Discussion Question

https://doi.org/10.1177/1043454217713452

Journal of Pediatric Oncology Nursing 2017, Vol. 34(6) 422 –426 © 2017 by Association of Pediatric Hematology/Oncology Nurses Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043454217713452 journals.sagepub.com/home/jpo

Research

Background

According to the U.S. Census Bureau (2015), the minor- ity population is projected to rise to 56% in 2060 com- pared with 38% in 2014. And as such, the current breadth of ethnic and cultural backgrounds of individuals in the United States requires that the nursing profession be cul- turally competent (Campinha-Bacote, 2002; Taylor & Alfred, 2010). Culturally congruent care is considered a standard of practice for nurses and a curriculum require- ment for nursing schools (National League for Nursing Accrediting Commission, 2016). Since nurses provide the most direct health care services, the expectation to be knowledgeable about diverse health beliefs and practices is critical (Bauce, Kridli, & Fitzpatrick, 2014). Literature supports the importance of practices, beliefs, value sys- tems of diverse cultures, and emphasizes culturally con- gruent care (Hart & Mareno, 2013; Mareno & Hart, 2014; Lin, Chang, Wang, & Huang, 2015) as this has shown to improve patient outcomes and reduce health care dispari- ties (Gallagher & Polanin, 2015; Garneau & Pepin, 2015).

Campinha-Bacote(2002) defined cultural competence as an “ongoing process in which health care provider(s)

continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community)” (p. 181). Although a universally agreed-upon definition is lacking, the consensus is that cul- tural competence calls for a conscious process whereby pro- viders, such as nurses, respect and appreciate values, beliefs, and worldviews of diverse populations. To better serve diverse populations, nurses need to be practicing culturally congruent care. This is important as nurses’ perception of themselves as culturally competent caregivers is reflected in the way they communicate with patients and families.

A large urban children’s hospital serves a culturally diverse patient population, and as a quaternary care center draws patients from different countries and continents. Thus, it is of paramount importance for nurses to understand

713452 JPOXXX10.1177/1043454217713452Journal of Pediatric Oncology NursingEche and Aronowitz research-article2017

1Boston Children’s Hospital, Boston, MA, USA 2University of Massachusetts Boston, MA, USA

Corresponding Author: Ijeoma Julie Eche, MSN, FNP-BC, AOCNP, CPON, BMT-CN, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Email: [email protected]

Evaluating Cultural Competence of Pediatric Oncology Nurses at a Teaching Hospital: A Pilot Study

Ijeoma Julie Eche, MSN, FNP-BC, AOCNP, CPON, BMT-CN1, and Teri Aronowitz, PhD, FNP-BC2

Abstract This cross-sectional descriptive study evaluated registered nurses’ self-ratings of cultural competence on the hematology/oncology unit at a large Northeastern urban children’s hospital. The Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals was used to measure 5 constructs of cultural competence. The study findings show that there were significant correlations between the knowledge and skill subscales (ρ = .57, P < .001) and the knowledge and desire subscales (ρ = .42, P < .05). The highest mean among the 5 subscales was cultural desire (mean = 15.5), indicating that nurses were motivated to engage in the process of becoming culturally competent. The lowest mean among the 5 subscales was cultural knowledge (mean = 11.2), followed by cultural skill (mean = 11.8), indicating that nurses did not perceive themselves to be well informed in these areas. The findings from this pilot study suggest that nurses on this pediatric oncology unit are most likely to possess cultural desire and cultural awareness, but there is certainly opportunity to engage and educate the staff. Targeted interventions to improve cultural competence on this inpatient unit are being explored and a larger scale study is being planned to assess the cultural competence of nurses across the hospital.

Keywords cultural competence, culture, nurses, ethnic differences

Eche and Aronowitz 423

themselves in the context of cultural differences that exist and integrate new knowledge that would positively influence health care interventions for diverse populations (Campinha- Bacote, 2002; Purnell, 2005). The purpose of this study was to evaluate registered nurses’ self-ratings of cultural compe- tence in order to develop educational materials or programs to improve cultural competence hospital wide.

Theoretical Framework

Campinha-Bacote’s (2002) conceptual model of cultural competence in the delivery of health care services was the guiding theoretical framework of this study. In the model, Campinha-Bacote (2002) describes cultural competence as an ongoing process whereby health care providers, such as nurses, engage with their clients and families in a culturally appropriate way.

Since cultural competence is not considered an event, nurses, for example, should see themselves as becoming culturally competent instead of already being culturally competent. The 5 constructs of the model are the follow- ing: (a) cultural awareness which involves self-examina- tion of one’s cultural background and recognition of biases and prejudice; (b) cultural knowledge which involves seeking and obtaining broad knowledge base of diverse populations; (c) cultural skills which involves collecting relevant cultural data and utilizing information to perform culturally based assessments; (d) cultural encounters which involves face-to-face interactions with patients of diverse backgrounds to prevent stereotyping; and (e) cultural desire which involves caring and engaging in the process of cultural competence (Campinha-Bacote, 2002). The underlying assumption in this model is that the 5 constructs are interrelated and needed to achieve cultural competence, which is essential in providing culturally responsive ser- vices (Campinha-Bacote, 2002, 2003).

Materials and Methods

Design

Descriptive cross-sectional studies are typically referred to as a “snapshot” of frequency and characteristics of a condition in a population at a particular point in time. In this study, nurses’ self-ratings of cultural competence on one inpatient unit at a large urban children’s hospital were examined. The primary investigator’s institutional review board approved exempt status, as survey completion was voluntary and anonymous.

Instruments

The Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals (Campinha- Bacote, 2003; IAPCC-R) was used to measure 5 constructs

of cultural competence: cultural desire, cultural knowl- edge, cultural skill, cultural encounters, and cultural aware- ness. The IAPCC-R is a well-established self-assessment instrument used in the field of transcultural health care to measure cultural competence among health care providers. The survey included 25 items in a 4-point Likert-type scale format and took approximately 10 to 15 minutes to com- plete. The scores range from 25 to 100 and are grouped as follows: culturally proficient (91-100), culturally compe- tent (75-90), culturally aware (51-74), and culturally incompetent (25-50). Higher scores equate with higher cultural competence. The instrument has demonstrated sound psychometric measures (Campinha-Bacote, 2003; Kawashima, 2008). An investigator-designed 3-item basic demographic form was also administered and asked ques- tions about age, racial/ethnic background, and years of nursing experience.

Sample and Setting

Registered nurses working on the hematology/oncology unit were invited to participate. The cultural makeup of registered nurse staff on the unit was similar to other units throughout the hospital (see Table 1 for the sample char- acteristics). Clinical assistants and administrative staff were excluded. The administrative staff were excluded because they do not provide direct patient care. Although clinical assistants provide direct patient care, they were excluded because the instrument has not been validated with assistive personnel. The target number of nurses was 38 as this was the population of permanent staff nurses on the hematology/oncology unit at that time.

Recruitment Procedure

The primary investigator attended staff and leadership meetings to explain the study to registered nurses work- ing day, evening, and night shifts as well as provided a cover letter explaining the purpose of the study clarifying that participation was voluntary and anonymous. Each registered nurse has a file folder in a large cabinet on the unit. The surveys were placed in the file folders for distri- bution to each nurse. In addition, a flyer was posted in the

Table 1. Sample Characteristics (N = 21).

Age Range = 25-62; mean = 38; SD = 10.3

Racial background White = 20 (96%); Black = 1 (4%)

Ethnic background Non-Hispanic 16 (77%); 5 nurses (23%) did not report their ethnic background

Years of nursing experience Range = 0-35; mean = 14.9; SD = 10.3

424 Journal of Pediatric Oncology Nursing 34(6)

nursing conference room on the unit in an effort to recruit nurses in the study who may have missed the staff meet- ings. Registered nurses were instructed to put the com- pleted survey in a sealed envelope that was provided and place in a locked box on the nursing unit. The primary investigator was the only person who had access to the locked box. Nurses’ completion and return of the IAPCC-R implied consent to participate in the study.

Data Analysis

Data were analyzed using SPSS version 12. The demo- graphic data were analyzed using frequencies and per- centages to describe the sample. In addition, Spearman correlation coefficients were used to analyze the data because of the small sample size and the level of data was ordinal. Mean and median scores were reported on the IAPCC-R.

Results

Twenty-one of the 38 nurses completed the survey in its entirety. Twenty out of 21 (96%) nurses reported their racial/ethnic background as White, non-Hispanic. One nurse (4%) identified as African American. The other racial/ethnic minority groups were not represented. The mean age of nurses is 38 years, with a range of 25 to 62 years. The mean years of nursing experience is 14.9, with a range of 0 to 35 years. The demographic form did not have question pertaining to nurses’ level of educa- tion. Five nurses (19.2%) did not answer every question, and these data were not included in the correlational analysis.

The mean and median scores of each construct are included in Table 2. The highest mean score among the 5 subscales was cultural desire (mean = 15.5), indicating that nurses were motivated to engage in the process of becoming culturally competent. In the cultural encounter subscale, the mean score was 13.0, indicating that the nurses are making efforts to engage in cross-cultural interactions with patients. The lowest mean among the 5 subscales was cultural knowledge (mean = 11.2), fol- lowed by cultural skill (mean = 11.8), indicating that

nurses did not perceive themselves to be well informed in these areas. The overall competence scores (out of 100) included a mean of 65.2 with scores that revealed that only 1 nurse self-reported at the “culturally competence” level; the remainder of the nurses (n = 20, 96%) scored at the “culturally aware” level. No nurses scored in the “cul- turally proficient” or “culturally incompetent” levels. Bivariate analyses seen in Table 3 demonstrate signifi- cant correlations between both the knowledge and skill subscales (ρ = .57, P < .001) and the knowledge and desire subscales (ρ = .42, P < .05).

Discussion

The demographic composition of the nurses in this study is similar to that of the 2008 National Sample Survey of Registered Nurses (Health Resources and Services Administration, 2010) findings, which showed that 83.2% of nurses are White, non-Hispanic. Basically, minority nurses are underrepresented nationally in the workforce and this reflects in multiple health care organi- zations across the country. Literature has well docu- mented the need to diversify the nursing workforce (Mulholland, Anionwu, Atkins, Tappern, & Franks, 2008; Nnedu, 2009; Terhune, 2006). Therefore, the homogene- ity of the nursing workforce may not allow the process of cultural congruent care as the workforce does not repre- sent the population it serves.

The findings from this pilot study revealed that the majority of pediatric oncology nurses on this unit were culturally aware yet scored low on the subscales of cul- tural knowledge and skill. This is consistent with other studies (Songwathana & Siriphan, 2015). Mareno and Hart (2014) compared cultural competence of nurses with undergraduate and graduate degrees and found that the nurses with undergraduate degrees scored lower than nurses with graduate degrees on cultural knowledge. Songwathana and Siriphan (2015) examined nurses’ cul- tural competence in the multicultural setting of Thai- Malaysian border region. Differences in nurses’ educational level and geographic and cultural context of the study settings could explain the inconsistences in the

Table 2. Responses to Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals.

Constructs N Mean SD Median Range

Cultural desire 26 15.5 1.8 15.0 11-20 Cultural knowledge 25 11.2 2.1 11.0 8-16 Cultural skill 24 11.8 1.8 12.0 10-18 Cultural encounters 22 13.0 1.5 13.0 10-17 Cultural awareness 24 13.4 1.1 13.0 12-15

Table 3. Inventory for Assessing the Process of Cultural Competence Construct Correlations (N = 21).

Constructs 1 2 3 4 5

1. Cultural desire — .42* .34 .35 .35 2. Cultural knowledge — .57*** .27 −.02 3. Cultural skill — .35 .16 4. Cultural encounters — .07 5. Cultural awareness —

*P < .05. **P < .01. ***P < .001.

Eche and Aronowitz 425

study findings. Our pilot study unfortunately did not include questions about nurses’ level of education or pre- vious diversity training; therefore, it is difficult to discuss potential impact of education and/or previous diversity training on the study results.

Since cultural awareness calls for an in-depth explora- tion of one’s personal biases (Fitzgerald, Cronin, & Campinha-Bacote, 2009), it is important that nurses are authentically able to explore their own cultural back- grounds in order to prevent them from imposing their own cultural beliefs on their patients and families. Cultural imposition can prevent them from accepting racial/ethnic backgrounds that differ from their own. Nurses’ lack of acceptance of another’s differences means that they may treat every patient the same way, which fundamentally impedes the process of culturally congru- ent care. In this study, the mean competence score was 65.2, which correlated with being culturally aware, sug- gesting that these nurses are able to recognize prejudices and biases about others. These findings were similar to Kardong-Edgren and Campinha-Bacote (2008), who reported that nursing students scored only in the cultur- ally aware level but was in contrast with other studies’ findings that suggested that nurses scored at the level of cultural competence (Bauce et al., 2014; Dauvrin & Lorant, 2015).

The highest mean among the 5 subscales was cultural desire (mean =15.5), indicating that nurses want to learn and are motivated to engage in the process of cultural competence. The lowest mean among the 5 subscales was cultural knowledge (mean = 11.2), followed by cultural skill (mean = 11.8). This indicates that the nurses did not perceive themselves to be knowledgeable in navigating the health care experience of patients from diverse backgrounds.

Given that the results of this study will help inform tar- geted interventions hospital wide, it is important to iden- tify types of intervention studies that have been used in cultural competence research. Findings suggest that there needs to be variety of educational interventions used to improve cultural competence. Elminowski (2015) devel- oped and implemented a cultural awareness workshop for nurse practitioners that involved a 3-hour cultural educa- tional training; however, it was not clear how often these practitioners were expected to enroll in the program at their place of employment. Other studies developed sim- ple lectures and discussion format workshops where stu- dents were encouraged to engage in conversations about cultural competence information with fellow classmates and practitioners (Berlin, Nilsson, & Tornkvist, 2010; Sanner, Cannella, Charles, & Parker, 2010). For instance, Berlin et al. (2010) developed a 3-day training program with curricula that was designed to improve cultural com- petence. On the other hand, cultural competence training

for nursing students was integrated in the curriculum with a research-based model guiding its framework (Gebru & Willman, 2010; Lin et al., 2015).

Limitations

A major limitation of this study is the cross-sectional design. Causal inferences cannot be made limiting gener- alizability of study results. The responses from nurses on one inpatient unit may be unique compared with the other units in the hospital. The use of a self-report instrument is another limitation as it gives respondents opportunity to give socially acceptable responses. Irrespective of these limitations, the results of this pilot study can be used to inform continuing education on this unit as well as inform development of larger scale descriptive studies.

Conclusion and Implications for Future Research

The delivery of nursing care requires nurses to acquire cul- tural competence to care for diverse patient populations. Results of this study provided preliminary data to inform a future study at this institution with the goal of eventually developing targeted interventions to improve cultural com- petence. Targeted interventions to improve cultural compe- tence on this inpatient unit are being explored and a larger scale study is underway to assess the cultural competence of nurses across the hospital. Future research is needed to evaluate cultural competence in different regions of the United States specifically including nurses from diverse backgrounds at multiple health care organizations and increasing sample sizes to detect statistically significant differences to make inferences about cultural competence and add to the body of knowledge.

Acknowledgments

This article is dedicated to Dr Nancy Kline, without whose mentorship, guidance, and support this study would not have come to fruition.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies

Ijeoma Julie Eche, MSN, FNP-BC, AOCNP, CPON, BMT-CN, is a doctoral candidate at the University of Massachusetts Boston currently working on her dissertation. She has been a staff nurse at Boston Children’s Hospital for over 12 years.

Teri Aronowitz, PhD, FNP-BC, is an assistant professor at the University of Massachusetts Boston and is the chair of Ijeoma Julie Eche’s dissertation committee.