Teaching and Learning in Nursing (2011) 6, 84–88
www.jtln.org
Do nurse educators feel competent to teach cultural competency concepts? Sharon Starr PhD, RN a,⁎, Mona M. Shattell PhD, RN b , Clifford Gonzales MSN, CRNA b a b
Health Education, Gaston College, Dallas, NC 28034, USA School of Nursing, University of North Carolina at Greensboro, Greensboro, NC 27402, USA KEYWORDS: Cultural competency; Cultural competence; Nurse educators
Abstract Cultural competence has been proposed as one way to reduce health disparities in racial and ethnic minority populations. Nursing program accreditation standards mandate the inclusion of cultural competence concepts in the nursing curricula; however, are nursing educators prepared to teach culturally competency concepts and do nurse educators feel competent? The purposes of this article are to examine the literature about nurse educators' comfort with cultural competency concepts and to provide some suggestions for improvement. © 2011 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
The United States population is culturally and ethnically diverse (U.S. Census Bureau, 2004; U.S. Census Bureau, 2008). As outlined in the Institutes of Medicine landmark publication Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare (Smedley & Stith, 2003), health care disparities exist in these culturally and ethnically diverse populations. The current focus on health care disparities, patient-centered health care (American Hospital Association, 2009; Centers for Medicare and Medicaid Services [CMS], 2009; Institute of Medicine, 2009), and health care evaluation (CMS, 2009; Joint Commission on Accreditation of Healthcare Organizations, 2009) all support a role of nursing education in preparing nurses who are capable of caring for diverse populations. The multidimensionality of health disparities prevents a straightforward, distinct solution. One promising strategy that has emerged is cultural competence. Cultural competence means “having the knowledge, understanding, and skills about a diverse cultural group that allows the health ⁎ Corresponding author. E-mail address:
[email protected] (S. Starr)
care provider to provide acceptable cultural care” (Giger et al., 2007, p. 100). The demonstration of this knowledge, understanding, and skills is based on “diverse and relevant cultural experiences” (Doorenbos, Schim, Benkert, & Borse, 2005, p. 326). Cultural competence is believed to be an ongoing process as health care providers strive to “match their competencies to the specific populations and subgroups with whom they work” (Doorenbos et al., 2005, p. 326; Giger et al., 2007). In addition, cultural competence means to accept and respect differences and not letting one's personal beliefs have an undue influence on those whose worldview is different from one's own (Giger et al., 2007). Cultural competence in the health care system acknowledges and incorporates the importance of culture and adapts to meet the unique needs of ethnic and minority populations (Betancourt, Green, Carrillo, & Ananeh-Firepong, 2003). Increasing cultural competence of health care providers has been proposed to effectively address health disparities due to race and ethnicity (Betancourt, Green, Carrillo, & Park, 2005). Exploring the status of cultural competence in nursing education can lead to a greater understanding of the role that nursing education plays in promoting the delivery of
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Cultural competence culturally competent nursing care. Nursing program accreditation standards mandate the inclusion of cultural competence concepts in the nursing curricula (American Association of Colleges of Nursing [AACN], 2008a, 2008b; Cavillo et al., 2009; Commission on Collegiate Nursing Education [CCNE], 2008; National League for Nursing Accrediting Commission [NLNAC], 2008). Exposure to cultural competence content in nursing school curricula can positively influence nursing students' awareness of the concept (Campinha-Bacote, 2003; Doutrich & Storey, 2004; Sargent, Sedlak, & Martsolf, 2005); however, are nurse educators prepared to teach cultural competence concepts and do nurse educators feel competent? The purposes of this article are to examine the literature about nurse educators' comfort with cultural competency concepts and to provide some suggestions for improvement.
1. Background literature The concept of considering the cultural backgrounds of diverse clients when instituting nursing care was introduced by Madeleine Leininger in the 1950s when she initiated the field of transcultural nursing (Leininger & McFarland, 2006). Nursing as a profession has a primary interest in considering the culture of clients to provide holistic, culturally competent care to all clients. Nurses serve as cultural brokers as they help vulnerable clients from racial and ethnic minority groups navigate the confusing and often inaccessible health care system. To do this, nurses must increase their awareness and knowledge and improve their skills in providing culturally competent care to those from racial and ethnic minority groups and their families (Bau, 2007). Development of nursing students' cultural competence, knowledge, and skills during prelicensure nursing programs and for nurse educators through professional development activities are essential steps to ensure a culturally competent nursing workforce. Nurse educators have the potential to influence nursing students' understandings of cultural competence. However, studies that have examined the cultural competence of nurse educators revealed a lack of confidence in teaching the concepts. For example, Kardong-Edgren et al. (2005) used the Cultural Attitudes Scale, the Cultural Self-Efficacy Scale, and a response to an open-ended question to assess the cultural competence of 94 nurse educators attending two nursing conferences. Of the 94 nurse educators, 7 attended the National Association of Hispanic Nurses; all others attended the Mosby Nurse Educator Conference. The Cultural Attitudes Scale (Rooda, 1993) asks participants to respond to questions pertaining to their knowledge and attitudes specifically concerning the ethnic backgrounds of African American, Hispanic, and Asian Americans. The Cultural Self-Efficacy Scale used in this study was an updated version of the Transcultural Questionnaire (Bernal & Froman, 1987) that included assessment of confidence in
85 caring for individuals from four ethnic groups: Hispanics, African Americans, Southeast Asians, and Anglos (Kardong-Edgren et al., 2005). Kardong-Edgren et al. (2005) found moderate to positive attitudes toward and moderate to high confidence levels in cultural knowledge related to caring for Hispanics, Anglos, Asians, and African Americans. Overall, faculty expressed feeling inadequately prepared for caring for those from cultures different from their own (Kardong-Edgren et al., 2005). Factors that increased faculty members' comfort in delivering culturally competent care were continuing education courses, teaching cultural competence content in the curriculum, and repeated encounters caring for those from cultures different from their own. Sealey, Burnett, and Johnson (2006) used the Cultural Diversity Questionnaire for Nursing Educators to assess the cultural competence levels of 313 nurse educators in the state of Louisiana. The Cultural Diversity Questionnaire for Nursing Educators was a researcher-designed instrument that included researcher-developed items and items from various other tools (Sealey et al., 2006). Cultural knowledge and cultural encounters were the factors that were most predictive of the overall cultural competence of participants. Few nurse educators were prepared to teach transcultural nursing, and most did not express confidence in teaching this content (Sealey et al., 2006). Sargent et al. (2005) evaluated cultural competence levels of 51 nursing faculty members and first- and fourth-year prelicensure nursing students from a baccalaureate program in Ohio. Cultural competence content was integrated throughout the curriculum. The level of cultural competence of the faculty members was significantly higher than the first-year nursing students' levels but similar to the fourthyear nursing students who had been exposed to the content. Faculty members were chosen for the study due to their significant role coordinating the cultural competence content in the curriculum, which could have been a factor influencing their levels of cultural competence (Sargent et al., 2005; Tulman & Watts, 2008). A study by Ryan, Carlton, and Ali (2000) revealed a limited number of nurse educators with formal education in transcultural nursing. Ryan et al. (2000) surveyed all baccalaureate and higher degree National League for Nursing schools of nursing in the United States and found that of the 166 programs responding to a question about the number of faculty members with formal education to teach transcultural nursing, 80 (48%) reported they had none. Of the 163 programs responding to whether they had a sufficient number of faculty prepared in transcultural nursing, 22% said that they had, and 78% said that they had not. So, a dilemma exists—exposure to cultural competence content in nursing curricula has been proposed to positively influence levels of cultural competence in nursing students and nurse educators, yet many nurse educators do not feel confident in presenting the content. Moreover, there are insufficient numbers of nurse educators prepared in transcultural nursing.
86 Based on this evidence, the status of cultural competence in nurse educators depends in a large part on their exposure to cultural competence content, often in coordinating cultural competence activities for students. Some nursing educators are intimidated by the responsibility of teaching the content as they do not feel qualified unless they have had additional preparation in transcultural nursing or they have had repeated exposure to the content or to individuals from diverse cultures and ethnicities.
2. Implications The role of nursing education in improving delivery of culturally competent care in the existing health care system includes developing and shaping a culturally competent nursing workforce that can practice in multicultural practice environments with diverse populations (Siantz & Meleis, 2007). This begins by incorporating cultural competence concepts in the nursing curricula (Maddalena, 2009) and is aided through building policies and partnerships with community members, hospitals, primary care, long-term care, and public health facilities (Chrisman, 2007). Developing and shaping a culturally competent nursing workforce include creatively developing and implementing curricula for nurse educators. With many cultural competence nursing models and theoretical frameworks available (Campinha-Bacote, 2003; Giger & Davidhizar, 2007; Leininger & McFarland, 2006; Purnell, 2008; Schim, Doorenbos, Benkert, & Miller, 2007; Spector, 2008; Warren, 2002), using a model to guide curricular development is an important first step (Lipson & Desantis, 2007). Guidance about desirable curricular competencies along with resources to aid in cultural competence curricular development and implementation is also available (AACN, 2008a, 2008c; Bosher & Pharris, 2009; Cavillo et al., 2009). Collaboration with international nursing programs during curricular development is one suggestion to enhance incorporation of cultural competence concepts (Fitzpatrick, 2007). The dilemma for nursing education is that many nurse educators do not feel comfortable teaching cultural competence content. In addition, the possibility exists that some educators are simply more interested in teaching concepts other than cultural competence. Inclusion of a transcultural specialty focus at the master's level (Lipson & Desantis, 2007) and including transcultural exemplars in nurse educator master's programs could prepare nurse educators who are more confident with cultural competency. These measures, in addition to institutional support for faculty development in transcultural nursing concepts (Cavillo et al., 2009), must be available to increase the numbers of certified nurse educators. In addition, the numbers of nurse educators from diverse backgrounds must be increased (Hinds, 2008). Ensuring the pipeline for
S. Starr et al. potential nurse educators from diverse backgrounds can begin at the high school level (or earlier) and extend through the university experience with enrichment experiences and increased support (Pacquiao, 2007). If needed, culturally and ethnically diverse students can be given more flexibility in time to complete plans of study, admission criteria can be more flexible, and more financial support can be made available (Pacquiao, 2007). Most of the studies on faculty members' competence in teaching cultural competency concepts were conducted in baccalaureate nursing programs, or the studies were not specific to associate degree (AD) program faculty. More research and training are needed that specifically examines AD program faculty, especially in light of our state (North Carolina) community college system, which recently instituted a concept-based curriculum for the entire community college system. Cultural competence is one of the concepts. Therefore, education and training of AD faculty in cultural competence concepts are needed. Because AD faculty are often not specialized but are generalized to teach in multiple clinical areas, it is likely that a disparity or lack of transculturally trained AD faculty members exists. Research is needed to assess the preparation and competence of AD faculty to adequately teach cultural competence concepts.
3. Conclusion Health disparities exist for the diverse populations encountered in the health care system. The delivery of culturally competent nursing care is one strategy proposed to address these disparities. Nursing education, on several levels, influences the delivery of culturally competent care. Preparation of additional nurse educators who feel confident and equipped to teach transcultural nursing concepts and cultural competence and increasing diversity among nursing educators are paramount to assure that nursing students are exposed to the most relevant and appropriate educational experiences.
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