Cultural Competence

Student Paper

Cultural Competency in Baccalaureate Nursing Education: A Conceptual Analysis

Deborah Byrne, RN, MSN, La Salle University, Villanova University

Abstract The ability to deliver culturally competent nursing care is an expected competency of undergraduate nursing education programs. The American Association of Colleges of Nursing (AACN) and the National League for Nursing (NLN) have developed toolkits that provide nurse educators with models and teaching strategies to facilitate student learning in cultural competency. However, the concept of cultural competency varies as does the best method for integrating and evaluating cultural competency in undergraduate nursing curriculum. With the growing number of diverse clients, it is imperative that nursing students deliver culturally competent care. This article explores the current view of the concept of cultural competency from the standpoint of nursing education and the methods used to evaluate cultural competency in undergraduate nursing education programs.

Keywords: cultural competency, simulation, undergraduate nursing education, cultural

awareness, cultural humility

Background and Significance Health care is increasingly complex, diverse,

and growing in the United States. The United States Census Bureau (2009) predicts that the U.S. population of non-European Caucasians will be equivalent to Caucasian Americans by 2050. According to Healthy People 2020, there are significant health disparities among minority groups. A fundamental goal of Healthy People 2020 is to eliminate health disparities for all groups (U.S. Department of Health and Human Services [USDHHS]). The need for culturally competent health care is essential to reduce health disparities and ensure positive health outcomes.

The National League for Nursing (NLN) and American Association of Colleges of Nursing (AACN) include culturally appropriate care in their accreditation standards and have developed toolkits for nurse educators to assist with incorporating cultural competency in undergraduate nursing curricula (NLN, 2009; AACN, 2008). There is, however, no consensus in the literature regarding effective ways to teach cultural competency to undergraduate baccalaureate nursing students. Most nursing programs in the United States include the concept and skill of cultural competency as a program outcome and attempt to integrate cultural competency into their curricula. Attempts at integration have been reported as inadequate in developing culturally competent nurses (Brennan & Cotter, 2008). As the diversity of the population increases, so too must the cultural competency of nurses in practice. It is imperative that undergraduate nursing students develop cultural competency knowledge, awareness, and skills while experiencing didactic courses, clinical, and simulation experiences.

Culture is integral to how people view death, birth, illness, and health (Delgado et al., 2013). For individuals to seek health care, they need to feel safe and secure with their providers. Health care providers need to understand client culture and deliver culturally sensitive and competent care to achieve the best patient outcomes. For health care providers to deliver culturally competent care, they must be aware of their own biases about the culture they are serving to prevent poor patient outcomes (Campinha- Bacote, 2007).

In nursing education, interaction with culturally diverse clients, families, and communities is essential for student development of cultural competence (Campinha-Bacote, 2003). Integration of cultural nursing skills, knowledge, and attitudes will produce the best outcomes. Cultural knowledge is the basis of cultural competence, but it is the application of knowledge in clinical, simulation, and immersion experiences that will develop culturally competent nurses (Campinha-Bacote, 2003). The concept analysis model by Walker and Avant (1988) clarifies understanding of the various attributes of the term cultural competence. This method provides a systematic process by which a concept can be clarified further by identifying the attributes, antecedents, and consequences of the concept. In order to deliver quality care to a diverse population, it is imperative that nurse faculty incorporate cultural competency skills in undergraduate nursing programs.

Background of Concept Culture is defined as a pattern of traditions,

beliefs, values, norms, symbols, and meanings among a group of people (Campinha-Bacote, 2007). Competency refers to performing, ‘‘in a manner that is satisfactory to the demand of the situation, to interact effectively with the environment’’ (Thomas, 1993, p. 429). The definition of the concept cultural competence varies, but a commonly used definition of cultural

competency is ‘‘the ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, community)’’ (Campinha- Bacote, 2003, p. 5). Cultural competency is embedded in various fields of study, including social and behavioral sciences, law, and nursing. All three disciplines profess the same definition of culture but apply the term cultural competency based on relevance to their respective fields (Singer, 2012; Gould & Martindale, 2013; Leininger & McFarland, 2002).

Numerous definitions of culture are based in the social and behavioral sciences; however, there are four basic concepts that the social and behavioral sciences use in their definitions (Singer, 2012). The first concept describes culture as learned through the process of socialization from birth. This concept is incorporated in many psychological interpretations of culture. The second concept is that all members of the same group share the same cultural values and beliefs. This concept is broad and does not include subgroups of larger cultural groups. For example, in the Jewish faith there are multiple subgroups with shared values and beliefs; each has some variation from the larger group (IJS Israel & Judaism Studies, n.d.). The third concept of culture is the adaptability of a cultural group to social and environmental conditions, and the fourth concept states that culture is an ever- changing process (Singer, 2012). The third and fourth concepts appear crucial to delivering culturally competent care. Each generation presents with new circumstances that affect the care they receive. An older Hispanic client may believe in folklore to treat illnesses, but a younger Hispanic client may prefer technology and modern medicine.

In the legal field, cultural competency and sensitivity are increasingly important when performing child custody evaluations (Gould & Martindale, 2013). The authors define culture as a ‘‘pattern of traditions, beliefs, values, norms, symbols, and meanings’’ (Gould & Martindale, 2013, p. 3.). More than half the U.S. population are from immigrant families, and many of the families are experiencing separation or divorce. In the field of matrimonial law, it is understood that cultural competence has three broad dimensions. Attorneys and child evaluators need to have an awareness of their own beliefs toward different cultures and an awareness of the expectations of their clients. They also need to utilize culturally appropriate assessment tools when conducting evaluations with culturally diverse people. The

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attorneys and evaluators are aware of the importance of delivering culturally competent assessments to properly arrange the best custody arrangement for children. Gould and Martindale (2013) noted the lack of literature providing guidance on how to address cultural issues in child custody assessments.

There are several components to integrating cultural competency into a child custody evaluation: interviews, psychological testing, direct parent-child observations, record review, expert opinions, cultural relativism, and responsible opinion formulation. Cultural sensitivity and awareness must be integrated into all of these components. The evaluator should retain professional interpreters when necessary when interviewing a parent or child. The evaluator should also be cognizant of the family’s beliefs, customs, and attitudes when evaluating direct parent-children observations, psychological testing, and record review. Experts engaged in the case should also be familiar with the cultural background of the child and parents.

In nursing, culture has been defined as by Leininger and McFarland (2002) as, ‘‘the learned and shared beliefs, values, and lifeways of a designated or particular group that are generally transmitted intergenerationally and influence one’s thinking and action modes’’ (p. 9). This definition has been central in transcultural nursing and allows for a holistic approach to delivering culturally congruent nursing care. Both definitions and their concepts guide nurses delivering care to diverse groups of clients.

There have been numerous studies regarding cultural competency in nursing (Jeffreys & Dogan, 2013; Jeffreys & Dogan, 2012; Kardong-Edgren et al., 2010; Kardong-Edgren & Campinha- Bacote, 2008; Krainovich-Miller et al., 2008; Noble, Nuszen, Rom, & Noble, 2014; Caffrey, Neander, Markle, & Stewart, 2005; Reyes, Hadley, & Davenport, 2013). In nine studies, students measured the cultural awareness level based on self-perception reports. These studies all had cultural competency as a program outcome in a nursing curriculum and tested various teaching methods and interventions to increase cultural competency. The studies also showed a positive outcome when cultural competency was integrated throughout the curriculum.

The application of cultural competence in social and behavioral sciences, law, and nursing is closely related and shares similar concepts. In social and behavioral science, law, and nursing, cultural competence is needed to ensure positive and fair outcomes. In social and behavioral sciences, cultural competency is implemented in many fields including psychology. A psychologist needs to be culturally competent to deliver best practices. If psychologists are not aware of client culture, they can cause undue harm. In law, a

child custody evaluator needs to deliver culturally competent care in order to ensure the optimal custody arrangement is made for the child. In nursing, a nurse needs to practice culturally congruent care in order to ensure positive health outcomes and reduce health disparities.

Significance of the Concept for Nursing There are several cultural competency

theories and models in the literature related to nursing. Campinha-Bacote’s Cultural Competence Model (2007) has been widely documented in global nursing research studies. Her model has five interdependent constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. Campinha-Bacote (2007) contends that as individuals move toward cultural competence, they must experience all of these constructs. A pilot study by Delgado et al. (2013) evaluated the effectiveness of implementing a 1-hour class on cultural competence at a large Midwestern medical center. In this study, the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals–Revised (IAPCC-R) was administered to participants to assess baseline cultural competence prior to an intervention, and then another assessment was given at 3 and 6 months post training. This instrument was developed by Campinha-Bacote based on her cultural competency conceptual model and integrates five cultural competency constructs. The intervention was a 1-hour class to promote cultural competency and show the impact of cultural competency on quality of care. The intervention included participants examining their own ethnic heritage, issues related to health care, and implications for health care providers. Participants included registered nurses, patient care assistants, and unit secretaries. Results showed a statistically significant difference (p¼ .02) in cultural awareness over time (Delgado et al., 2013). Kardong-Edgren et al. (2010) evaluated cultural competency in graduating baccalaureate nursing students. The investigators evaluated six nursing program outcomes with different methodologies for teaching cultural competence. They used the IAPCC-R to measure cultural competency in graduating nursing students. All the participating nursing programs integrated Campinha-Bacote’s cultural care model into the nursing curriculum except for Program 1, which did not integrate any specific cultural care model in the curriculum. The results showed an increase in all five constructs by implementing this conceptual model in the undergraduate nursing programs (Kardong-Edgren et al., 2010).

Jeffreys (2009) also developed a conceptual model, the Cultural Competency and Confidence model (CCC). In a study by Jeffreys and Dogan (2013), an instrument was administered to evaluate culturally specific care provided for a

diverse population. The Clinical Cultural Competency Evaluation Tool (CCCET) was based on the CCC model. In the model, Jeffreys defines cultural competence as a ‘‘multi-dimensional learning process that integrates transcultural skills in all three education learning domains (cognitive, practical, and affective), involves transcultural self-efficacy (TSE), and aims to achieve culturally congruent care’’ (Jeffreys & Dogan, 2013, p. 189). The CCCET has three subcategories including provision of cultural-specific care, cultural assessment, and cultural sensitivity. The instrument was administered to second-semester students at the end of their medical-surgical course. The findings in this study suggest that educational interventions in the clinical setting move nursing students from a passive role to an active role (Jeffreys & Dogan, 2013).

In all three studies, cultural competency conceptual models framed the research. Some authors agree that cultural competency models are needed to guide teaching cultural competence; however, disagreements center on the best way to integrate the models into the curriculum. The literature supports the proposition that delivering culturally congruent care can decrease health disparities.

Attributes of the Concept There are several characteristics of the

concept of cultural competence in the literature: (a) cultural awareness, (b) cultural knowledge, (c) cultural skill, (d) cultural encounters, (e) cultural desire, (f) cultural sensitivity, and (g) cultural humility. Cultural awareness is the self-evaluation of our personal biases and prejudices about individuals from a culture different than our own and requires individuals to explore their own cultural heritage (Campinha-Bacote, 2007). Since biases are ingrained in the mind and not easily recognized, cultural competence is difficult to accomplish. Van Ryn and Burke (2000) investigated 193 physician-patient interactions. Findings revealed that physicians rated African- American patients as less intelligent, less educated, less likely to comply with medical advice, and more likely to abuse drugs (van Ryn & Burke, 2000).

Cultural knowledge is the process of acquiring a strong educational base about culturally diverse groups. This construct includes the common knowledge of health-related beliefs, disease incidence and prevalence, treatment efficacy, and diagnostic clarity (Campinha-Bacote, 2007). For example, the genetic disease Tay-Sachs is more prevalent in the Jewish-American community (National Tay-Sachs & Allied Diseases, n.d.). Nurses who practice culturally competent care possess the knowledge and skills to identify at- risk Jewish patients for genetic screening. Cultural skill is the ability to perform culturally competent care, including collecting relevant

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cultural data and performing a culturally sensitive health assessment. Several assessment instruments are available on cultural assessment, which health care providers can employ to ensure accurate assessment is obtained from an individual, group, or community.

Cultural encounters are interactions with patients from diverse backgrounds (Campinha- Bacote, 2007). The purpose of cultural encounters is to improve verbal and nonverbal communication with different cultures. The exposure to diverse cultures will assist in obtaining effective communication skills and increasing awareness of other cultures. Additionally, cultural desire is the motivation of an individual to participate in the process of becoming culturally competent (Campinha- Bacote, 2007). The motivation of the individual must be genuine for the process to be successful. To achieve this construct, the individual has to possess the characteristics of caring, sacrifice, commitment to social justice, and humility.

The concept of caring is fundamental to the construct of cultural desire and is based on a humanistic view of caring (Campinha-Bacote, 2007). Cultural sensitivity is the acceptance and understanding of cultural differences. The implementation of cultural sensitivity produces better health outcomes because the practitioner is sensitive to the beliefs, values, and attitudes of a different culture (Burnard, 2005). For example, a culturally sensitive, female, registered nurse would possess the cultural knowledge to refrain from shaking hands with a male Muslim patient. Cultural humility is the ability of individuals to be humble and think less of themselves. This concept translates into the realization that one’s own culture is not paramount (Schuessler, Wilder, & Byrd, 2012). Schuessler et al. (2012) used reflective journaling to evaluate undergraduate nursing students’ level of cultural humility. Results showed novice nursing students began to understand cultural humility by interacting with patients from different cultures. Students stated they began to be aware of how other cultures interacted with each other and with health care practitioners.

Model Case Kate, a community health registered nurse,

cares for Mary, an elderly client who lives alone in an inner city housing complex. Mary is an 85- year-old African-American woman with several chronic conditions including diabetes, hypertension, peripheral vascular disease (PVD), obesity, and transient ischemic attacks. Mary has been hospitalized several times in the past year for exacerbation of her chronic conditions. Upon arriving at Mary’s home, Kate notices the unhealthy food on Mary’s kitchen counter, lack of assistive devices, and swelling in Mary’s lower extremities.

Kate has been working in this community for several years and is aware of the beliefs, values, behaviors, and past experiences of this African- American community. As a result, Kate understands the importance and value of religion in this community. The church in this community serves not only as a place of worship but also as a community of support. Therefore, Kate has developed a relationship with the church leaders in this community. She also has an open line of communication with various social programs in this community.

Upon assessing Mary, Kate is aware of Mary’s mistrust of health care providers based on past encounters. In addition, Mary has a reluctance to ask for help and likes to eat good ‘‘home cooking.’’ Mary is on a fixed income and believes she cannot afford to eat healthier. Mary has missed several doctor’s appointments owing to her lack of transportation.

Kate acknowledged and was sensitive to Mary’s mistrust of health care professionals and worked to develop a trust-based relationship with Mary. Kate developed a comprehensive care plan, in collaboration with Mary, to reduce her frequent hospital admissions. Kate was sensitive to the importance of religion to Mary and contacted the minister of her church to see if they had any programs to assist seniors with running errands and transportation to medical appointments. In addition, Kate contacted a local senior group to see if they had social gatherings to help combat Mary’s loneliness. Kate found a food cooperative (co-op) that was not far from Mary’s apartment.

Within 6 months of implementing this comprehensive plan of care, Mary did not have any hospital admissions, started to enjoy outings with people from the senior center, and received rides from church volunteers to visit her physicians. Mary started going with a friend to the food co-op to begin eating healthier. Mary expressed feeling respect and understanding from Kate, and they continue to work together. Overall, Mary’s health has improved, and she feels she is a participant in her health.

This model case demonstrates positive health outcomes when culturally competent care is delivered. This client represents an underserved minority group that faces health disparities at an alarming rate (USDHHS, 2010). The registered nurse is aware of the culture of the group that she serves and has developed the knowledge, skills, and attitude needed to deliver culturally competent care. The registered nurse also demonstrated a cultural desire and sensitivity to customs and beliefs held by the cultural group. The client responded positively to the nurse’s recommendations because she said she felt the nurse listened and respected her beliefs and feelings.

Borderline Case Joseph is a registered nurse with 20 years

experience caring for a largely Hispanic population. Through his work experience, Joseph has learned a few key Spanish terms in order to communicate with his patients. He feels confident interacting with patients in the Hispanic community. He is aware that many Hispanic patients use complementary medicine and implement healing traditions different from American culture. Joseph is caring for an elderly Hispanic woman named Maria who presents with shortness of breath. Joseph uses his limited Spanish to communicate with Maria and her family. The family speaks limited English, but through hand gestures and some Spanish, Joseph asks Maria and her family if they take any over-the-counter herbal supplements or practice any healing rituals.

About 4 hours into his shift, Joseph notices Maria’s shortness of breath is increasing despite breathing treatments and administration of steroids. The attending physician contacts Maria’s family physician and learns she has chronic obstructive pulmonary disease (COPD) and just finished a course of steroids. The dose of steroids Maria is currently receiving is too low to explain increased shortness of breath. Maria’s medications are adjusted and within 2 hours her shortness of breath decreased.

Upon reviewing this case with his nurse manager, Joseph realized that although he showed awareness toward this patient from a different culture, he still did not have the cultural knowledge and skill to call for a professional interpreter. Joseph and the nurse manager developed an in-service program to educate the staff on the benefits of using a professional interpreter.

This borderline case demonstrates the need to develop cultural competency skills continually. The nurse in this case had the self-efficacy desire, awareness, and knowledge to perform a culturally sensitive assessment on his patient but did not have the knowledge or skill to utilize a professional interpreter. Not using an interpreter could have led to further harm of the patient.

Contrary Case Lisa, a registered nurse, works on a busy

telemetry floor at a small community hospital with a predominantly white population. She has had little experience with people from a different culture and does not think it is an important part of her job. Lisa received a report on a 22-year-old, African-American male patient named Anthony, with a diagnosis of exacerbation of sickle cell anemia. Lisa notes in her report that the patient is requesting a stronger dose of hydromorphone for increased pain. Lisa comments to the reporting nurse, ‘‘Of course, I get the drug addict. This is going to be a long shift.’’ Lisa enters Anthony’s

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room and proceeds to perform a brief assessment. Anthony appears in distress and rates his pain as a 10 out of 10 on the pain scale. He begs the nurse for more pain medication. Lisa calls the attending physician and states, ‘‘The patient, Anthony, in room 383, is complaining of pain. He is getting plenty of pain medication and is just drug seeking. I recommend we discontinue his narcotics and give him ibuprofen. He will want to go home quicker if we stop feeding his addiction.’’ The physician discontinues the hydromorphone, and Lisa gives Anthony ibuprofen with a lecture about abusing narcotics. Anthony remains in pain for the rest of Lisa’s shift. Upon discharge, Anthony feels dissatisfied with the care he received, and he develops a distrust of physicians and nurses.

This case demonstrates a complete lack of cultural competency of the nurse and physician. The nurse did not demonstrate cultural knowledge, skills, awareness, desire, sensitivity, or humility. The nurse works with a predominantly white population and lacked knowledge of sickle cell anemia. However, if Lisa had the cultural awareness, desire, and humility, she would have educated herself about the disease. She would have been culturally sensitive to the pain caused by sickle cell anemia. She did not have the cultural awareness of her own biases and stereotypes of cultural humility to know that each

culture is different, which resulted in harm to the patient.

Assumptions for the Concept There are several assumptions about the

cultural competency model: � Cultural competence is a life-long process. � Cultural competence is a fundamental component in delivering culturally congruent care.

� Cultural awareness is essential for cultural competence to occur.

� Rendering culturally competent care will reduce health disparities.

These assumptions are based on experiential knowledge and the literature (Campinha-Bacote, 2007; Jeffreys & Dogan, 2012).

Antecedents and Consequences Prior to the development of cultural

competence, certain behaviors, attitudes, and ideas must occur. The following are cultural competency antecedents based on the literature:

� Self-awareness: Practitioners must be aware of their own biases, stereotypes, and attitudes toward other cultures. They must also be aware of their own cultural heritage.

� Encounters: Practitioners’ past cultural encounters can affect their interactions with other cultures.

� Attitude: Practitioners’ attitudes must be open, flexible, and sensitive to others.

� Communication: Practitioners’ level of communication skills must be high in order to effectively interact with other cultures.

� Knowledge: Practitioners should have a basic knowledge of the prominent culture in which they are delivering care.

� Self-efficacy: Practitioners should have the confidence to deliver culturally competent care.

When cultural competence has been demonstrated, the consequences of those behaviors and events result in improved health outcomes. Behaviors represent the actions of healthcare providers. If those actions or behaviors are culturally competent, improved health outcomes may follow for the patient. Events are the actual interactions between healthcare provider and patient. The following are cultural competency consequences based on the literature:

� Culturally competent registered nurses deliver culturally congruent care to all patients.

� Clients become active participants in their health care.

� Clients have decreased fear of the health care system and health care practitioners.

� Clients have increased satisfaction with health care services.

Figure 1

A Cultural Competency Conceptual Model

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� Decreased health disparities are reported. � Better health outcomes result by increasing health promotion and preventive care.

� Nurse educators support culturally competent practices in undergraduate nursing students.

� Health status of ethnic, racial, and low- income groups improves.

Conceptual Model The conceptual model in Figure 1 illustrates

the cyclical direction of attaining cultural competency. The antecedents need to exist in order for the nurse to attain the characteristics needed to reach cultural competency. If cultural competency is reached, the consequences demonstrate a benefit to the individual, community, and nation.

Discussion of Concept The concept of cultural competency is integral

to giving the best care possible to individuals, families, and communities. It is imperative that nursing students receive cultural competency education in the classroom, and in clinical and simulation settings. The literature establishes the effectiveness of cultural competency education in the classroom and study abroad. However, study abroad and immersion experiences are expensive and only available to a select few. The research conducted on simulation (Jeffries, 2009; Miller, 2010; Shin, Park, & Kim, 2015) demonstrates the effectiveness of using simulation to bridge the gap between the classroom and practice.

The literature illustrates the effectiveness of students engaging with patients of a different culture in study abroad or immersion experiences. Reeves and Fogg (2006) gathered data on the perceptions of undergraduate nursing students regarding their life experiences with cultural diversity. The authors noted several themes during the analysis of the interviews. One unexpected theme emerged—defining life experience—and is the only one discussed in this study. The authors elaborated on this theme with direct quotes from the participants. The quotes from the students highlighted the lack of cultural exposure in the nursing curriculum and how various exposures outside of nursing helped them become culturally aware. Participants in the study reported unique cultural experiences that shaped how they viewed different cultures. One participant spoke about attending camp as a counselor where the majority of the staff were lesbians. The participant had never been exposed to a homosexual culture and had a difficult time with adjustment. At the end of the summer, however, she acknowledged it was an exceptional educational experience and had changed her views. The experience reinforced the need for cultural awareness and exposure during nursing education programs (Reeves & Fogg, 2006).

Reeves and Fogg (2006) illustrated the importance of exposing undergraduate baccalaureate students to other cultures. Exposures help to cultivate cultural awareness in nursing students so that they can continue to develop cultural competency knowledge and skills. Specific cultural skills emphasized in the literature are culturally appropriate assessment tools, diagnosis, planning, interventions, and evaluation methods. Cultural competency affects how patients interact with nurses in the hospital setting. With the implementation of the Patient Protection and Affordable Care Act (2010) and an aging population, health care is moving from the acute care setting to the community. In public and community health, culturally appropriate attitudes, skills, knowledge, awareness, humility, and sensitivity are essential to delivering culturally congruent care. In ethnic minority communities, there are many barriers to attaining quality health care, including language barriers, distrust of the medical profession, immigration status, and lack of preventive care and health promotion. By delivering culturally congruent care in the community setting, health disparities and health outcomes of a community can be improved.

Conclusion The delivery of culturally competent care is a

benefit to society. The need for culturally competent care is evident in the literature without a clear consensus as to best methods. With a growing, diverse population, health disparities will increase unless health care professionals educate students and clinicians to provide culturally competent care. A review of nursing education literature reveals various methods to integrating cultural competency in the curriculum. In order to meet the needs of the population, consensus is needed to ensure all nursing students are given the same cultural competency knowledge and application in practice.

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Author Note Deborah Byrne, RN, MSN, is Assistant

Professor at the School of Nursing and Health Sciences, La Salle University, Philadelphia, Pennsylvania, and a doctoral student in nursing at the College of Nursing, Villanova University, Villanova, Pennsylvania.

Correspondence concerning this article should be addressed to Deborah Byrne, School of Nursing and Health Sciences, La Salle University, 1900 West Olney Avenue, Philadelphia, PA 19141, USA. E-mail may be sent to byrned@lasalle.edu.

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