Nursing

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Keywords cultural competency, knowledge, skills, attitudes, diversity education

Effects of Cultural Competency Education on Radiography Students Doris Abrishami, EdD, R.T.(R)

A s the United States becomes more diverse and global interactions increase, health care professionals must be equipped with the tools to interact with diverse populations.

Differences in health status, health care access, and quality of health care practices contribute to health disparities.1 Factors that contribute to health disparities include a health care professional’s lack of cultural awareness and lack of knowledge about multicultural

health care environments, as well as bias, stereotyping, and prejudice by health care professionals.2

Cultural competency and diversity education for health care professionals can address the changing patient population. This would require medical- imaging educators to develop content and curriculum in the areas of cultural competency, diversity, and sensitivity. A comprehensive health care education that can instill cultural awareness, sensitivity, and empathy

Purpose To determine if radiography students’ classroom knowledge transformed into skills and positive attitudes about cultural competency, and to determine whether students were sensitive, empathetic, and culturally competent toward their patients while conducting radiographic procedures.

Methods The first stage of the research focused on giving the Jefferson Scale of Empathy (JSE) survey to a group of 24 first- year, 19 second-year, and 27 third-year radiography students. The first-year students were given the survey once before the start of their program in the fall and once after the fall semester. The second- and third-year students were given the survey once during the fall semester. The main method of this study was a qualitative approach. Nine students then were interviewed, and 4 faculty members participated in a focus group.

Results Two students indicated the cultural competency education adequately provided them with pertinent information about this subject. Most students indicated that there should be more education in the form of discussions and case studies or a new course specifically dedicated to cultural competency. The JSE survey average score for first-year students before the start of their program was 108.7 points on a 120-point scale, and the average score for first-year students after the first semester was 113.4 points. The average score for second-year students was 113.5 points, and the third-year students’ average JSE score was 110.6 points.

Discussion The results from student interviews and faculty focus groups indicated that students learned the importance of cultural competency. However, students and faculty recognized the need for more lectures, discussions, and courses specific to cultural competency in the curriculum. Students and faculty members acknowledged the existence of a diverse patient population and the crucial need to be sensitive toward different cultures, beliefs, and value systems in society. Students in this program were aware of the importance of cultural competency but also thought they needed more reminders throughout the program to stay current on this concept.

Conclusion Education programs might be able to provide the knowledge and information on cultural competency through lectures, courses, discussions, and hands-on practices, but students’ backgrounds, life experiences, and their willingness to learn might ultimately determine the efficacy of their cultural competency.

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individual’s interaction with groups that have a different culture, background, and ethnicity from them. Empathy in patient-care situations is defined by Hojat et al as “a cognitive attribute that involves an ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding.”4

One study explored undergraduate health care stu- dents’ perceptions of their cultural competence.5 This qualitative study placed students through a classroom simulation exercise to encounter different cultures. At the conclusion, students learned how their attitudes can affect their perceptions about cultural differences in their patients. Students also were able to feel discom- fort when interacting with a different cultural group.5 If health care professionals can learn to be empathetic and communicate that empathy to patients who are different from them, they can provide unbiased care to all patients. Unbiased and culturally competent health care professionals can provide meaningful and empa- thetic care to patients, especially those who suffer from health disparities.

Another study explored the effects of three 90-minute speaker series on 118 undergraduate students in athletic training and nutrition education programs and concluded that the speaker series changed the students’ attitudes considerably related to health care quality and cultural sensitivity.6 Similarly, a 3-year study conducted at the University of Utah examined the effect of cultural competency and mutual respect education programs on 2124 students studying medicine, pharmacy, nursing, or physical therapy.7 The results demonstrated that students who were exposed to cultural competency and diversity awareness education substantially progressed toward cultural competence but were not yet culturally proficient. This study concluded that to reduce health care disparities and medical errors, more research in academic and clinical settings needs to be conducted to examine culturally competent practices among health care professionals.7

The results of these studies demonstrate that education in cultural competency and diversity is beneficial to students; however, more research is needed on the effect of cultural competency education on health care professionals’ attitudes and practices toward patients. In addition, the quality of these

can not only change the health care environment to reduce racial biases and embrace the diversity of the United States, but it also can improve health care access and quality for racial and ethnic minorities.

Cultural competency can be taught by a variety of methods in classrooms. However, until medical imaging students can apply their knowledge into clinical practice when interacting with patients, there is no guarantee that those pedagogical approaches will be successful. The purpose of this study is to discover if students’ classroom knowledge from cultural compe- tence education transformed into skills and attitudes in the clinic; it specifically analyzed if students are sensi- tive, empathetic, and culturally competent toward their patients while conducting radiographic procedures. The guiding research questions were:

� What effect does the radiography curriculum have on students’ perspectives about cultural competency?

� What pedagogical approaches influence cultural competency education in radiography programs?

� What clinical practices and skills affect cultural competency education in radiography programs?

Literature Review Health care students must be trained to work with

diverse groups of patients and collaborate with a diverse team of health care professionals. Other professions also emphasize empathy, diversity education, and multicultural awareness. For example, in counseling psychology, Wang et al first defined the term ethnocultural empathy as an ability and personal trait comprising intellectual empathy, empathic emotions, and communication of the 2, which can be learned.3 They developed a scale to quantitatively measure the construct of ethnocultural empathy and used it on 323 psychology students at 3 midwestern universities and colleges. The researchers discovered that African American, Asian American, Pacific Islander, or biracial participants had substantially higher levels of ethnocultural empathy than did White participants. In addition, women were more ethnoculturally empathetic than were men in empathetic feeling expression and awareness.3 A conclusion of this study was that a greater understanding and more empathy can result from an

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to physicians and students in medical school or other allied health professions.10 This scale recently has been modified for health care professionals and students in programs such as physical therapy, nursing, diagnostic imaging, and other health care professions.

During the interview, students were asked questions regarding:

� a procedure that made them more empathetic toward a patient with a different ethnicity

� an assignment, a lecture, or other information related to cultural competency that they remember from the program

� effect of cultural competency education on their practices toward patients

� most difficult aspect of the program � preference for online vs face-to-face classes � suggested changes in the curriculum concerning

cultural competency education � their view on faculty and clinical instructors’

cultural competence � whether cultural competency education provided

in the program prepared them for interaction with patients

In the focus group, clinical instructors openly discussed their answers to questions regarding:

� preference for online vs face-to-face classes � effectiveness of their teaching methods

regarding cultural competency education (ie, the students gained competency in their cultural competency skills)

� student behavior and skills that created a positive outcome for the patient

In the students’ radiography program, cultural competency topics are taught primarily in the

education programs needs to be determined by conducting curricular evaluations and assessments. More research needs to be conducted in health care professions to evaluate the content and methods of delivery of cultural competency education. Educators need to evaluate their own personal experiences and attitudes toward diversity and cultural competency. They also need to consider what pedagogical methods are most effective in a classroom and how to integrate cultural competency as part of classroom knowledge and practice of patient care.

Methods This study was explored from a social constructivism

point of view, which required the researcher to focus on and be actively involved with the reality of the participant’s environment.8 The conceptual framework of this study is a cultural competency model originally proposed by Cross et al, which includes concepts of knowledge, skills, and attitudes (see Figure 1).9 This model often is used by health care professionals in educational settings; it directs educators on how to provide an appropriate curriculum, model the skills and practices, and recognize the attitudes of their students to help them reach the highest levels of cultural competence.9

Study Design To measure students’ empathy and sensitivity

toward patients, the health professions students version of the Jefferson Scale of Empathy (JSE) was used. The JSE is a self-reported, 20-item scale. Each item is answered on a 7-point Likert scale (1 5 strongly disagree to 7 5 strongly agree). The scale’s total scores range from 20 to 140; higher scores indicate that the individual self-reports more empathy. The JSE was first developed to measure empathy among medical students and physicians.4 The results of 2 large-scale studies conducted in the United States and Italy indicated that physicians who scored higher on their JSE survey had patients who were in better control of their disease compared with patients of physicians with lower JSE Scores. Patient outcomes, clinical competence, and personality measures have been validated by many studies that were conducted by giving the JSE survey

Culturally competent professional

Knowledge (Didactic, Cognitive)

Skills (Psychomotor, Applied)

Attitude (A�ective, Empathy)

Figure 1. Concepts of the Cultural Competence Theoretical Framework. Figure courtesy of the author.

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identified as Latino or Latina, Asian, or South Asian, and 1 student identified as White.

In addition, 4 randomly chosen clinical faculty members participated in a focus group that explored their knowledge and perceptions of the program’s curriculum on cultural competency and their individual teaching methods. The focus group included 3 women and 1 man. One faculty member identified as Latino, 1 identified as African American, and the remaining 2 identified as White. Each instructor had been practicing in the radiography profession for more than 10 years. One of the clinical instructors had been teaching for more than 20 years, and another instructor had been teaching for a little more than a year.

Data Analyses Quantitative data from the survey questions

were analyzed using spreadsheet formulas to calculate average JSE score. Qualitative data from the student interviews and faculty focus group were transcribed and thematically analyzed. Terms and patterns in the responses were identified based on the themes of knowledge, skills, and attitudes and categorized accordingly.

Results The results of this qualitative study are separated

into the 3 concepts knowledge, skills, and attitudes from the cultural competency model by Cross et al.9

classroom environment, which is considered knowledge in the cultural competency model. This study introduced more in-depth discussions of cultural competency and diversity issues in the form of lectures, class assignments, diversity lunches, and group discussions (see Table). These additions were applied program wide, not selectively for participants in the study. In addition, a skill-based or psychomotor method of teaching was used by faculty to teach students how to apply the cognitive knowledge of cultural competency in clinical environments. The students’ understanding of cultural competency, respect for cultural differences and diversity, and empathy toward their patients are examples of attitude.

Participants and Data Collection This study was approved by the California State

University, Northridge Institutional Review Board (1617-200). Quantitative data were collected by administering the JSE survey to first-, second-, and third-year radiography students attending California State University, Northridge. In August 2017, a survey was sent to 70 students; of these, 70 students participated in the study, for a response rate of 100%. Twenty-four first-year students completed the JSE survey before the start of the first fall semester and at the end of the first fall semester. The first-year participants had not had any lessons or discussions in cultural competency. The JSE survey also was administered to 19 second-year and 27 third-year students once during the fall semester to examine their attitudes and perceptions of cultural competency.

Qualitative data were collected through interviews conducted during the fall semester. An email request for interview was sent to the 70 survey participants; 12 students responded, and 9 were selected to interview using a randomized sampling method. Three radiography students from each cohort (first-, second-, and third-year students) were randomly selected for interviews. Each cohort in this study was at a different point in the radiography program but followed a standardized course schedule. Three women and 6 men aged 21 to 25 years were interviewed. Eight students

Table

Program Content Per Cohort From the Cultural Competency Theoretical Framework Concept Program content per cohort

Knowledge First-year students: hospital orientations, patient-care modules Second-year students: professional development course

Skills First-year students: 500 clinical hours Second-year students: 1000 clinical hours Third-year students: .2000 clinical hours

Attitudes First-year students: diversity lunch Second-year students: diversity lunch

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that people are not the same. They are not going to view things the same way you do. I think working in the hospital you need to…It is important to make everyone feel like you understand them, and you are there for them, even if you do not believe in the same morals and values.

A second-year student, who identifies his ethnicity as Chinese American, mentioned that students should be provided with 1 or 2 dedicated lectures specific to cultural competency. He also thought that the hospital orientation modules were extreme in length and number and that most of the modules were making assumptions about certain groups of people by placing them in groups or labeling them. His point of view might be because of his experiences while spending most of his teenage and young adult life in other countries and living among cultures that were different from his own. For example, he said:

People get offended if you treat them a certain way or stereotype them. They don’t want to feel stereotyped, especially in this country. In any foreign country, no one wants to feel stereotyped. Oftentimes that is the reason why they want to adapt to a way of life there and not seem different from others.

This point of view supports the conclusions from previous research conducted by Wang et al that suggested more empathy can result from an individual’s interaction with groups from a different culture, background, and ethnicity.3

All second-year participants remembered and seemed to have enjoyed 1 lecture on cultural competency that was given by an instructor in the program at a professional seminar. However, they could not remember other formal didactic education provided to them during the program. Most second- and third-year students had forgotten about the initial student orientation presentations and hospital modules related to cultural competency, perhaps because they were initially overwhelmed with didactic classes on campus and clinical internships. The third-year student participants, however, remembered the discussions about cultural competency as a part of the professional development course provided in the previous semester,

Knowledge Most students expressed that they learned more

when attending face-to-face classes. For example, a second-year student said, “I like the face-to-face interaction. I like to be able to raise my hand and ask a question if I don’t understand.” A third-year student expressed that she prefers face-to-face classes saying:

I like the face-to-face classes because with online classes, I don’t focus as much. I don’t feel like I concentrate as much online even though I can be at home. I don’t know, there is something about being face-to-face that I kind of take it in more.

However, another student indicated that it would be more convenient for him to take online classes to save time driving to campus because he had a 2-hour commute to the university. He felt that if the instructor could clearly convey the information in an online class, he would welcome it. When the clinical instructors in the focus group were asked if they preferred online or face-to-face classes, they indicated that they prefer to teach face-to-face in combination with hands-on practice in clinical settings so that they can demonstrate how to interact with patients of different cultures to students.

Two students indicated the cultural competency education adequately provided them with pertinent information and prepared them to meet the challenges in clinical settings. However, most students indicated that there should be more education in the form of discussions and case studies or that a new course should be added to the curriculum specifically dedicated to cultural competency. One first-year student indicated that he did not have enough experience regarding cultural competency to determine if he needs more education. Whereas, a third-year student thought the education in the radiography program provided her with enough information about cultural competency, and she felt ready to enter the workforce and interact competently with patients. When this student was asked how she determined she received an adequate education in cultural competency, she replied:

I don’t know. I just think, I just know maybe how I was raised, my background maybe. I just know

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One first-year student expressed how important it was to be able to communicate with Spanish-speaking patients and said, “Maybe you can have a class and teach us how to speak Spanish.”

One clinical instructor suggested that students should complete a project recording video of diverse patients discussing their good or bad experiences. The videos could be shown in all classes to point out how patients can be affected by their health care providers’ cultural competency knowledge and skill levels. Another clinical instructor suggested creating a new course dedicated to cultural competency or replacing some of the other course content with cultural competency subject material.

Skills All instructors thought it would be difficult

to evaluate the effectiveness of teaching cultural competency. However, 1 instructor said:

You compare their [skills] when you get a first-year [student] and when you get a second-year student and you see a big difference. I don’t know if it is something I said or something we all said, but there is a difference, big change. As a second- or third-year student, they are more sensitive and more competent.

In addition, another clinical instructor expressed her concern that some students might be culturally competent or aware when they enter the program. In this case, it would be difficult to determine whether the program’s education had any effect on the students’ skills and competency. Other instructors agreed that students need to be evaluated objectively and that might be difficult to do if students know they are being watched by the instructors. However, every instructor agreed that most students show growth and competency in their skills as they progress through the second and third year in the program.

When asked what student behavior or skills created a positive outcome for the patient, 1 instructor indicated, “When I see students being able to connect with the patient and communicate effectively, I think that would make them a better technologist.” Another instructor expressed that she recently witnessed a timid student who was quiet in the past using his limited Spanish

primarily because they had recently completed the course.

All 9 students indicated that time management was the most difficult issue to tackle in the program. One third-year student stated, “The most challenging aspect of the program is probably time management while you are going to clinic. Being able to squeeze in the time to study while you go to clinic.” A first-year student who considers herself to be Filipino American said:

So far, the most challenging would be time, definitely! When you get home, you are tired from the clinic, and you still have to do homework and all of that. I think the most difficult part is just adjusting to everything.

During the focus group, the clinical instructors also indicated that the first year of the program is the most challenging because students are not used to taking 12 to 14 academic units in addition to performing clinical internships. The clinical instructors indicated that they emphasize the importance of time management to students before the start of the program. Though the first year of the program might be overwhelming to most students, the content or amount of cultural competency education might also be a factor that should be considered. Cultural competency education could be infused into every aspect of the radiography program and included in every course.

Most students and instructors indicated there should be more education in cultural competency and sensitivity in the forms of courses, lectures, and case studies throughout the program. Some individuals suggested inviting patients from different backgrounds to speak in classes and share their experiences with students. Students also suggested that more face-to-face lectures and discussions should be given to students in the first and second years of the program. Some students believed taking a professional development for radiographers course during the last semester of the second year was too late in the program and more emphasis on cultural competency education should be made at the beginning of the program. Also, some first- year students suggested adding a course dedicated to cultural competency, but they were not certain which semester would be most appropriate to offer this course.

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empathetic after they started the program. The second- year students had almost the same average score as the first-year students’ second survey, 113.4 and 113.5 respectively. The students in the third year had the lowest average empathy score (110.6) compared with the other 2 cohorts in the program.

During the focus group, clinical instructors expressed that the third-year students showed more empathy and sensitivity skills toward patients. However, according to the JSE survey results, the third-year students’ empathy average was lower than second- or first-year students’ scores. This finding supports a previous study by Vander Hoek which indicated that senior students in a radiography program had the lowest survey scores about understanding people from different backgrounds.12

Further analysis of this topic highlights an opinion that was stated by the clinical instructors. During the focus group, 1 clinical instructor raised a concern about whether students are truly empathetic to the patients or are merely pretending to show empathy in front of their preceptors and clinical instructors. When anonymous surveys were conducted, students were able to express their attitudes more freely. In addition, because of the time limitations of this study, the third-year students were not able to take the pre-JSE survey, which means that their empathy scale was not measured before

words to communicate with a patient. This student’s method of communication made the patient happy and more cooperative. Being responsive to diverse cultural beliefs and using patients’ preferred language is part of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care that were published by the U.S. Department of Health and Human Services Office of Minority Health.11

Most students indicated their education made a substantial difference in their practical skills at clinical sites. For example, a third-year student said, “I think [education] helps you have more empathy toward patients, and it makes you more aware.” She continued with an example and said:

I was doing a hand and wrist x-ray on a patient who had bracelets on, and I asked him to take the bracelets off, but the patient said that they are religious bracelets, and he cannot take them off. After listening to him, I respected his religious beliefs and did not insist on him taking them off.

This example shows the effect of cultural competency education on this student’s communication skills. She realized how important religious beliefs are to some patients and that she should not force patients to do something that is against their culture, background, and values. In fact, forcing patients to remove their religious symbols, hair coverings, or any other symbol of their culture are considered cultural destructiveness according to the model of cultural competence continuum.9 Another third-year student noticed being more cautious about his words, gestures, and facial expressions in front of patients after completing cultural competency education. He had learned to be aware of his verbal and nonverbal communication methods through many years of working in the customer service industry. This is another example showing that many students might use their life experiences as the foundation on which to build their patient-care skills.

Attitudes The JSE average score for students increased

from 108.7 before they entered the program in the fall to 113.4 after their first semester (see Figure 2), indicating that the first-year students became more

Preprogram First year Second year Third year

Sc or

es

114

113

112

111

110

109

108

107

106

0

Figure 2. Average scores on the health professions students version of the Jefferson Scale of Empathy per cohort. Figure courtesy of the author.

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patient, who seemed to have a nondocumented status, told her that he was afraid of being deported from the United States and subsequently not being able to obtain the medication needed for him to continue maintaining his health after the procedure. She said:

The patient left without getting the procedure done, and I never saw him after. That made me sad and made me think of my own dad. If my dad was in the same situation, I would be like, I don’t care, do it, and even if you get deported, we will get the money to buy the medication somehow.

This finding correlates with Wang et al’s finding demonstrating higher levels of ethnocultural empathy in the African American, Asian American, Pacific Islander, and biracial participants in their study.3 In addition, 2 first-year students provided examples to support Hojat and his colleagues’ description of empathy as a cognitive attribute in an individual who understands the patient’s inner experiences and is able to communicate this understanding.4 One referred to a recent death in his family and his response to an older female patient of Middle Eastern descent who was in much pain and expressed her wish to die. Another first-year student referred to interacting with a 3-year-old patient with cognitive disabilities who was

they entered the program. Therefore, their empathy scale numbers might have been lower before entering the program.

The last question on the JSE survey stated, “I believe that empathy is an important factor in patient’s treat- ment.” Most students agreed or strongly agreed with this statement, indicating that most students believe being empathetic toward patients is an important part of their responsibilities as health care professionals (see Figure 3).

When comparing the average student participant scores of men with women, the second- and third-year student surveys show that female students had higher empathy scores; whereas, in the first-year student surveys, male students had a higher empathy score. On average, male students had a higher empathy score compared with female students for all 3 cohorts. This is inconsistent with the research conducted by Wang et al and Hojat et al, which indicated female participants showed a higher level of empathy than did male participants.3,4

Most student participants stated they relied on their life experiences, family values, and personal beliefs to make them culturally aware and sensitive toward patients. For example, a second-year student indicated that he was raised well by his parents; they told him to treat everyone the same regardless of color or ethnicity. A third-year Latina student believes she is more aware of different cultures and backgrounds compared with many of her classmates because she is a minority student. Another student with a chronic illness stated she has had numerous interactions with health care professionals who were culturally insensitive or culturally incompetent, so she was determined to treat patients with dignity and compassion. In addition, a few clinical instructors stated that their life experiences have been important in making them sensitive toward their patients

When students were asked if there was 1 procedure that made them more empathetic toward a patient with a different ethnicity, most students were able to provide a specific example that affected them deeply or reminded them of their family members and loved ones. A third-year Latina student remembered a patient in the cardiac catheterization laboratory who seemed to refuse further treatment after the cardiologist suggested that he needed an invasive procedure on his heart. The

First year Second year Third year Pe

rc en

ta ge

o f s

tu de

nt s

(% )

89

88

87

86

85

84

83

82

81

80

0

Figure 3. Percentage of students who believe being empathetic toward patients is an important part of their responsibilities as health care pro- fessionals. Figure courtesy of the author.

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The student interviews and faculty focus group discussions indicate that the students in this study learned the importance of cultural competency. However, students and faculty recognized the need for more lectures, discussions, and courses specific to cultural competency in the curriculum. Students and faculty members acknowledged that a diverse patient population exists and that there is a crucial need to be sensitive toward different cultures, beliefs, and value systems in society. Students in this program were already aware of the importance of cultural competency but also thought they needed more reminders throughout the program to keep current.

Throughout this study, the concepts of knowledge, skills, and attitudes were examined from different perspectives. As Rose and Cross et al suggested, these 3 concepts are the foundations of cultural competency education.1,9 Health care professionals are influenced by their life experiences and the knowledge and infor- mation provided to them in education programs. Individuals use their personal experiences and attitudes as well as their pedagogical knowledge throughout their professional careers. Educational programs can provide knowledge and information through lectures, courses, discussions, and hands-on practice, but the students’ background, life experiences, and willingness to learn might ultimately determine the efficacy of their cultural competency education. The results of this study suggest that student attitudes and personal values might have a more important part in their cultural competency than does their knowledge and skills. This finding is similar to Purnell’s model that describes the influence of an individual’s family, community, and personal values in shaping their interaction with diverse populations.13

Most students in this study continually referred to their life experiences, the way they were raised by their family, and their cultures as the main reasons for becoming culturally competent. Therefore, although there were references throughout the participants’ responses regarding the effectiveness of the radiogra- phy program, personal influences and life experiences appear to play a more important role in developing their cultural competence. Ultimately, many students thought they still needed to gain more knowledge and skills, but some thought their background and life

accompanied by his mother. The patient was moving so much that after a few attempts at imaging, the technologist and student were unable to complete the examination. She said, “We tried different ways, but the patient was moving around, sitting down, going back up, and at the same time he was yelling, so it was very hard to complete the exam.” She stated that she empathized with the parent’s frustration and felt powerless; she thought about what more could have been done to serve the patient and his parent.

When students were asked if their faculty and clini- cal instructors were culturally competent, all students expressed that although their clinical instructors seem to be culturally competent and sensitive, the technolo- gists and preceptors working at various clinical sites did not always demonstrate culturally competent behavior toward patients. One student said, “I have heard some comments from the techs that I would never say myself. People are mean; we live in a cruel world. I have heard things that should not have been said or done.” A sec- ond-year Latino student said:

There are also those few who never change and say racist things, and that is kind of annoying, which [in] one way or another you kind of forget about it. But mass majority of people in my clinical experience so far have been appreciative and tolerant and open-minded for the most part.

Another student expressed her concern about a time when her patient did not want to take her necklace off during a procedure because of religious reasons, and the technologist insisted on her taking the jewelry off. These interview remarks point out 2 important issues. First, having culturally competent role models is an important part of student learning, and second, medical-imaging professionals need to be educated or re-educated regarding diversity and the importance of respecting patients regardless of their background, appearance, age, or other characteristics.

Discussion This study explored whether cultural competency

education in a radiography program afforded students sufficient preparation and proper tools to provide sensitive and culturally competent care for patients.

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values, languages, and traditions should be taught in the form of discussions and scenarios to create awareness in students. For example, because of the large community of Latino and Latina patients in the Southern California area, learning a few radiology-related phrases in Spanish would be beneficial to students. Several students expressed the need to know more phrases in Spanish to communicate with their patients. The course should be offered early in the program and be followed by a capstone project in which students could demonstrate their knowledge and understanding of how to be culturally competent.

The second recommendation is to incorporate cul- tural competency throughout the curriculum. Many second- and third-year students expressed that they had forgotten their cultural competency education material from the first year and needed to be reminded of this subject throughout the program. In addition, many of the courses are science-based and therefore taught by practitioners who might not be familiar with the con- cept of cultural competency. As Romello suggested, to integrate cultural competency in an education program, a strategic plan is needed to encourage the faculty to become dedicated to diversity.14 Life experiences related to culture, race, and discriminatory behavior were important to the faculty members and students in this study. Instructors could benefit by incorporating reflec- tions and discussions related to diversity in their courses to emphasize students’ cultural beliefs and values.

Program instructors need to recognize and respect students’ cultural values and focus on the students’ voices in each course to create an attitude-centered cur- riculum throughout the program. As long as students’ attitudes are positioned at the center, they will be able

experiences, in addition to what they learned in the program, were enough to make them a culturally com- petent medical-imaging professional.

A New Cultural Competency Education Model As a result of this study, a model to describe

cultural competency education was developed, the Attitude-Centered Cultural Competency Model, which encompasses a combination of models presented by Cross et al9 and Purnell (see Figure 4).13 Although knowledge, skills, and attitudes are important concepts in reaching cultural competence, the Attitude-Centered Cultural Competency Model portrays a more holistic view of individuals and considers students’ attitudes and personal characteristics as the key component in achieving the highest levels of cultural competence.

The Attitude-Centered Cultural Competency Model emphasizes the importance of carefully lis- tening to students’ voices and considering their life experiences, values, and backgrounds as important concepts in teaching cultural competency in class- room and clinical settings. Knowledge and skills, as stated by Cross et al and Purnell, are important parts of cultural competency education.9,13 In addition, this model assumes that when students believe their points of view, life experiences, and important aspects of their lives are being noticed and respected they can achieve the advanced levels of cultural competence through- out their professional careers. Although the program instructors cannot force students to become empathetic toward their patients, they can help students view a situation from the patient’s perspective. For example, they can help students understand how it feels to have a mammogram for the first time, to be in the magnetic resonance imaging scanner with the noise coming from the machine and not being able to move for an extended period, or to have a radiograph in a cold room with no warm blankets.

Recommendations The first recommendation that emerged from

this study is to add a course to the curriculum that is specific to cultural competency and cultural sensitivity. This was suggested by students and clinical instructors for future curricular improvement. Diverse cultural

Attitude

Knowledge Skills

Figure 4. Schematic of the Attitude-Centered Cultural Competency Model. Figure courtesy of the author.

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were interviewed. Another limitation of the study was that the principal investigator was a full-time faculty member in the radiography program, and students might have felt the need to answer questions to satisfy the faculty member. In addition, because of the small sample size in this study, the quantitative results must be interpreted with caution.

Conclusion This study provides clarity on the positive effects

of cultural competency education on radiologic technology students. However, it also reveals a critical need for education programs and instructors to recognize the attitudes, life experiences, and beliefs of these future professionals. As society becomes more diverse, radiologic sciences programs should have a strategic plan to integrate cultural competency education into its curriculum. The plan should include introducing students to different cultural definitions and concepts of cultural competency at the beginning of the program. As students move to the second year of the program, they can build on this knowledge and information while infusing their own life experiences and attitudes to acquire compassionate skills at clinical sites. By learning from culturally competent role models that exist inside and outside of the classroom and by reflecting on their own values and beliefs, students obtain the cultural competency skills necessary to interact with diverse patients. These future professionals will be able to reach higher levels of cultural competency, respond to patients’ unique needs, and ultimately reduce health disparities by providing patient-centered care.

Doris Abrishami, EdD, R.T.(R), is director and associate professor for the radiologic sciences program at California State University, Northridge. She currently serves as president-elect for the California Society of Radiologic Technologists, which she has been actively involved with for the past 15 years.

The author thanks Nina Kowalczyk, PhD, R.T.(R)(CT) (QM), FASRT, for her mentorship, advice, and encouraging words of affirmation, which have been instrumental in the author’s publishing journey.

to navigate the academic language and knowledge of the industry, navigate their professional behavior and skills, and claim their own attitudes and use them to improve their patient-care services. By following this recommendation, the curriculum will not only prepare skillful radiologic technologists, but also provide oppor- tunities for students to become culturally competent health care professionals.

To address the faculty member’s concern about whether students pretend to be empathetic, the aim of the program is not to change the students but to create an environment where students use proper academic language that will enable them to infuse compassion and empathy when communicating with patients.

The third recommendation is that opportunities, such as a diversity lunch meeting, should be used for faculty and students to recognize each other’s values and beliefs and become more collaborative. The more faculty members know about each student’s values, cultural background, and life experiences, the better they might understand students’ attitudes and personal characteristics. This might result in a more open-minded and productive relationship between faculty and students that can ultimately produce more successful students in a culturally competent setting. Although many students expressed that their faculty were culturally competent, many radiologic technologists and preceptors at the clinical sites were not modeling cultural sensitivity. Role modeling is important, and students need to witness their faculty and clinical instructors exhibiting culturally competent behavior in and out of the classroom.

Lastly, more research is needed to determine the level of competency obtained by the students as they move forward in their health care professions. A longitudinal study that can follow the students from their first year in a radiologic science program to becoming practicing radiologic technologists would be ideal to determine individual levels of cultural competency knowledge, skills, and attitudes.

Limitations A limitation of this study was that only 1 group of

radiography students took the survey twice (before the semester and at the end of the semester), and because of time restrictions, only 3 students from each class

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Original Article

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Effects of Cultural Competency Education on Radiography Students

U.S. Department of Health and Human Services Office of Minority Health. Accessed March 23, 2018. https://think culturalhealth.hhs.gov/clas

12. Vander Hoek NJ. Student Perceptions of Educational Quality in Radiologic Technology Programs: A Comparative Analysis of Specialized and Institutional Accreditation. Dissertation. University of South Dakota; 2013.

13. Purnell LD. Transcultural Health Care: A Culturally Competent Approach. 4th ed. FA Davis Company; 2013.

14. Romanello ML. Integration of cultural competence in physical therapist education. J Phys Ther Educ. 2007;21(1):33-39. doi:10.1097/00001416-200701000-00005

Received March 24, 2022; accepted after revision August 4, 2022.

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References 1. Rose PR. Cultural Competency for the Health Professional. Jones

and Bartlett Learning; 2013. 2. Shaya FT, Gbarayor CM. The case for cultural competence in

health professions education. Am J Pharm Educ. 2006;70(6):124. doi:10.5688/aj7006124

3. Wang YW, Davidson MM, Yakushko O, Savoy HB, Tan JA, Bleier JK. The scale of ethnocultural empathy: development, validation, and reliability. J Couns Psychol. 2003;50(2):221-234. doi:10.1037/0022-0167.50.2.221

4. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry. 2002;159(9):1563-1569. doi:10.1176/appi.ajp.159.9.1563

5. Kratzke C, Bertolo M. Enhancing students’ cultural competence using cross-cultural experiential learning. J Cult Divers. 2013;20(3):107-111.

6. Karpinski C, Heinerichs S. Exploring the effect a speaker series has on students level of multicultural sensitivity and cultural competence awareness. Internet J Allied Health Sci Pract. 2015;13(3). doi:10.46743/1540-580X/2015.1533

7. Musolino GM, Burkhalter ST, Crookston B, et al. Understanding and eliminating disparities in health care: development and assessment of cultural competence for interdisciplinary health professionals at The University of Utah—a 3‐year investigation. J Phys Ther Educ. 2010;24(1):25- 36. doi:10.1097/00001416-201010000-00006

8. Bloomberg LD, Volpe M. Completing Your Qualitative Dissertation: A Road Map From Beginning to End. 3rd ed. SAGE Publications; 2016.

9. Cross TL, Bazron BJ, Dennis KW, Issacs MR. Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. National Criminal Justice Reference Service; 1989. Accessed August 2016. https://www.ojp.gov/ncjrs/virtual-library/abstracts /towards-culturally-competent-system-care-monograph -effective

10. Hojat M, DeSantis J, Shannon SC, et al. The Jefferson Scale of Empathy: a nationwide study of measurement properties, underlying components, latent variable structure, and national norms in medical students. Adv Health Sci Educ Theory Pract. 2018;23(5):899-920. doi:10.1007/s10459-018-9839-9

11. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.

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