REVIEW OF THE LITERATURE
Introduction
The purpose of this descriptive correlational study was to generate data to address
the impact of the cultural encounter on the cultural competence of baccalaureate nursing
students. Research focusing on the importance of providing education to increase cultural
competence in healthcare is occurring in greater frequency in nursing. The specific aims of
this study are: 1) to determine the frequencies of the demographic and cultural competence
measures of baccalaureate nursing students, 2) to determine if there are significant
differences in the cultural competence of first semester baccalaureate nursing students and
final semester baccalaureate nursing students, and 3) to investigate the association of self-
reported cultural awareness, cultural skill, cultural knowledge, cultural encounter, cultural
desire, total cultural competence, year in school, and academic program credits of
baccalaureate nursing students.
This chapter provides an extensive review of the literature as well as research
related to the cultural encounter and cultural competence to support this study. It will begin
with a discussion of the significance of cultural competence, and then move into a
discussion of cultural competence and how it is presented in nursing education. Finally, it
will conclude with a discussion of a cultural encounter in nursing education. The chapter
will be divided into sections that include (a) the significance of studying cultural
competence by looking at healthcare generally, and nursing education, specifically, (b)
the current cultural competence methodologies in baccalaureate nursing education, (c) an
overview of current theories and models on culture, and (d) the current state of research
related to cultural competence and the cultural encounter, and its contribution to nursing
education, with identification of the gaps in the literature.
Cultural Competence in Healthcare and Nursing Education
There is a great deal of literature describing the importance of acquiring cultural
competence in response to changing demographics and the increased health disparities
among many cultural groups. In fact, the majority of literature states that health disparities
exist, they are increasing, and that healthcare is in a position to impact the growing health
disparities through improved cultural education (Anderson, Calvillo, & Fongwa, 2007;
Cavillo, et al., 2009; Dudas, 2012; Sumpter & Carthon, 2011, Zoucha, et al., 2011). In
response to the growing cultural diversity in the United States, cultural competence has
become a focus in healthcare. According to Betancourt et al., (2003) cultural competence
in healthcare requires the practitioner to understand the impact of the complex influences
of culture and society on a person’s beliefs and behaviors, and requires the healthcare
provider to tailor interventions to “assure quality healthcare delivery to diverse patient
populations” (p.297). These authors recommend an evaluation of how cultural competence
is addressed and urged greater implementation educationally, organizationally, and
structurally (Betancourt, et al., 2003). There is a need for change at the systems level,
requiring the development of a partnership with healthcare organizations, academic
institutions, and community agencies. The goals of the partnership would be the
establishment of a standard of cultural competence for all involved, a reduction in the
existing discrepancies, and the provision of quality healthcare for all (Bolton, 2007;
Bornemisza et al., 2010; Brach & Fraser, 2000; Chrisman, 2007).
There is also a growing body of literature specific to nursing education and the need
to incorporate culture within the curriculum. Cultural competence requires nurses to
demonstrate those skills, actions, and values that create effective care to patients from a
variety of cultures. However, cultural competence is not associated with one theoretical
foundation and is instead often presented related to skill or technique, creating difficulty in
evaluation of its effectiveness (Williams, 2006). Though there is an awareness of the need
to incorporate cultural competence education into nursing curricula, there is not a formal,
integrated, consistent way of doing so (Bentley & Ellison, 2007; Chrisman, 2007; Kardong-
Edgren, et al., 2010; Long, 2012). While it has become “an essential component of nursing
practice”, there has not been a clearly articulated definition, mainly because the concept
has many meanings depending upon its scope (Suh, 2004, p.93). Nursing education is in a
position to affect change in the growing health disparities, but it will require improved
cultural education and the acquisition of cultural competence in graduating nursing
students (Anderson, et al., 2007; Cavillo, et al., 2009; Reye, Hadley & Davenport, 2013;
Sumpter & Carthon, 2011; Zoucha, et al., 2011). All individuals are entitled to culturally
competent care. Nursing students need to be equipped with knowledge about how
ethnicity, living conditions, socio-economic status, gender, and geographic location create
barriers to healthcare access and perpetuate health disparities, as well as be given the skills
to provide culturally competent care (Anderson, et al, 2007; Wilcox & Taylor-Thompson,
2012; Zoucha, et al., 2011). Calvillo et al., (2009) assert, “improved health professions’
education is one of the critical and potentially most effective interventions to eliminate
health care disparities” (p.137).
In the past 20 years, national organizations have recommended that culturally
competent standards be incorporated into nursing curriculum. These recommendations are
fairly broad but are specific to the following concepts: cultural sensitivity or awareness,
cultural knowledge, and cultural skills and behaviors (DeSantis & Lipson, 2007; Hughes
& Hood, 2007; Hunt & Swiggum, 2007; Jeffreys, 2008; Lipson & DeSantis, 2007). The
research has provided evidence that having cultural knowledge is important because the
lack of knowledge may “cause deficits in practice” leading to nurses who treat their patients
based upon their own stereotypes and ethnocentric attitudes (Kokko, 2011, p. 674). Lack
of culturally competent nurses can lead to barriers in the nurse-patient relationship, such as
increased stress and dissatisfaction by both the patient and the nurse, and poorer health
outcomes for the patient (Jeffreys, 2010; Kokko, 2011; Leininger & McFarland, 2002).
Cultural competence education, on the other hand, has shown to improve patient
satisfaction and patient outcomes (Betancourt et al., 2003; Pacquiao, 2008; Waite &
Calamaro, 2010). According to Jeffreys (2010), the goal of providing culturally competent
care requires “active, ongoing learning based on theoretical support and empirical
evidence…and can only be achieved through the process of developing (learning and
teaching) cultural competence” (p.12).
The AACN’s Essentials of Baccalaureate Nursing Education articulated five
cultural competencies to be incorporated into baccalaureate nursing programs as a guide
for nurse educators as they prepare culturally competent graduates (AACN, 2008;
Calvillo, et al., 2009). These competencies include:
1. Apply knowledge of social and cultural factors that affect nursing and
health care across multiple contexts.
2. Use relevant data sources and best evidence in providing culturally
competent care.
3. Promote achievement of safe and quality outcomes of care for diverse
populations.
4. Advocate for social justice, including commitment to the health of
vulnerable populations and the elimination of health disparities.
5. Participate in continuous cultural competence development.
(Calvillo et al., 2009, 139-140).
The American Association of Colleges of Nursing (AACN), the Commission on
Collegiate Nursing Education (CCNE), the state boards of nursing, and the National
League of Nursing (NLN), all require nurse educators to teach nursing students about
cultural (Calvillo et al., 2009; Chrisman, 2007; Hughes & Hood, 2007). The AACN (2008)
addressed culturally competent care in the Essentials for Baccalaureate Education for
Professional Nursing Practice, articulating support for liberal arts education and the
importance of protecting human dignity and patient safety through cultural competence.
Nursing curricula has responded and included a variety of methodologies to teach about
culture. The evidence appears to support a variety of educational interventions and their
positive impact on skills, attitudes, and knowledge of nursing students; however, the
evidence does not clearly determine which methodology is the most effective, or if indeed
they are (Amerson, 2010; Rutledge et al., 2008).
Cultural Competence Defined
Though the specific definitions vary a bit, there is agreement in the literature that
cultural competence is an ongoing process (Table 1). Worrell-Carlisle’s (2005) definition
of cultural competence describes the values of the nurse and how values “led” her to learn
about “differences and similarities” in the human race in order to provide care that is equal
to all people (p.185).
Table 1
Cultural competence definitions in the literature
Definition of Cultural Competence
Author(s)
An ongoing process of the nurse attempting to practice
with the cultural context of the client, including their
family and their community.
Axtell, Avery & Westra
(2010)
Specific set of nursing behaviors and skills within the
culture of the client, family and community.
Waite & Calamaro
(2010)
A process consisting of five constructs: cultural awareness,
cultural knowledge, cultural skill, cultural encounters and
cultural desire. Cultural encounter is the pivotal construct
in developing competence.
Campinha-Bacote,
(2008)
A flexibility in dealing with the various cultures, as well
as being able to adapt and modify plans of care, depending
upon the culture.
Betancourt, et al.,
(2003), and Chrisman
(2007)
The ability of the nurse to care for a client who differs in
beliefs, values and behavior with healthcare tailored to
meet the patient’s social, cultural and linguistic needs.
Woods & Atkins (2006)
The nurse’s values which lead her to learn about the
similarities and differences in the human race in order to
provide care that is equal to all people; a dynamic process.
Worrell-Carlisle (2005)
Care adapted to the culture that is a nonlinear, conscious
process.
Purnell (2002)
A never-ending, ever expanding, non-linear process that
includes the dimensions of cultural awareness, cultural
knowledge, cultural understanding, cultural sensitivity and
cultural skill.
Rosenjack-Burchum
(2002)
The dimensions of cultural sensitivity, cultural knowledge
and cultural skills.
Kim-Godwin, Clarke &
Barton (2001)
Others have defined cultural competence as an ongoing process of the nurse
attempting to practice within the cultural context of the client, including their family and
community, while tailoring the needs to meet each specific client within their culture
(Axtell, Avery & Westra, 2010; Campinha-Bacote 1999; Campinha-Bacote, 2002; Waite
& Calamaro, 2010; Woods & Atkins, 2006).
As one can see, most of the definitions are similar to each other, with slight
variations in terminology. The concept of cultural competence is continually evolving and
it will be important at some point in time to have agreement on exact terminology
(Cowan & Norman, 2006).
Educational Methodologies and Considerations
The literature posits that existing curricula are weak when it comes to effectively
teaching about culture and preparing graduates to become culturally competent. Educators
are being challenged to develop new and better ways of emphasizing care of diverse
cultures; focus of the curriculum needs to include acquisition of knowledge, attitudes and
skills and be incorporated through leveling within the program (CampinhaBacote, 2007;
Long, 2012). Though educating nursing students about culture is required, there is growing
evidence nursing graduates do not have the cultural competence required to care for the
increasingly diverse population (Kardong-Edgren & Campinha-Bacote, 2008; Reeves &
Fogg, 2006). Nursing educators have utilized several educational methods to teach about
culture: reading books, didactic content within courses on culture, stand alone courses on
culture, theoretical models infused throughout curriculum, simulation, and face to face
experiences through clinical, community engagement, service learning, and immersion
experiences (Axtell, Avery, & Westra, 2010; KardongEdgren & Campinha-Bacote, 2008;
Long, 2012; Marcinkiw, 2003; Noble et al., 2014).
Integrating culture throughout the curriculum appears to be the most common teaching
method (Caffrey et al., 2005; Calvillo et al., 2009; Kardong-edgren et al, 2010; Lipson &
DeSantis, 2007; Long, 2012), and allows students to develop new ways of understanding
based upon their previous experiences (Easterby et al., 2012). Integration of culture in
nursing curricula means intentionally threading content on culture throughout all nursing
courses utilizing various methodologies. Nurse educators can integrate culture by adding
the five Baccalaureate Essentials competencies to their existing curriculum. These
competencies call for a partnership between faculty, clinical and community settings, and
administration to work on achieving the integration of the nursing cultural competencies
(Callen & Lee, 2009; Calvillo et al., 2009; Hughes & Hood, 2007). However, nursing
education has not been consistent in the way culture is taught, and there is confusion as to
the best method for teaching culture and increasing cultural competence (Easterby, et al.,
2012). The literature is not in agreement, leaving a gap related to which of the various
methodologies is effective (Brennan & Cotter, 2008;
Carey, 2011; Lipson & DeSantis, 2007).
Ethnocentrism
Ethnocentrism, the inherent belief in the superiority of ones’ ethnic group or culture,
can impair the ability of the healthcare provider to give culturally appropriate care
(Campinha-Bacote, 2002; Capell, et al., 2008; Kokko, 2011). The literature supports that
nursing graduates feel inadequately prepared to provide culturally competent care, they
have experienced discomfort in caring for patients whose backgrounds were different from
their own, and they held deeply ingrained attitudes and beliefs about cultures different from
their own. The need for students to initially deal with their own ethnocentrism, biases and
prejudices is a first step in the development of cultural awareness, because ethnocentrism
has been linked to patient alienation, incorrect diagnosis, and poor or inadequate treatment.
(Alpers & Zoucha, 1996; Amerson, 2010; Capell, et al., 2008; Dayer-Berenson, 2011;
Dunagan, et al, 2014; Hunt & Swiggum, 2007; Long, 2012). Zoucha (2002) described the
need for students to understand their cultural self in order to provide culturally competent
care. Without understanding our own culture and the values that align with that culture,
we inhibit our ability to understand another’s culture. However, when we understand our
cultural self we are able to step outside of our own culture and into another’s, thereby
reducing the risk of ethnocentrism. Cultural education must address students’
ethnocentrism as a first step in the process of developing cultural competence.
Courses and integrated curriculum
Didactic lessons on culture, stand-alone courses on culture, or reading books
followed by reflection and discussion, while helpful in providing information, have proven
to be more focused on stereotypes, biases, or cultural characteristics rather than in
promoting awareness, knowledge and understanding (Brennan & Cotter, 2008; Halloran,
2009; Kardong-Edgren & Campinha-Bacote, 2008). Halloran (2009) found that students
who read about other cultures learned about stereotyping and began to develop cultural
sensitivity, while other students thought the novel actually perpetuated known stereotypes.
They also found some students had difficulty changing ingrained stereotypes about other
cultures. Understanding ones biases and stereotypes is an important part of cultural
awareness, but it is only one part of a much larger whole.
Another study comparing graduating nursing students who learned about culture
either through an integrated curriculum or through a stand-alone course on culture, found
the students were more culturally aware overall, but not culturally competent
(KardongEdgren & Campinha-Bacote, 2008). In a study of 219 freshman, senior and
masters level nursing students over two years, it was established that though students had
received foundational education on culture through liberal arts courses, they desired more
in-depth knowledge on how to practically apply their knowledge to reduce biases in both
the classroom and clinical setting. Additionally, the integration of culture in the curriculum
was often weighted more heavily on the didactic content and was lacking in clinical
application. Even so, the same didactic content was often used repeatedly, which is neither
efficient nor effective (Brennan & Cotter, 2008). Based upon the results of their qualitative
study, Reeves and Fogg (2006) found exposure to cultural content within the nursing
curriculum was not enough for graduating nursing students to perceive themselves as
culturally competent, and recommended a more culturally comprehensive curriculum.
Noble et al., (2014) described a small increase in cultural awareness for students who
received a two hour culture lecture and student presentation intervention, while Reyes, et
al., (2013) found graduating nursing students who experienced culturally integrated
curriculum perceived their cultural competence significantly higher than beginning
sophomore nursing students in the same curriculum. Didactic learning can be a passive
means of gathering information, and can lead to poor retention when compared to other
methodologies (Long, 2012).
The studies on cultural courses and integrated curricula describe evidence that
reading about culture improves stereotypes and cultural sensitivity, exposure to cultural
content is not as effective as a culturally integrated curriculum, and culture integrated into
curricula is often heavier in didactic content than clinical experiences leading to poorer
retention of cultural learning. The findings from these studies are not consistent,
undoubtedly due to diverse curricula across schools of nursing, and support the evidence
that there is not a clear determination on what methodology is the most effective
(Amerson, 2010; Long, 2012; Rutledge et al., 2008).
Simulation
Simulation has the potential to develop a deeper understanding of culture for
students than reading a book or stand-alone courses, because students can role play in a
non-threatening way and make mistakes or face their biases in a more controlled
environment (Long, 2012; Rutledge et al., 2008). Skills are honed and confidence is
increased. However, there are also weaknesses. First, faculty creating the simulations must
be culturally competent; this is difficult to achieve because it requires cultural expertise,
academic and administrative support, and commitment on the part of the faculty within the
course and across the curriculum (Kardong-Edgren & CampinhaBacote, 2008; Leininger
& McFarland, 2002; Lipson & DeSantis, 2007; Mixer, 2008; Waite & Calamaro, 2010).
According to Kardong-Edgren and Campinha-Bacote (2008), not all faculty were culturally
competent and able to effectively teach about culture. Additionally, Lipson and DeSantis
(2007) state many faculty teach culture out of personal interest, but do not have training or
experience to do so. The authors feel that without the necessary training and expertise on
the part of the faculty, simulation scenarios will be lacking in depth and richness.
Simulation is also limited to the nurse-patient encounter in a controlled setting.
There are many nuances within a culture that cannot be replicated during a simulation.
The experience of the real world elements such as the economic, political and cultural
