Cultural in the curriculum, and (4) Use of a

Competence in the ClassroomThe task of delivering
culturally competent education belongs to the faculty. Health school faculty
members need to be aware of how their own cultures influence various aspects of
their lives like how they educate nursing students. There are four dimensions
of teaching related to cultural diversity (Rew, et al, 2003); (1) Awareness of
the role one’s cultural background and experiences play in forming beliefs,
attitudes, and behaviors,  (2) Knowledge
and understanding of how students from different cultural or ethnic backgrounds
may experience the classroom differently, (3) Incorporation of diverse cultural
and social perspectives in the curriculum, and (4) Use of a variety of teaching
methods to more effectively accommodate learning styles of students from
different backgrounds.Cultural awareness and
sensitivity affect not only the way health care information is delivered but
also how students are able to internalize the information (Redican, et al, 1994;
Rew, et al, 2003). There are various studies using separate approaches to
achieving cultural competence among nursing students. One study looked at the
effectiveness of using the BaFa BaFa and Barnga games for learning cultural
awareness (Koskinen; et al, 2008.) These games simulate cultural conflict among
the players and guide them to become aware of their own cultural stereotypes,
prejudices, and misunderstandings. This study showed that these are powerful
methods to learn cultural awareness in nursing. One quasi-experimental study,
students were placed in experimental and control groups and assessed using the
pretest-posttest design (Hsui-Chin; et al, 2011). They found that the students
in the experimental group had a significant increase in their cultural
knowledge and cultural competence. This was supported by Jeffreys (2011) study
were assessment of students’ transcultural self-efficacy perceptions found that
educational interventions influenced transcultural efficacy changes and
students regardless of cultural background can benefit from formalized cultural
competence education. Kratzke and Bertolo (2013) carried out a cross-cultural
experiential learning exercise as an educational approach to cultural
competence for health students. Reflective writing was used to elicit students’
attitudes of other cultures and their coping skills. The study showed the need
for student academic preparation to enhance cultural competence. There is no one
curricular approach more effective than another in achieving essential cultural
competency among health students. Faculty members must know their students’ and
their cultural needs to will facilitate the process of students developing
their own racial identities.Cultural
Competence in Clinical Practice and ResearchBeyond the classroom,
students also develop cultural competence in the clinical practice and
research. Students are taught by their lectures and professional health workers
during clinical practice. Ozkana (2013) concluded that clinical stimulation
supports cultural competent care by providing as safe environment to conduct
culturally appropriate assessment, elicit students’ attitudes towards
cross-cultural situations and improve communication, critical thinking, and healthcare
skills. But gaps still exist regarding the effectiveness of clinical simulation
to enhance cultural competent nursing care. This was reflected in a qualitative
study found by Berger, Conroy, and Peerson, (2011) in Australia found that
clinical supervisors were unable to define cultural competency in ways that
could enable them to apply the concept to clinical training of students.
Contrary to Berger’s results, another study found that if students and clinical
instructors worked closely together on issues surrounding cultural diversity
then cultural competence can be achieved (Jeffreys, 2013). Cultural
Competence and Patient Centered CarePatient centered care is
the practice of caring for patients and their families in ways that are
meaningful and valuable to the individual patient. The Picker Institute (1987)
came up with eight principles of patient centered care; (1) Respect for patient
preferences, (2) Coordination and integration of care, (3) Information and
education, (4) Physical comfort, (5) Motional comfort (6) Involvement of family
and friends, (7) Continuity and transition, and (8) Access to care. Understanding,
integration, and application of these principles leads to provision of holistic
patient care. Cultural processes
differ within the same ethnic or social group because of differences in age
cohort, gender, political association, class, religion, ethnicity, and
personality (Epner and Baile, 2012). Evidence shows the multicultural approach
to cultural competence results in stereotypical thinking rather than clinical
competence. Patient centered care relies on identifying decision-making
preferences, communication styles, family roles, gender, mistrust, and racism
issues among other factors. It also helps overcome cultural imposition. Therefore,
health professionals providing culturally competence patient-centered care improve
patient satisfaction, quality of care, and access to health services leading to
better health outcomes for culturally diverse groups (Gallagher, 2011)Conceptual

Madeleine M. Leininger
(1991) the founder of the transcultural nursing theory, defined transcultural
nursing as a comparative study of cultures to understand similarities and
differences among human groups. In
her Sunrise Model
of Cultural Care Diversity and Universality,
Madeleine M. Leininger (2001) addressed the importance of knowledge
about individuals, families, communities, and institutions in culturally diverse
healthcare systems. She also addressed the generic (folk, indigenous, or
home-made) care systems in patient care which are culturally learned and
transmitted knowledge and skills used to provide assistive, supportive,
enabling, or facilitative acts towards evident or anticipated needs to improve
health. Therefore, transcultural health care results from caring for
patients from other cultures than one’s own culture. She also formulated the three modes of nursing care decisions
and actions; (1) Cultural Care
Preservation (Maintenance) includes professional decisions and actions that
help people of a particular culture to retain relevant care values so as to
maintain their wellbeing. (2) Cultural
Care Accommodation (Negotiation) includes professional decisions and
actions that help people of a particular culture to adapt or negotiate with
others for a satisfying health outcome. (3) Cultural
Care Repatterning (Reconstruction) includes professional decisions and
actions that help a client to reorder, change, or modify their life ways for
new, different, and beneficial health care patterns while respecting their
cultural values and beliefs. Therefore, health professionals providing
culturally competence patient-centered care improve patient satisfaction,
quality of care, and access to health services leading to better health
outcomes for culturally diverse groups (Gallagher, 2011). Culturally competent care
and culturally-congruent actions place the universal principles of social
justice and human rights for people’s lives in the environment in which they
situated (Pacquiao, 2008). Culture influences how the health care providers and
patients perceive illness because different cultures have different values,
beliefs, and patterns of behaviors when caring for different health conditions
(Wayne, 2014). Therefore, health students need specific knowledge, attitudes,
and skills to be able to take care of people from different cultures. This will
improve the relationship between the patient and professional. Health students
should be culturally competent in all their encounters to optimize patient
outcomes. Also, cultural awareness makes the health students sensitive and
appreciative of the values, practices, and problem-solving skills from the
patient’s cultural background (Campinha-Bacote, 1994; Campinha-Bacote, 1997).
This helps to prevents cultural imposition which Madeline Leininger (1978)
defined as imposing one’s beliefs, values, habits, and problem-solving skills
upon another person’s culture.  Papadopoulos,
Tilki and Taylor (1998b) formed the Cultural
Competence Model which addressed the stages of developing
cultural competence; (1) Cultural
awareness (affective dimension): This is an in-depth self-examination of
one’s culture and professional back ground. The nature of construction of one’s
personal identity and its influence on their health belief is an essential
learning platform. (2) Cultural knowledge
(cognitive dimension): This is the process of seeking and obtaining
information on various cultures and ethnic groups. This can be achieved
through, education, exposure, and reading. It builds a firm understanding of
different cultures and helps one understand the links between personal position
among other cultures. (3) Cultural
sensitivity (attitudinal dimension): This is how health professionals view
patients in their care.This is the diagrammatic
presentation of the various components of this study and how they interact. Demographic
factors will influence how a student interacts with other people and their
environment, how they perceive health and practice healthcare, and how they
learn through various modes of education. With all these factors interacting
will in turn influences the student’s cultural awareness and competency.The CAS assessment tool was
developed by created by Catterson, Cookston, Martinz, and Rew (2003). The scale
was based on cultural competence elements, such as; cultural awareness,
cultural sensitivity, cultural knowledge, and cultural skills (Hadziabdic, et al, 2016). The 36 items designed to
measure cultural awareness where it is considered as the minimum level of
cultural competence. It was based on Pathways Model analysis (Hadziabdic, et
al, 2016) and consistent with Purnell Model of Cultural Competence theory
(Purnell and Paulanka, 2008). Psychometric validation
is the process of testing whether the instrument is acceptable in terms of
reliability and validity for the intended population and this for Japan and
Sweden, and also done for Portugal to make sure that it is representative of
the original internal reliability. The original reliability of the CAS
was done in United States of America on a population of 190 nursing students
and an overall Cronbach’s alpha coefficient of .82 was obtained and among the
CAS subscales it ranged from .71-.85 (Rew, et al, 2003). Among Japanese nursing
students (N=122) Cronbach’s alpha coefficient was .83 (Suzuki, et al, 2015) and
among Swedish nursing students (N=158) Cronbach’s alpha for the CAS subscales
ranged from .65-.86 (Hadziabdic, et al, 2016). Figure 2, shows that American
nursing students had higher Cronbach’s alphas for the CAS subscales. 

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