extent and specificity of its benefits remains at issue [52].

Results of this study indicate that participation in an informal peer experience was only partially effective in promoting students’ academic and social well-being, and professional socialization. There are several areas which require further research and explorations. The study was conducted during a summer session (7 weeks long). This might not have been enough time for students to establish trust amongst themselves. Majority of the accelerated second-degree students enter field of nursing for employability and job security. This might promote competitiveness and individualistic behaviors. Accelerated programs are a rapidly growing trend at universities across the United States. Accelerated students enter the program for learning new skills for clinical practice. The program is usually 12-18 months in duration. Faculty may encounter challenges if students perceive a mismatch between their expectations and their new role as baccalaureate nursing (BSN) students in a fast-paced and intense program. Foci of the program are: nursing knowledge, nursing situations and practice, and nursing professionalism. Students may require more time to master caring behaviors and to be able to internalize that. To create more diversity in each group, heterogeneous groups were formed. Participants appeared to work more effectively with those who had similar interests and where from the same geographical area. Most students participate in cocurricular and extra-curricular activities for earning the extra points. This study also had an external reward attached to it, which should be modified in the future studies.

The study started with forming 12 groups (4-5 members per group). After canceling the group activities on week four, four groups decided to continue with their group activities until the end of the semester and several of group members remained in the same study group until graduation. These students were the ones who benefited from the collaborative “Caring Bunch” project and exhibited more caring behaviors toward each other and the faculty. In order to troubleshoot and remedy problematic cooperative learning groups, Candler [53] provides a check list (Table 1).

Lessons Learned

Researchers in the field of education have experimented with different learning environments which draw upon communities of learners to determine which ways of fostering such communities are most effective [54,55]. Even though a vast amount of studies have corroborated the positive effects of cooperative interventions, there have also been studies [56,57] which have diminished the positive appraisal of cooperative interventions, arguing that pupils often sit in small groups but are rarely assigned to real collaborative tasks. Individual studies on cooperative learning have provided relevant and sometimes contradictory information about its effectiveness. Cooperative learning has been defined by Johnson and Johnson [58], as a situation in which there is a positive interdependence among student’s goal attainment; therefore, students perceive that they can only reach their learning goals if all the members of the group achieve the learning goals as well. The topics of collaborative learning and community of learners have been discussed in the literature for more than three decades. The premise of this study was that communities of learners can be fostered by learning environments that offer the opportunity and stimulus for people to form such a community having in mind the principles of collaborative learning: individual accountability, stimulate interdependence, communication, consensus making, and special attention to the process. Achieving high grades and passing NCLEX is a desired goal communicated by many nursing instructors to the students. The college system reinforces this competitive sense by giving awards to students who excel academically, outplay, and outsmart their peers.

This individualistic approach to success does not prepare nursing students for entering the health care arena in which full participations in interdisciplinary tasks and team work are required. According to Bruffee [7], knowledge at the university or college level is “mostly” non-foundational eliciting questions with a range of “arguable or ambiguous” responses. Therefore, knowledge is being socially constructed and reveals classroom authority as shared by students and instructor. This theoretical stance engages the instructor and student as mutual inquirers in substantial and subjective issues and shifts classroom authority to include both.

I considered the participants as adult learners as defined in adult education literature, and that the literature regarding adult characteristics would apply to them: 1) adults are self-directed learners, 2) adults possess the ability to relate to teachers as facilitators or helpers and to take the initiative in making use of their resources, 3) shared learning gives students an opportunity to engage in discussion and take responsibility for their own learning, and makes them more critical thinkers [15], 4) collaborative learning benefits students in the long term by helping them work effectively in groups, and 5) as students realized their personal strengths and weaknesses, they would be able to define a personalized set of goals and objectives to improve themselves and, through guided reflection, would become self-directed in their learning efforts [59], and 6) as students experienced dialogue with others, they would actively participate in the collaborative learning techniques [60]. Therefore, I intended to help providing an environment in which my students could substantially develop needed knowledge, skills, and social sensitivity or maturity for transfer to the workforce.

As a nurse educator, I have always been striving to develop a community of learners that would engage students in self-directed learning tasks facilitated in a collaborative, experientially-based learning environment. Therefore, I invited my students to participate in this voluntary activity and practice caring at intrapersonal and interpersonal levels. They were supposed to follow the initial instructions to complete the project while they were provided flexibility and were encouraged incorporating their own creativity. Acting professionally and focusing on the social interaction were not mentioned to the students since these are required attributes for professional nursing practice. It was assumed that working in groups would help them find more effective ways to communicate, exchange ideas, and engage in shared reflective learning [61]. As stated earlier, studies have identified some components that mediate the effectiveness of cooperative learning, such as: (a) positive interdependence, which allows students to perceive that they are linked with each other in such a way that one cannot succeed unless everyone succeeds, (b) individual accountability, which gives each member of the group a sense of personal responsibility toward goal achievement, (c) promotive interaction, which takes place when students facilitate each other’s efforts to learn through exchanging resources, help, motivation, and points of view, (d) interpersonal and small group skills, which means that students must be taught social skills for high quality cooperation, and (e) group processing, which exists when group members discuss how well they are achieving their goals and maintaining their working relationships [62]. It is clear that effective communication skills through listening, explaining and sharing ideas is critical part of the process. Also, effective group work depends on the individuals learning to trust and respect each other and having skills to plan and organize their group work, make considered group decisions, reach a compromise and avoid petty disputes. In agreement with Baines, Blatchford, and Kutnick [56], it is important not to allow personality types or group conflict to dictate the success, or failure, of groups.

What we learned from this study is in line and supports Trowler’s [63] assertions in that communities of learners tend to have been portrayed in ways which emphasize consensus making rather than conflict, homogeneity rather than difference and dynamism, and boundedness rather than opennesss and permeability. Therefore, more recognition needs to be given to the agency of individual learners and to the dispositions, life history and personal construals that they bring to a particular community of learners [64]. Also, it can be asserted that our culture conspires against collaborative thinking by conditioning us to think adversarially. Disagreements and controversies are valued as promoters and markers of the students’ engagement in and ownership of their own learning [65], however, in this study, adversarial thinking and acting were not productive and/or reconciling. It was assumed that forming a community of learner help students to help themselves striving for the greater good. Therefore, they all would contribute to it to grow and develop. The learners had a role to play in building a learning community but that might have competed with individual interests and individual needs. Although all the students participated in this class activity, building a community without buy-informal learners is a futile effort. In general, students are taking courses to learn the content, complete and earn a grade and move on to the next course. They have limited time and energy. Most of the students in this study and in this program (2nd degree accelerated program) were not from the same area and were from other cities and states. Therefore, living in an unfamiliar environment was another challenge. The students had a role in fostering trust and interdependence among themselves. While a few accomplished that many did not make an effort to do so. The goal of this project was to provide an opportunity for student collaboration and achieving academic success. The goal was not a “team-work.” The hope was that the “collaboration” creates “values” to share their knowledge, experience, and creativity to arrive at a shared understanding. Was this a realistic expectation and in line with the individualistic culture we live in? Throughout our lives, we are encouraged to work towards personal goals, and to put our own needs before those of our community. Competition and lack of shared goals are barriers to collaboration. Mutual trust and shared goals help encourage it. Getting people to trust and believe in each other requires a change in culture. 

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