Cultural Competency

Nursing Science Quarterly 2016, Vol. 29(2) 124 –127 © The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318416630100 nsq.sagepub.com

Scholarly Dialogue

The last 20 to 25 years have seen a remarkable increase in incorporating cultural competence in nursing and healthcare curricula and measuring cultural competence, primarily as a means for decreasing health and healthcare disparities among vulnerable populations. In addition, culturally competent care purports to decrease costs. As of yet, this has not been seen on a national basis. The number of theories, models, and approaches to culturally competent care has also increased, especially among nurses. Documents addressing cultural com- petence and tools to measure cultural competence have been developed by individuals, teams of professionals, and govern- mental and professional organizations and associations. However, most of the tools are self-rated either by students, faculty, or practicing health professionals and measure knowl- edge, skills, and abilities for cultural competence. Tools to truly measure culturally congruent clinical practice of nurses and other healthcare providers have not been developed.

Culturally competent practice as defined by the American Nurses Association includes the application of evidence- based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the healthcare consumer and other stakeholders. Cultural competence rep- resents the process by which nurses demonstrate culturally congruent practice. Nurses design and direct culturally con- gruent practice and services for diverse consumers to improve access, promote positive outcomes, and reduce dis- parities (American Nurses Association, 2015).

Knowledge of cultures comprises culture general and cul- ture specific knowledge as well as knowing one’s own cul- ture through critical reflection (Purnell, 2013; 2014). Learning specific attributes and characteristics about a patient’s culture is a definite asset. However, having knowl- edge of cultural frameworks used to guide assessment is probably more important and can be used as a tool for

self-assessment and critical reflection. Cultural specific knowledge builds on the cultural general framework and pro- vides deeper interpretations and patterns in a specific culture. The more the healthcare provider knows about a patient’s culture, the better assessments can be performed so that rec- ommendations for care can be incorporated for culturally congruent care. The provider must recognize that cultural specific attributes and characteristics are true for the group, but not necessarily the individual (Purnell, 2013; 2014). This is a basic tenant of qualitative research.

Selected Theories, Models, Approaches, and Tools

Space does not permit an extensive list and description of the numerous theories, models, and approaches to teaching and conducting research in culture, so only a few commonly used in nursing and healthcare are presented. They are listed in alphabetical order by the name of the theory, model, or approach along with their primary uses. Each theory, model or approach has advantages and disadvantages.

1. COA 360 Model (LaVeist, Richardson, Richardson, Relosa, & Sawaya, 2008) is used for assessing cul- tural competency of the healthcare organization and has an accompanying tool to measure organizational competence.

630100 NSQXXX10.1177/0894318416630100Nursing Science QuarterlyClarke / Scholarly Dialogue research-article2016

1Professor, University of Delaware

Contributing Editor: Pamela N. Clarke, RN, PhD, FAAN, Professor, University of Wyoming, School of Nursing, Dept. 3065, 1000 E. University Ave., Laramie, Wyoming 82079. Email: [email protected]

Are We Really Measuring Cultural Competence?

Larry Purnell, RN; PhD; FAAN1

Abstract One of the major goals of culturally competent nursing and healthcare practice is to decrease health and healthcare disparities. All healthcare professionals need similar information for cultural competence. However, to date, most of the tools measure knowledge, skills and abilities but not true competence from a clinical practice setting. Several tools measure and/or evaluate the organization’s cultural diversity mission but not the providers of healthcare.

Keywords Cultural competence, measurement, nursing science

Clarke / Scholarly Dialogue 125

2. Culture Care Diversity and Universality Theory (McFarland & Wehbe-Alamah, 2015) is primarily used for research and education. The theory does not have a tool for measuring cultural competence.

3. Cultural Competence and Confidence (CCC) Model: Transcultural Self-Efficiency (Jeffreys, 2010) is pri- marily used for teaching and research in teaching cul- tural competence.

4. Dimensional Puzzle Model of Culturally Competent Care (Schim, Dorenbos, Benkert & Miller, 2007) has been psychometrically tested and is primarily used by healthcare providers and has been used in research.

5. Giger and Davidhizar Transcultural Assessment Model (Giger, 2012) has primarily been used in edu- cation but research has been conducted using the model. The model does not have a tool for measuring cultural competence.

6. Lipson, Dibble, and Minarik’s assessment guide does not have an official name but uses a consistent approach for patient and family assessment (Lipson, Dibble, & Minarik, 1996).

7. The Model of Heritage Consistency (Spector, 2013) is primarily used in education The model does not have a tool for measuring cultural competence.

8. The Papadopoulos Model for Developing Culturally Competent and Compassionate Healthcare Professionals has primarily been used for education (Papadopoulos, 2011). The model does not have a tool for assessing cultural competence.

9. The Process of Cultural Competence in the Delivery of Healthcare Services (Campinha-Bacote, 2015) has been used in education, practice, and research and has four self-reported tools for measuring cultural competence (a) Inventory For Assessing The Process Of Cultural Competence Among Healthcare Professionals Revised (IAPCC-R), (b) Inventory For Assessing The Process Of Cultural Competence Among Healthcare Professionals- Student Version (IAPCC-SV), (c) Inventory For Assessing A Biblically Based Worldview Of Cultural Competence Among Healthcare Professionals (IABWCC), and (d) Inventory For Assessing The Process Of Cultural Competence Among Healthcare Professionals In Mentoring (IAPCC-M) (Campinha-Bacote, 2015).

10. The Purnell Model for Cultural Competence (Purnell, 2013; Purnell 2014) with an extensive assessment guide has primarily been used in clinical practice and in education but a number of researchers have used the model. The model and theory do not have a tool for measuring cultural competence.

11. Rew, Becker, Cookston, Khosropour, & Martinez (2003) do not have a specific model, but they have developed and psychometrically validated a tool for measuring cultural awareness in nursing students and it has been used for clinical staff as well.

12. The Transcultural Nursing Assessment Guide is pri- marily used for assessment and in nursing education (Andrews & Boyle (2015). The guide does not have a tool for measuring cultural competence.

Governmental and Professional Organizations and Associations Documents

A very recent important document is Guidelines for Implementing Culturally Competent Nursing Care (Douglas, et al., 2014). The guidelines were developed by a collaborative task force of members of the American Academy of Nursing Expert Panel on Global Nursing and Health and the Transcultural Nursing Society. They were developed with input from multiple countries and stakeholders over a seven-year period. The guide- lines started out as standards but were changed to guidelines to make them more applicable to nurses around the globe because in some settings, standards may be interpreted as central require- ments for practice. The guidelines have been endorsed by the International Council of Nurses (Douglas, et al., 2014). The 10 guidelines provide examples for the caregiver and for healthcare organizations leaders and managers.

The American Association of Colleges of Nursing has four salient documents addressing cultural competence (a) Cultural Competency in Baccalaureate Nursing Education (2008a), (b) Tool Kit of Resources for Cultural Competent Education for Baccalaureate Nurses (2008b), (c) Establishing a Culturally Competent Master’s and Doctorally Prepared Nursing Workforce (2009), and (d) Tool Kit of Resources for Establishing a Culturally Competent Master’s and Doctorally Prepared Nursing Workforce (2011). More recently, the American Nurses Association (2015) has added Standard 8: Culturally Congruent Practice to the Nursing Scope and Standards of Nursing Practice.

The U.S. Department of Health and Human Services Office of Minority Health (2015) has numerous documents; the most recent one is Promotores de Salud (Health Promoters). The site also has the National Standards for Culturally and Linguistically Appropriate Services (CLAS Standards) cultural competence training, Think Cultural Health website, and oral health.

Additional tools that have been used to study culturally competent nursing and healthcare can be found in the Table . Space does not permit a review of these tools but retrieval data are given for each of them. Although this is not an exhaustive list, providers may find ideas for developing more comprehensive tools to measure true clinical cultural competence in nursing and health care.

Systematic Reviews

In addition to cultural theories, models, approaches, and tools to measure culturally competent practice, several sys- tematic reviews can be found in the literature. Only three are

126 Nursing Science Quarterly 29(2)

reported here due to space allocation. However, a browser search will direct the reader to several more. Gozo and col- leagues (2012) completed a systematic review on self- administered instruments that measure cultural competence of health professionals. Pearson and colleagues (2007) com- pleted a systematic review on embracing cultural diversity for developing and sustaining a healthy work environment.

Truong, Paradies, and Priest (2014) conducted a system- atic review of review articles published between 2000 and 2012. The three main categories of outcomes were patient- related outcomes, provider-related outcomes, and health ser- vice access and utilization outcomes. The majority of reviews found moderate evidence of improvement in provider outcomes and healthcare access and utilization outcomes but weaker evidence for improvements in patient/client outcomes.

Knowledge for the Future

Overall, there is much room for cultural competency improvement among providers. Most studies of cultural competence training used self-administered tools that have not been fully psychometrically validated. While cultural competency is widely promoted, the lack of comprehensive tools to measure cultural competency limits the ability to evaluate when culturally congruent care is truly delivered. Cultural competence education could be interpreted more accurately if validated tools were used. In one study, nurses had culturally competent knowledge and attitudes, but were unable to fully and consistently enact these in practice (Starr & Wallace, 2009).

The health professions have made significant progress in culturally competent and congruent care. However, what is now needed is development of tools that truly measure cul- tural congruent care; tools that can be used interprofession- ally. To truly measure culturally competent care at the clinical level with patients and families, a tool that measures not only knowledge, skills, and abilities, but shows evidence in the clinical practice. Can evidence of culturally competent prac- tice be seen in the patient’s medical record, including assess- ment data? What about direct observations of professionals while practicing? A literature search for this dialogue did not reveal any articles that addressed all three elements.

Conclusion

Most students and healthcare professionals in self-adminis- tered questionnaires reported a moderate level of cultural competence. However, cultural awareness and cultural sensi- tivity scores were higher so at least this is a beginning. Room exists for cultural competency improvement among provid- ers. Results of observations and literature reports show the need for interprofessional education and research as well as increased diversity efforts in the workforce (Casillas, et al.). Becoming a culturally- competent health professional result- ing in culturally congruent care is a prerequisite in a multi- cultural society. Patients are entitled to culturally congruent care.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the authorship and/or publication of this review.

Table. Tools and Retrieval Data

Name of Tool Retrieval data

Checklist for the Examination of Cultural Competence in Social Service Agencies

http://rsw.sagepub.com/content/2/2/220.short

Cultural Competence Self-Assessment Questionnaire (CCSAQ) http://racialequitytools.org/resourcefiles/mason.pdf Cultural Self-Efficacy Scale (CSES) http://www.sciencedirect.com/science/article/pii/

S0147176709000261 Measuring Cultural Awareness in Nursing Students http://www.austincc.edu/shirin/Measuring_Cultural_Awareness_

Nursing.pdf Multicultural Competence in Student Affairs Scale (MCSA-P2) http://eric.ed.gov/?id=EJ621102 Cultural Competence Self-Assessment http://nccc.georgetown.edu/resources/assessments.html Diversity Mission Evaluation Questionnaire http://www.shrm.org/templatestools/samples/interviewquestions/

pages/diversity.aspx California Brief Multicultural Competence Scale. http://calswec.berkeley.edu/files/uploads/pdf/CalSWEC/2007_FE_

CBMCSWorksheet.pdf Client Cultural Competence Inventory http://mha.ohio.gov/Portals/0/assets/Planning/OutcomesResearch/

cbcc-form.pdf Tool for Assessing Cultural Competence Training for Curriculum

Evaluation https://www.aamc.org/initiatives/tacct/

Multicultural Counseling Self-Efficacy Scale – Racial Diversity Form (MCSE-RD)

http://www.ncbi.nlm.nih.gov/pubmed/22122166

Clarke / Scholarly Dialogue 127

Funding

The author received no financial support for the authorship and/or publication of this review.

References

American Association of Colleges of Nursing. (2008a). Cultural Competency in Baccalaureate Nursing Education. (2008). Retrieved from http://www.aacn.nche.edu/leading-initiatives/ education-resources/competency.pdf

American Association of Colleges of Nursing. Tool Kit of Resources for Cultural Competent Education for Baccalaureate Nurses (2008b). Retrieved from http://www.aacn.nche.edu/education- resources/toolkit.pdf

American Association of Colleges of Nursing. (2009). Establishing a Culturally Competent Master’s and Doctorally Prepared Nursing Workforce. Retrieved from www.aacn.nche.edu/ education-resources/CulturalComp.pdf

American Association Colleges of Nursing (2011). Tool Kit of Resources for Establishing a Culturally Competent Master’s and Doctorally Prepared Nursing Workforce. Retrieved from http://www.aacn.nche.edu/education-resources/Cultural_ Competency_Toolkit_Grad.pdf

American Nurses’ Association. (2015). Nursing: Scope and Standards of Practice (3ed). American Nurses Association: Washington, DC.

Andrews, M., & Boyle, J. (2015). Transcultural concepts in nursing care (7ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Campinha-Bacote, J. (2015). The Process of Cultural Competence in the Delivery of Healthcare Services. Retrieved from http:// transculturalcare.net/the-process-of-cultural-competence-in- the-delivery-of-healthcare-services/

Casillas, A., Paroz, S., Green, A.R., Wolff, H., Weber, O., Faucherre, F., Niane, F., & Bodenmann, P. (2014). Cultural competence of health-care providers in a Swiss university hospital: Self-assessed cross cultural skillfullness in a cross- sectional study. BMC Medical Education. Retrieved from http://www.biomedcentral.com/1472-6920/14/19

Douglas, M., Rosenketter, M., Pacquiao, D., Clark Callister, L., Hattar-Pollara, M., Lauderdale, J., Milsted, J., Nardi, D., & Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109-221.

Giger, J.N. (2012). Transcultural nursing: Assessment & Intervention, (6ed). St. Louis, MO: Elsevier.

Gozo, A., Beach, M.C., Price, E.G., Gary, T.L., Robinson, K., Palacio, A., Smarth, C., Jenckes, M., Feuerstein, C., Bass, E.B., Powe, N.R., & Cooper, L.A. (2007). Self-administered instru- ments to measure cultural competence of health professionals: A systematic review. Teaching and Learning in Medicine: An International Journal, 19(2), 180-190.

Jeffreys, M. A. (2010). A Model to Guide Cultural Competence (CCC): Transcultural Self-Efficiency. In M. A. Jeffreys (Ed.), Teaching cultural competence in nursing and health care. New York: Springer Publishing Company.

LaVeist, T., Richardson, W.C., Richardson, N.F., Relosa, R., & Sawaya, N. (2008). The COA360: a tool for assessing the cultural competency of healthcare organizations. Journal of Healthcare Management, 53(4). Retrieved from http://www. biomedsearch.com/article/COA360-tool-assessing-cultural- competency/182976470.html

Lipson, J., Dibble, S.L., & Minarik, P.A. (1996). Culture and nurs- ing care: A pocket guide. San Francisco: University California Nursing Press.

McFarland, M., & Wehbe-Alamah, H.B. (2015). Culture care diversity and universality (3ed). Burlington, MA: Jones & Bartlett Learning.

Papadopoulos, I. (2011). The Papadopoulos Model for Developing Culturally Competent and Compassionate Healthcare Professionals. Retrieved from http://cultureandcompassion. com/what-is-culturally-competent-compassion-2/

Purnell, L. (2013). The Purnell model for cultural competence. In L. Purnell, Transcultural health care: A culturally competent approach (pp. 15-44). Philadelphia: F.A. Davis.

Purnell, L. (2014). Guide to culturally competent health care. Philadelphia: F.A. Davis.

Rew, L., Becker, H., Cookston, J., Khosropour, S., & Martinez, S. & Measuring, (2003). Cultural awareness in nursing students. Journal of Nursing Education, 42(6), 249-257.

Schim, S.M., Doorenbos, A. Z., Benkert, R., & Miller, J. (2007). Culturally congruent care: Putting the puzzle together. Journal of Transcultural Nursing, 18(2), 103-110.

Schim, S. M., Doorenbos, A. Z., & Borse, N.M. (2005). Cultural competence among Ontario and Michigan healthcare provid- ers. Journal of Nursing Scholarship, 37(4), 354-360.

Spector, R.E. (2013). Cultural Diversity in Health and Illness (8 ed). Upper Saddle River, NJ: Pearson Education, Inc.

Starr, S., & Wallace, D.C. (2009). Self-reported cultural compe- tence of public health nurses in a southeastern U.S. public health department. Public Health Nursing, 26(1), 48-57.

Pearson, A., Srivastava, R., Craig, D., Tucker, D., Grinspun, D., Bajnok, I., Griffin, P., Long, L., Porritt, K., Han, T., & Gyi, A. (2007). Systematic review on embracing cultural diversity for developing and sustaining a health work environment in healthcare. Retrieved from http://joannabriggslibrary.org/ index.php/jbisrir/article/view/239

Truong, M., Paradies, Y., & Priest, N. (2014). Interventions to improve cultural competence in healthcare: A systematic review. BMC Health Services Research. Retrieved from http:// www.biomedcentral.com/1472-6963/14/99

U.S. Department of Health and Human Services Office of Minority Health. (2015). Retrieved from http://minorityhealth.hhs.gov/ omh/browse.aspx?lvl=1&lvlid=6