CulturalCompetence in the ClassroomThe task of deliveringculturally competent education belongs to the faculty. Health school facultymembers need to be aware of how their own cultures influence various aspects oftheir lives like how they educate nursing students. There are four dimensionsof teaching related to cultural diversity (Rew, et al, 2003); (1) Awareness ofthe role one’s cultural background and experiences play in forming beliefs,attitudes, and behaviors, (2) Knowledgeand understanding of how students from different cultural or ethnic backgroundsmay experience the classroom differently, (3) Incorporation of diverse culturaland social perspectives in the curriculum, and (4) Use of a variety of teachingmethods to more effectively accommodate learning styles of students fromdifferent backgrounds.Cultural awareness andsensitivity affect not only the way health care information is delivered butalso how students are able to internalize the information (Redican, et al, 1994;Rew, et al, 2003). There are various studies using separate approaches toachieving cultural competence among nursing students.
One study looked at theeffectiveness of using the BaFa BaFa and Barnga games for learning culturalawareness (Koskinen; et al, 2008.) These games simulate cultural conflict amongthe players and guide them to become aware of their own cultural stereotypes,prejudices, and misunderstandings. This study showed that these are powerfulmethods to learn cultural awareness in nursing. One quasi-experimental study,students were placed in experimental and control groups and assessed using thepretest-posttest design (Hsui-Chin; et al, 2011). They found that the studentsin the experimental group had a significant increase in their culturalknowledge and cultural competence. This was supported by Jeffreys (2011) studywere assessment of students’ transcultural self-efficacy perceptions found thateducational interventions influenced transcultural efficacy changes andstudents regardless of cultural background can benefit from formalized culturalcompetence education.
Kratzke and Bertolo (2013) carried out a cross-culturalexperiential learning exercise as an educational approach to culturalcompetence for health students. Reflective writing was used to elicit students’attitudes of other cultures and their coping skills. The study showed the needfor student academic preparation to enhance cultural competence. There is no onecurricular approach more effective than another in achieving essential culturalcompetency among health students. Faculty members must know their students’ andtheir cultural needs to will facilitate the process of students developingtheir own racial identities.CulturalCompetence in Clinical Practice and ResearchBeyond the classroom,students also develop cultural competence in the clinical practice andresearch. Students are taught by their lectures and professional health workersduring clinical practice. Ozkana (2013) concluded that clinical stimulationsupports cultural competent care by providing as safe environment to conductculturally appropriate assessment, elicit students’ attitudes towardscross-cultural situations and improve communication, critical thinking, and healthcareskills.
But gaps still exist regarding the effectiveness of clinical simulationto enhance cultural competent nursing care. This was reflected in a qualitativestudy found by Berger, Conroy, and Peerson, (2011) in Australia found thatclinical supervisors were unable to define cultural competency in ways thatcould enable them to apply the concept to clinical training of students.Contrary to Berger’s results, another study found that if students and clinicalinstructors worked closely together on issues surrounding cultural diversitythen cultural competence can be achieved (Jeffreys, 2013). CulturalCompetence and Patient Centered CarePatient centered care isthe practice of caring for patients and their families in ways that aremeaningful and valuable to the individual patient. The Picker Institute (1987)came up with eight principles of patient centered care; (1) Respect for patientpreferences, (2) Coordination and integration of care, (3) Information andeducation, (4) Physical comfort, (5) Motional comfort (6) Involvement of familyand friends, (7) Continuity and transition, and (8) Access to care. Understanding,integration, and application of these principles leads to provision of holisticpatient care. Cultural processesdiffer within the same ethnic or social group because of differences in agecohort, gender, political association, class, religion, ethnicity, andpersonality (Epner and Baile, 2012).
Evidence shows the multicultural approachto cultural competence results in stereotypical thinking rather than clinicalcompetence. Patient centered care relies on identifying decision-makingpreferences, communication styles, family roles, gender, mistrust, and racismissues among other factors. It also helps overcome cultural imposition. Therefore,health professionals providing culturally competence patient-centered care improvepatient satisfaction, quality of care, and access to health services leading tobetter health outcomes for culturally diverse groups (Gallagher, 2011)ConceptualFrameworkMadeleine M. Leininger(1991) the founder of the transcultural nursing theory, defined transculturalnursing as a comparative study of cultures to understand similarities anddifferences among human groups.
Inher Sunrise Modelof Cultural Care Diversity and Universality,Madeleine M. Leininger (2001) addressed the importance of knowledgeabout individuals, families, communities, and institutions in culturally diversehealthcare systems. She also addressed the generic (folk, indigenous, orhome-made) care systems in patient care which are culturally learned andtransmitted knowledge and skills used to provide assistive, supportive,enabling, or facilitative acts towards evident or anticipated needs to improvehealth. Therefore, transcultural health care results from caring forpatients from other cultures than one’s own culture. She also formulated the three modes of nursing care decisionsand actions; (1) Cultural CarePreservation (Maintenance) includes professional decisions and actions thathelp people of a particular culture to retain relevant care values so as tomaintain their wellbeing. (2) CulturalCare Accommodation (Negotiation) includes professional decisions andactions that help people of a particular culture to adapt or negotiate withothers for a satisfying health outcome. (3) CulturalCare Repatterning (Reconstruction) includes professional decisions andactions that help a client to reorder, change, or modify their life ways fornew, different, and beneficial health care patterns while respecting theircultural values and beliefs. Therefore, health professionals providingculturally competence patient-centered care improve patient satisfaction,quality of care, and access to health services leading to better healthoutcomes for culturally diverse groups (Gallagher, 2011).
Culturally competent careand culturally-congruent actions place the universal principles of socialjustice and human rights for people’s lives in the environment in which theysituated (Pacquiao, 2008). Culture influences how the health care providers andpatients 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 willimprove the relationship between the patient and professional. Health studentsshould be culturally competent in all their encounters to optimize patientoutcomes. Also, cultural awareness makes the health students sensitive andappreciative of the values, practices, and problem-solving skills from thepatient’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 skillsupon another person’s culture.
Papadopoulos,Tilki and Taylor (1998b) formed the CulturalCompetence Model which addressed the stages of developingcultural competence; (1) Culturalawareness (affective dimension): This is an in-depth self-examination ofone’s culture and professional back ground. The nature of construction of one’spersonal identity and its influence on their health belief is an essentiallearning platform. (2) Cultural knowledge(cognitive dimension): This is the process of seeking and obtaininginformation on various cultures and ethnic groups. This can be achievedthrough, education, exposure, and reading. It builds a firm understanding ofdifferent cultures and helps one understand the links between personal positionamong other cultures. (3) Culturalsensitivity (attitudinal dimension): This is how health professionals viewpatients in their care.
This is the diagrammaticpresentation of the various components of this study and how they interact. Demographicfactors will influence how a student interacts with other people and theirenvironment, how they perceive health and practice healthcare, and how theylearn through various modes of education. With all these factors interactingwill in turn influences the student’s cultural awareness and competency.The CAS assessment tool wasdeveloped by created by Catterson, Cookston, Martinz, and Rew (2003).
The scalewas based on cultural competence elements, such as; cultural awareness,cultural sensitivity, cultural knowledge, and cultural skills (Hadziabdic, et al, 2016). The 36 items designed tomeasure cultural awareness where it is considered as the minimum level ofcultural competence. It was based on Pathways Model analysis (Hadziabdic, etal, 2016) and consistent with Purnell Model of Cultural Competence theory(Purnell and Paulanka, 2008). Psychometric validationis the process of testing whether the instrument is acceptable in terms ofreliability and validity for the intended population and this for Japan andSweden, and also done for Portugal to make sure that it is representative ofthe original internal reliability.
The original reliability of the CASwas done in United States of America on a population of 190 nursing studentsand an overall Cronbach’s alpha coefficient of .82 was obtained and among theCAS subscales it ranged from .71-.
85 (Rew, et al, 2003). Among Japanese nursingstudents (N=122) Cronbach’s alpha coefficient was .83 (Suzuki, et al, 2015) andamong Swedish nursing students (N=158) Cronbach’s alpha for the CAS subscalesranged from .65-.86 (Hadziabdic, et al, 2016).
Figure 2, shows that Americannursing students had higher Cronbach’s alphas for the CAS subscales.