Discussion Question

BACKGROUND: The United States has become a diverse society, and healthcare professionals must view culture from a global perspective. The purpose of this study was to determine cultural competence levels of entering and exit- ing health science students within and across differing pro- fessional programs using the Global Worldview Cultural Competence Survey (GWCCS). PARTICIPANTS: 196 stu- dents participated in the study: 146 were entering students and 59 were exiting students. From the 146 entering stu- dents, 138 surveys were usable in the data analysis, and 58 of the 59 exiting were usable. PROCEDURE: Two separate cohorts of health professional students completed the GWCCS. Cohort 1 completed the GWCCS during the first 2 weeks of their academic program, and Cohort 2 completed the GWCCS in their final-year post-clinical experience. RESULTS: A significant difference in GWCCS total score was observed between entering and exiting students in health sciences, with the exiting students being more cul- turally competent. CONCLUSION: Although this study did not utilize a longitudinal study design, the findings demon- strate that the exiting cohort of health science students was more culturally competent than the entering cohort of health science students as determined by the GWCCS. However, neither cohort of students reached the level of proficiency. J Allied Health 2017; 46(2):88–93.

DIVERSITY in the United States has increased the need for all healthcare professionals to be not only culturally aware but also to demonstrate culturally competent patient-centered healthcare.1 Healthcare professionals often interact with patients from differing cultural back- grounds whose points of reference regarding the provi- sion of healthcare are different from their own.2 When

healthcare professionals lack an awareness, apprecia- tion, and sensitivity to potential cultural differences, patient-centered care practices may be compromised. The literature suggests that improved provider-client communications, improved compliance with medical regimens, greater patient satisfaction with care, and better health outcomes are all associated with providing culturally competent care.3 Occupational therapists, speech language pathologists, physician assistants, and athletic trainers are among the many healthcare profes- sionals who must meet the needs of culturally diverse patients and practice patient-centered care supported with an appreciation for cultural diversity.1

With the increasing need for culturally competent care, the burden has been placed on the healthcare edu- cational system. Educational programs must be imple- mented to develop cultural awareness and competence in health professions students prior to entering the workforce. Providing healthcare professional students early exposure to cultural factors has been suggested to be foundational to the promotion of patient-centered care practices.2 The factors include a sound knowledge base, attitudinal framework, and skill set to appreciate, accommodate, and negotiate cultural and individual variations in beliefs, values, lifestyles, education, and any other elements that comprise a person’s culture. To meet the need of providing healthcare profes-

sional students exposure to cultural factors, healthcare educators have begun to explore different curriculums as a means to expose students to the principles of cultur- ally competent care. Researchers have suggested that a more formal method of developing cultural competence within health professional curriculums is needed.4–8

They support International Community Immersion Experiences, Immersion Learning Experience in a Cul- turally Diverse Setting, Phased Approach, Clinical Affil- iation Journaling, and Clinical Practicums as strategies that can provide a framework for teaching and learning cultural competence. Although many healthcare cur- riculums have adapted one or more of these methods to support the development of culturally competent stu- dents, a dominant or consistent method for developing a student’s cultural competence levels has not been noted.4–8 Furthermore, while professional education accrediting bodies require that cultural competence be addressed in a program’s curriculum, these bodies do

88

RESEARCH ARTICLE

Assessing Health Professional Students’ Cultural Competence Using a Global Perspective Sophia Jones, PhD Genevieve Pinto-Zipp, PT, EdD

Dr. Jones is a graduate of the Department of Interprofessional Health Sciences & Health Administration, Seton Hall University, and Dr. Pinto Zipp is Professor, at the Dep. of Interprofessional Health Sciences and Health Administration, School of Health & Medical Sciences, Rutgers the State University of New Jersey, South Orange, NJ.

The authors report no funding or conflicts of interest for this study.

RA1657—Received Dec 15, 2015; accepted Feb 2, 2017.

Address correspondence to: Dr. Pinto-Zipp, Dep. of Interprofessional Health Sciences and Health Administration, School of Health and Medical Sciences, Rutgers the State University of New Jersey Alfieri Hall Rm. 33, 400 South Orange Avenue, South Orange, NJ 07079, USA. Tel 973-275-2457, fax 973-275-2171. [email protected]. [email protected].

© 2017 Association of Schools of Allied Health Professions, Wash., DC.

not include any specific guidelines for developing evi- denced-based culturally competent curriculums that enhance knowledge, beliefs, and attitudes towards cul- tural differences.4 Of specific concern, healthcare educa- tional programs have adjusted their curriculums to include cultural competence exposures in an attempt to comply with their accreditation standards, with minimal evidence supporting the strength of these exposures. In the literature, it is evident there are different

teaching methods used to promote cultural competency, and there are also different definitions of cultural com- petency. Although several different cultural compe- tence theories are prevalent in healthcare, the Purnell model is of particular interest as it views cultural com- petence from a global perspective.9 According to the Purnell model, culture is a pattern of learned behaviors that emerges from our interactions with family mem- bers, educational institutions, religious institutions, or social groups.10 These learned behaviors are then trans- formed into our personal beliefs, norms, values, and ways of life. These behaviors in turn influence our com- munications, expressions, and relationships. Cultural influences can be challenging for healthcare

professionals, causing them to look at their own beliefs, norms, values, and how they deliver care to others.4 As health professionals begin to understand how they relate to and interact with others in their work and/or profes- sional environment, they begin to develop a better aware- ness, understanding, and appreciation of themselves and others, which eventually leads to the development of “cul- tural competence” over time. Extending this idea to pro- fessional healthcare practice, if the appreciation of differ- ences among humans giving and receiving care is included in a professional healthcare program’s curriculum, it could be assumed that eventually healthcare practitioners will begin to develop “culturally competent care.” In order to deliver culturally competent healthcare, professionals must be knowledgeable of more than a list of cultural traits and ethnic groups; they must learn to demonstrate cul- tural competency in their delivery of healthcare and understand the meaning of cultural competence.4

The purpose of this study was to assess the levels of cultural competence in health professional students using the Global (Worldview) Cultural Competence Survey (GWCCS). The GWCCS survey is based on the Purnell model which addresses cultural competency from a global perspective.11 Using a descriptive, exploratory, and cross-sectional two-group research design, this study explored three research questions. The first question sought to understand the level of cultural competence of health professional students as measured by the GWCCS in the Health Science Professional Programs within the university upon entering. The second ques- tion sought to understand the level of cultural compe- tence of health professional students as measured by the GWCCS upon exiting. The final question sought to

explore if there was a difference between cultural compe- tence levels in entering (first-year) and exiting (final-year) health science students as measured by the GWCCS.

Methods

The target study population included health profes- sional students from the School of Health and Medical Sciences and the School of Nursing within Seton Hall University. Specifically, those students entering (first- year pre-clinical) the first 2 weeks of the Health Science Professional Program or School of Nursing and stu- dents exiting (final-year post-clinical) during the final 2 weeks of the Health Science Professional Program or School of Nursing were eligible to participate.

Procedures

IRB approval was received from Seton Hall University. The primary investigator (PI) sent an email to the chairs of each health science professions department includ- ing athletic training, physical therapy, occupational therapy, speech language pathology, and physician assistant and the nursing program, which outlined the project and requested their approval to work with their secretary and a research assistant to distribute survey packets to the departments’ students meeting the inclu- sion criteria. Approval was received from five of the six department chairs. The PI provided training to all research assistants in the procedural mechanics associ- ated with the survey distribution. Survey packets were given to the research assistant for

distribution to the two cohorts of students (entering and exiting students). The survey packet provided students with instructions on the intent of the study and the vol- untary nature of participation, anonymity and instruc- tion on drop off of the survey if they chose to participate. Additionally, the questionnaires (survey) contained explicit instructions regarding how the participants should fill out each subsection of the surveys. To ensure confidentiality, personal identifiers were not requested by the participants, such as name or address. All participants were informed that they must complete the survey using paper-and-pen/pencil format. All participants were informed that they had the option to accept or decline to participate in the study and that their voluntary comple- tion of the questionnaire was considered their consent, as well as verification that they were over 18 years of age. Survey packets were distributed to the two cohorts of

students during an on-campus class session. Cohort 1, the entering first-year pre-clinical students, completed the GWCCS during the first 2 weeks of their academic program. Cohort 2, the exiting final-year post-clinical students, completed the GWCCS in their final year after completion of their clinical experience during the last 2 weeks of their academic program. Students were

Journal of Allied Health, Summer 2017, Vol 46, No 2 89

instructed to place the completed surveys into the survey packet envelope and to drop the packet in a drop box located in the back of the room. The research assistant retrieved all packets and delivered them to the Department Secretary of Graduate Programs in Health Sciences who in turn provided them to the PI.

Instrumentation

The GWCCS survey was created in a pilot study by the PI and used here to assess levels of cultural competence among healthcare professional students.11 The survey was constructed from emergent themes in the literature review.1,4,10,12,13 The cultural competence levels were iden- tified based upon 12 global domains assessed by the survey: nutrition, high-risk behaviors, pregnancy, death rituals, spirituality, healthcare practices, healthcare practi- tioners, overview/heritage, communication, family roles and organization, workforce issues, and bicultural ecology. The GWCCS consists of a total of 58 questions

divided into three sections. Sections 1 and 2 are ordinal scale and based on the 12 constructs of the Purnell model. Section 3 is nominal scale and contains demo- graphic questions. Instructional information regarding how to complete the survey is also provided prior to each section of the survey. The 58 survey questions included Likert scale (strongly disagree, disagree, neu- tral, agree, and strongly agree) and yes-and-no responses. The questions in section 1 of the survey were based on

the four concentric outer rims in the Purnell model, including global society, community, family, and person. All four outer rims surround 12 pie-shaped wedges repre- senting concepts and domains that provide the concep- tual framework for the Purnell model.10 The domains and concepts are essential for assessing cultural attrib- utes of an individual, family, or group and include nutri- tion, high-risk behaviors, pregnancy, death rituals, spiri- tuality, health-care practices, health-care practitioners, overview/heritage, communication, family roles and organization, workforce issues, and biocultural ecology. Section 1 of the survey also contained questions based on these 12 pie-shaped wedges. To gather additional information regarding students’ perceptions, section 2 of the survey included questions on the role of cultural competence in healthcare science professional education and practice. Section 3 of the survey was designed to gather demographic information about the students which would provide additional information on their educational and cultural experiences.

Analysis of Data

After the questionnaires were completed, they were screened and compiled in an Excel file in aggregate form, and each response item was then coded for analysis. Data were analyzed using both descriptive and inferen-

tial statistics (SPSS ver. 22.0, IBM-SPSS, Armonk, NY). The Mann Whitney U-test was used to determine differ- ences in cultural competence levels, based on the GWCCS, of the two student cohorts. The Mann Whit- ney U-test was used to test for the difference between two independent groups when the dependent variable is either ordinal or continuous, but not normally distrib- uted. The Mann Whitney U-test is the non-parametric alternative to the t-test for independent samples and thus was used in this study to assess continuous data that was not normally distributed. Descriptive statistics were used to report demographic

data as means, standard deviation (SD), frequencies, and percentages in order to address question 1. The Kruskal Wallis test was used to determine the difference between cultural competence levels in entering (first- year) and exiting (final-year) health science students.

Results

Using G-Power analysis software, an a priori power analysis was conducted to determine the number of respondents required. The total sample size calculated from this a priori G-Power analysis was a minimum of 290 subjects,14 with an alpha of 0.05 and a power of (1– b) of 0.8. A total of 454 surveys were distributed to entering

and exiting students within the graduate programs. A total of 205 surveys were received, including 146 from entering students and 59 from exiting students. Of the 146 surveys from entering students, 138 were consid- ered valid surveys, as all survey questions were com- pleted. Of the 59 exiting students’ surveys, 58 were con- sidered valid. Surveys were considered not valid and thus were not used in data analysis if any of the survey questions were left unanswered. In total, 9 students did not complete the survey and thus were not considered in the response rate calculation.15

Given that only 196 surveys were usable, a post hoc G-Power analysis was calculated. With a total sample size of 196 and an alpha of 0.05, a power of 0.8 was achieved post hoc. The total response rate for usable surveys was 43.17%. Cultural competence levels were measured by the

GWCCS. Cronbach’s alpha was run for entering, exit- ing, and overall surveys to obtain the reliability of the GWCCS tool. Table 1 shows the overall Cronbach’s alpha–reliability analysis for 30 questions—Entering/ Exiting and Overall.

Demographics

Entering students who participated in the study from all five programs included 78 females (81.3%) and 18 males (18.8%). Exiting students included 42 females (72.4%) and 16 males (27.6%). Females made up 77.9% of the

90 JONES, PINTO-ZIPP, Assessing Students’ Cultural Competence

total students in all five programs, and males made up 22.1%. Table 2 summarizes the demographics of the entering and exiting students. One hundred forty-four students provided personal

information on their international travel and educa- tional experience (Table 3). Sixty-four (70.3%) entering students stated they had no educational experience internationally, while 27 (29.7%) had educational expe- rience internationally. The majority of exiting students (34, 64.2%) stated they had no educational experience internationally, vs 19 (35.8%) exiting students who had educational experience internationally. Table 4 provides the scores for descriptive statistics

and analysis for entering vs exiting students and sup- ports that exiting students were more culturally compe- tent then entering students. The Mann-Whitney U-test determined a significant difference between cultural competence levels in entering and exiting health science students as measured by the GWCCS. Specifically, there was a significant shift up in mean rank (92.59)

from the entering students’ GWCCS category to the exiting students’ GWCCS category (112.57). In order to assess if the difference between cultural

competence levels in entering and exiting students was based upon their Health Science Professional Program within the university as measured by the GWCCS, the mean score and Kruskal Wallis statistical tests were employed. The mean score for the entering and exiting students by program showed that occupational therapists had the highest mean score of 120.94 (entering) and 123.99 (exiting), while the second highest score was for athletic training with a score of 120.09 (entering) and 120.33 (exiting). For exiting students, the mean scores by program showed occupational therapists again had the highest score of 120.94, followed by physician assistants with a score of 119.71. The analysis of students’ GWCCS suggests that there

was a homogeneous distribution of GWCCS scores within the entering and exiting students regardless of pro- gram. Therefore, if an improvement occurred in a stu- dent’s GWCCS score (cultural incompetence 38–74, cul- tural awareness 75–112, cultural competence 113–140, and cultural proficient 141–150), it may be as a result not of their program but of outside influences including per- sonal travel history, family, religion, or community involvement not measured within this study. Finally, the Kruskal-Wallis was used to assess the mean

rank of the five independent health professional pro- grams and showed that GWCCS scores were similar for entering and exiting students across programs (Figure 1).

Journal of Allied Health, Summer 2017, Vol 46, No 2 91

TABLE 1. Overall Cronbach’s Alpha Reliability Analysis

Valid Cases/ No. of Surveys Received Cronbach’s a Items

Entering 138/146 0.818 30 Exiting 58/59 0.872 30 Overall 196/205 0.841 30

TABLE 2. Demographic Characteristics for Entering and Exiting Students

Entering Exiting Total

Gender Female 78 (81.3%) 42 72.4% 120 77.9% Male 18 (18.8%) 16 27.6% 34 22.1% Total 96 100.0% 58 100.0% 154 100.0%

Age (yrs) 21 and less 49 50.5% 0 0.0% 49 31.6% 22–34 46 47.4% 51 87.9% 97 62.6% 35–44 1 1.0% 4 6.90% 5 3.2% 45–54 1 1.0% 2 3.4% 3 1.9% 55–64 0 0.0% 1 1.7% 1 0.6% Total 97 100.0% 58 100.0% 155 100.0%

Ethnicity Caucasian, non-Hispanic 69 71.1% 42 72.4% 111 71.6% African-American/black 9 9.3% 3 5.2% 12 7.7% Asian-Pacific islander 5 5.2% 2 3.4% 7 4.5% Hispanic 2 2.1% 4 6.9% 6 3.9% Other 12 12.4% 7 12.1% 19 12.3% Total 97 100.0% 58 100.0% 155 100.0%

Professional program Occupational therapy 18 18.6% 3 5.2% 21 13.5% Speech language pathology 10 10.3% 0 0.0% 10 6.5% Athletic training 22 22.7% 21 36.2% 43 27.7% Physician assistant 28 28.9% 33 56.9% 61 39.4% Nursing 19 19.6% 1 1.7% 20 12.9% Total 97 100.0% 58 100.0% 155 100.0%

Exploratory Statement Confirmation

Using a Likert scale (strongly disagree, disagree, neutral, agree, strongly agree), students were asked to respond to several statements in order to garner additional insight into their perceptions towards the role of cultural com- petence in health science professional education. When asked if cultural values should be a focus of profes- sional health science curriculums, 61.6% of the entering students (strongly agree 13.3%, agree 48.3%) and 57.6% of the exiting students (strongly agree 6.8%, agree 50.8%) responded positively. When asked if health science stu- dents should practice in a culturally competent manner, 96.7 % of the entering students (strongly agree 52.8%, agree 38.9%) and 96.6% of the exiting students (strongly agree 62.7%, agree 33.9%) responded positively. In sum- mary, student perceptions support that health profes- sional programs should infuse cultural values in their curriculums in order to promote the development of culturally competent healthcare professionals.

Discussion

The purpose of the study was to assess cultural compe- tence in health professional students (speech language pathologist, physician assistant, occupational thera- pist, physical therapist, athletic trainer, and nursing students) using the Global (Worldview) Cultural Com- petence Survey (GWCCS) which is based on the Pur- nell model.10 Regardless of professional program, a sig- nificant difference in GWCCS scores was observed between entering and exiting students in health sci- ences, with the exiting students being slightly more culturally competent. Surprisingly, entering students were considered culturally competent with scores ranging from 90–140 on the GWCCS. Exiting students were also considered culturally competent, with scores ranging from 99–150 on the GWCCS. While both cohorts of students in this study presented to be cul- turally competent, neither group was cultural profi- cient based on our scale. Therefore, the authors sug- gest that cultural competence must be assessed from a global perspective and offer the GWCCS as a possible tool to address this need. The United States continues to be an increasingly

diverse population, and it is critically important that healthcare professionals are educated specifically to address issues of culture in an effective manner. Cul- tural competence must be infused within curriculums in order to emphasize the importance of relationships between healthcare professionals and their patients. Curriculums must provide the healthcare student with the knowledge, skill, and attitude to work with a person from a different culture without stereotyping while pro- viding enough cultural competence to be aware of nor- mative cultural values. As with all studies, there were several notable limita-

tions in our study. The limitations included a small sample size that did not enable us to reach our a priori estimated sample size, possible selection bias, generaliz- ability, self-reported data, convenience sample, and a low return rate. As with any study, sample size is dependent on subjects’ willingness to participate. Also, while the researchers attempted to study all health sci- ence professional programs within the school, the Phys- ical Therapy Program administrators did not provide

92 JONES, PINTO-ZIPP, Assessing Students’ Cultural Competence

TABLE 3. International Travel and International Education Experiences of Students

Entering Exiting Total

International travel Yes 70 76.9% 42 79.2% 112 77.8% No 21 23.1% 11 20.8% 32 22.2% Total 91 100.0% 53 100.0% 144 100.0%

International education Yes 27 29.7% 19 35.8% 46 31.9% No 64 70.3% 34 64.2% 98 68.1% Total 91 100.0% 53 100.0% 144 100.0%

FIGURE 1. Independent-samples Kruskal-Wallis test between programs for both entering and exiting students. Test statis- tic is adjusted for ties. Multiple comparisons were not per- formed because the overall test did not show significant dif- ferences across samples.

consent to distribute the survey to their students, thereby further limiting the study sample size. The results of this study could be biased as participants vol- unteered to complete the survey and may have already had an interest in cultural competence. Also, the study results can only be generalizable to the health profes- sional students within this university. Data were also self-reported, and thus it was not possible to verify the accuracy of self-reported data. Students completing the survey also may have answered the way they thought the PI wanted them to answer. Some students may have embellished the truth and exaggerated or downplayed their real feelings toward cultural competence. The data were collected from a convenience sample from gradu- ate students in health professional programs within one university and not across multiple universities. Finally, since the authors of this study did not compare the par- ticipants’ outcome on the GWCCS to a gold standard, one might be concerned regarding the tools validity.

Conclusion

As our society becomes more diverse and global, culture can no longer be associated with ethnicity, race, or a particular cultural group. Healthcare institutions must continue to emphasize the importance of cultural com- petence and remain in position to have a positive

impact on cultural competence.16 Health professions educational programs that are preparing the future healthcare workforce must evaluate their educational experiences and practices and ensure that they are pro- viding opportunities for students to develop the neces- sary cultural-competence skills to meet the needs of today’s patients. The GWCCS is one tool that can be used to assess student’s cultural competence from a global perspective.

References

1. Velde B, Wittman P, Bamberg R. Cultural competence of faculty and students in a school of allied health. J Allied Health. 2003; 32(3):189–195.

2. Schim S, Doorenbos A, Borse N. Cultural competence among Ontario and Michigan healthcare providers. J Nurs Scholarsh. 2005; 37 (4):354–360.

3. Fortier JP, Bishop D. Setting the agenda for research on cultural competence in health care: final report. Brach C, ed. Rockville, MD: U.S. Department of Health and Human Services Office of Minority Health, Agency for Healthcare Research and Quality; Summer 2004.

4. Dupre A, Goodgold S. Development of physical therapy student cultural competency through international community service. J Cult Divers. 2007; 14(3):126–134.

5. Black J, Purnell L. Cultural competence for the physical therapy professional. J Phys Ther Educ. 2002; 16(1):3–10.

6. Shore S. A curricular model of cross-cultural sensitivity. J Phys Ther Educ. 2007; 21(2):53–59.

7. Wong C, Blissett S. Assessing performance in the area of cultural competence: an analysis of reflective writing. J Phys Ther Educ. 2007; 21(1):40–47.

8. Smith-Campbell B. Health professional students’ cultural com- petence and attitudes toward the poor: the influence of a clinical practicum supported by the National Health Service Corps. J Allied Health. 2005; 34(1):56–62.

9. Purnell L. Developing cultural competences in nursing: evi- dence-based and best practice. OJCCNH, 2008–2011. Available at: http://www.ojccnh.org/project/index.shtml. Accessed Jan 5, 2014.

10. Purnell L. The Purnell model for cultural competence. J Multicult Nurs Health. 2005; 11(2):7–15.

11. Jones S. Assessing cultural competence in health professional students [dissertation]. Seton Hall University, 2014, paper 2079.

12. Campinha-Bacote J. A model and instrument for addressing cul- tural competence in health care. J Nurs Educ. 1999; 38:203–207.

13. Capell J, Vennstra G, Dean E. Cultural competence in health- care: critical analysis of the construct, its assessment and impli- cations. J Theory Construct Test. 2007; 11(1).

14. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Meth. 2007; 39:175–191.

15. Halbesleben J, Whitman M. Evaluating survey quality in health services research: a decision framework for assessing nonre- sponse bias. Health Serv Res. 2013; 48(3):913–930.

16. Long T. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012; 19(3):102–108.

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TABLE 4. GWCCS Score by Program for Entering and Exiting Students

Mean SD N

Entering Occupational therapy 120.94 11.924 18 Speech language pathology 118.1 8.306 10 Athletic training 120.09 8.332 22 Physician assistant 119.71 7.393 28 Nursing 117.8 10.299 20 Total 119.47 9.144 98

Exiting Occupational therapy 123.33 6.658 3 Speech language pathology – – 0 Athletic training 120.33 10.901 21 Physician assistant 123.58 10.946 33 Nursing 115.00 – 1 Total 122.24 10.671 58

Total Occupational therapy 121.29 11.226 21 Speech language pathology 118.1 8.306 10 Athletic training 120.21 9.556 43 Physician assistant 121.8 9.605 61 Nursing 117.67 10.057 21 Total 120.5 9.798 156

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