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Nurse Educator Vol. 39, No. 4, pp. 193-198 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
A Comparative Study of Cultural Competence Curricula in Baccalaureate Nursing Programs Donna M. Mesler, PhD, RN, CPNP This study evaluated the cultural competence and cultural confidence (self-efficacy) levels of baccalaureate nursing students in 3 types of programs: those with integrated cultural content, those with a required nonnursing culture course, and those with a culture course in nursing. A sample of 759 students participated. Only the students in the nursing culture course program reached a level of cultural competence. Cultural competence and confidence increased significantly from freshman to junior year in all 3 programs. Keywords: baccalaureate curriculum; cultural competence; nursing education; nursing students
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ealthcare disparities have been well documented in reports generated about the current healthcare system in the United States. Ethnic minority groups do not have equal access and often do not receive equal care once they do access the healthcare system. The ethnic minority groups who are now experiencing these disparities are increasing in number and are expected to become the majority population by the year 2042.1 One way to address this potentially increasing healthcare disparity and engage minority populations more effectively in the evolving healthcare system is to provide more culturally competent healthcare. The goal of culturally competent care is to create a healthcare system and workforce that are capable of delivering the highest quality care to every patient regardless of race, religion, ethnicity, culture, or language proficiency.2 Nurses must be culturally competent to be effective in integrating their patients’ health beliefs and practices into plans of care. Studies have shown that nurses do not always practice in a culturally competent manner.3-7 In an effort to address the need for and lack of cultural competence in practice, nurse educators have an obligation to provide this education to their students to help them become culturally competent practitioners and provide more effective care and better outcomes for their patients.8-12 Author Affiliation: Assistant Professor, College of Nursing, Seton Hall University, South Orange, New Jersey. The author was a participant in the 2013 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education and Pocket Nurse. The author declares no conflicts of interest. Correspondence: Dr Mesler, College of Nursing, Seton Hall University, 400 S Orange Ave, South Orange, NJ 08802 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducator online.com). Accepted for publication: February 15, 2014 DOI: 10.1097/NNE.0000000000000040
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Some baccalaureate nursing programs integrate or thread culture content throughout the curriculum, whereas others require a nursing or nonnursing course on culture.13,14 No research has been found in the literature to support one program model over another.
Review of the Literature National Mandates for Cultural Competence in Nursing Programs In 2006, the American Association of Colleges of Nursing established the initiative Preparing a Culturally Competent Nursing Workforce. The purpose of this document was to create cultural competencies for baccalaureate nursing education.8 These competencies were developed in accordance with the Essentials of Baccalaureate Nursing Education,11 which provide direction and recommendations for nursing curricula. Calvillo et al15 predicted that these cultural competencies may become increasingly integrated into accreditation expectations and licensure examinations. The 5 cultural competencies are applying knowledge of social and cultural factors that affect nursing and healthcare; using relevant data sources and best evidence in providing culturally competent care; promoting achievement of safe and quality outcomes of care for diverse populations; advocating for social justice, including commitment to the health of vulnerable populations and eliminating health disparities; and participating in continuous self-cultural competence development.11 Cultural competence is a continuing practice that evolves over time and requires a lifelong commitment.15 Students should be encouraged to engage in self-awareness and self-reflection about values, prejudices, and stereotypes throughout their education and nursing careers. Current Trends in Cultural Competence Education A variety of innovative approaches to teaching cultural competence have been described in the literature and range Volume 39 & Number 4 & July/August 2014
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from integrating cultural material throughout the curriculum to entire courses devoted to cultural issues to pseudoimmersion and full immersion programs. Pseudo-immersion experiences take place when students, usually as part of their clinical education, visit cultural or ethnic communities for the day to care for patients and return back home or back to the campus at night.16-18 Other nursing programs offer international immersion experiences,19-21 where students live among the culture they are serving for a short period of time. For example, immersion studies have taken place in Honduras, Guatemala, Ireland, and Africa. Other teaching methodologies for cultural competence found in the literature are ethnographies, role play, works of literary journalism, and case studies.22-27 These teaching modalities may be used within any of the 3 forms of cultural competence programs previously identified (culture course, nonnursing culture course, or integrated).
Sample The sample consisted of 759 nursing students in 6 baccalaureate nursing programs. The 6 programs were chosen by convenience, as they were all within a reasonable driving distance from each other and those who had a nursing or nonnursing culture course required it during the sophomore year. The nursing culture course was a 3-credit required course taught by nursing faculty in both programs included in this study. The nonnursing culture course was also a 3-credit required course taught in the philosophy, sociology, or anthropology departments. Course objectives and syllabi were reviewed and were similar across programs. The programs that were integrated had culture content taught throughout the nursing courses. Culture content was included as a course objective and as required reading in the integrated programs.
Theoretical Foundation
Instruments Three instruments were used in the study: a demographic questionnaire, the Inventory to Assess the Process of Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R)31 to measure cultural competence, and the Transcultural Self-efficacy Tool (TSET)29 to measure self-efficacy or confidence. The demographic questionnaire asked respondents about gender, age, racial and ethnic background, highest academic degree, previous cultural competence education, and whether they valued cultural competence education. The IAPCC-R was developed by Campinha-Bacote31 and is based on her model of cultural competency. The IAPCC-R contains 25 items, 5 of which address each of 5 constructs inherent in this model. It is a self-administered tool that uses a 4-point Likert scale, with responses ranging from strongly agree to strongly disagree, very knowledgeable to not knowledgably, very comfortable to not comfortable, very aware to not aware, and very involved to not involved. There is no neutral scoring category, as there are only 4 points and some questions are negatively phrased for reverse scoring (1-to-4 or 4-to-1 point order). The total score, as summed across the 5 constructs, represents the level of cultural competence. There are 4 major score ranges: culturally incompetent (25-50), culturally aware (51-74), culturally competent (75-90), and culturally proficient (91-100). The higher the score, the higher level the level of cultural competence attained. The instrument has content validity and reliability, which was established by more than 10 previous studies with baccalaureate nursing students, nursing faculty, nurse practitioners, and registered community nurses.32-35 Reliability was assessed with Cronbach’s !, with coefficients of .85 or higher in each of these studies. Cronbach’s ! for the IAPCC-R in this study was .78, showing good reliability. The TSET was developed by Jeffreys29 to measure perceived self-efficacy or confidence in nursing students who were learning about or implementing the nursing process with diverse populations. This tool consists of 83 items designed to measure self-efficacy or confidence in performing general transcultural healthcare skills among diverse populations. The TSET is based on Bandura’s theory of self-efficacy and Jeffreys’ Model of Cultural Competence and Confidence.29
This study was based on 2 models of cultural competence. The 1st is the Process of Cultural Competency Model, which contains 5 constructs that should be addressed while seeking to become culturally competent: Cultural Desire, Awareness, Knowledge, Skill, and Encounters.28 According to this model, nurses must continuously strive to become culturally competent. Attaining cultural competence is a fluid, ongoing process. The second model that provided the foundation for this study was the Model of Cultural Competence and Confidence.29 This model is based on Bandura’s30 theory of selfefficacy, which states that individuals can learn if they are motivated and perceive that they are confident in learning. This motivation to learn is similar to Campinha-Bacote’s construct of desire, which is a necessary prerequisite to the 4 constructs. According to Jeffreys’ model, as individuals feel more confident in their own cultural competence, actual cultural competence increases. In the literature, within this model, the terms cultural competence and cultural confidence may be used interchangeably.
Purpose The primary purpose of this study was to evaluate the cultural competence and cultural confidence (self-efficacy) levels of baccalaureate nursing students in 3 different types of programs: those with integrated cultural content, those with a required nonnursing culture course, and those with a culture course in nursing. The secondary purpose was to determine how students transition across their academic journey to cultural competence, from freshman year (baseline) to juniors (after a culture course and preclinical education) to seniors (graduating practitioners).
Methodology Design This study used an exploratory, cross-sectional, betweengroups design. Nursing students’ cultural competence (measured directly) and self-efficacy or confidence (measured by how competent students perceived themselves to be) were compared in 3 different types of programs (nursing culture course, nonnursing culture course, and culture content integrated throughout the nursing programs) across 3 academic levels (freshman, junior, and senior). 194
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The TSET is a 10-point Likert scale ranging from 1 (not confident) to 10 (totally confident). There are 3 subscales of the TSET: cognitive, practical, and affective skills. The cognitive subscale contains 25 items and evaluates how confident students are with their cultural knowledge. The practical subscale contains 28 items and measures students’ confidence at interviewing patients of different cultural backgrounds to learn their values and beliefs. The affective subscale contains 30 items and addresses values, attitudes, and beliefs that students have related to cultural awareness. Previous research has established the validity and reliability of the TSET. The TSET is an effective tool that measures cultural competence of nursing students based on self-efficacy or confidence that students feel. Cronbach’s ! for this study was .986 for the TSET, showing good reliability. The level of cultural competence for nursing students was measured by calculating the individual and mean scores of the IAPCC-R, and the level of self-efficacy was measured by calculating the individual and mean scores of the TSET.
Data Collection The study had institutional review board approval. Data were collected during the first 2 weeks of the fall semester from freshmen and juniors. Students started clinical education during the junior year in all programs included in this study. Sophomores were excluded because students who took a culture course did so during the sophomore year. Because of time constraints, data were collected from seniors at the end of the fall semester instead of the end of the spring semester. Freshman data were considered baseline, junior-level data were considered post culture course (if there was one) as well as preclinical. Senior-level data were considered to be the final product. Data Analysis Frequency distributions were conducted on the demographic variables and correlations were done using Spearman >. A 2-way, 3 3 (3 academic levels and 3 program types) analysis of variance (ANOVA) was conducted to examine the relationships between the IAPCC-R and TSET scores and the type of program (nursing culture course, nonnursing culture course, and integrated program) and academic level (freshman, junior, and senior). Tukey honestly significant difference (HSD) test was conducted where significant differences were found on the ANOVA to show specific interactions. All the data were analyzed using Predictive Analysis Software, Version 18 (PASW 18) (SPSS Inc, Chicago, IL).
Results Demographics The Table, Supplemental Digital Content 1, shows the demographic frequencies and percentages (http://links.lww.com/NE/A130). As expected, about 90% of the participants were women, and most of the students were 18 to 27 years old. Most students in the nursing and nonnursing programs were white. Most students in the integrated program were black/African American. Otherwise, the demographics were similar between programs. Spearman > correlations were conducted on all demographic information and compared with the IAPCC-R and TSET scores. As age increased, IAPCC-R and TSET scores increased (P G .01). Students with past higher Nurse Educator
degrees scored significantly higher on both instruments (P G .01). Race/ethnicity also correlated with higher IAPCC-R but not TSET scores. The ethnic groups in the study scored significantly higher than the white group on the IAPCC-R (P G .05), and students with higher degrees also scored significantly higher (P G .01) on both instruments. Students who believed cultural competence education is important scored significantly higher (P G .05) on both instruments.
Overview of Cultural Competence and Self-efficacy Levels There were 363 subjects in the group with the nursing culture course, 237 subjects in the group with the nonnursing culture course, and 159 subjects in programs in which the cultural content was integrated. There was a significant positive correlation between the total survey scores on the IAPCC-R and TSET (r = 0.46, P = .001). As cultural competence increased, so did students’ self-efficacy or confidence. The mean IAPCC-R and TSET scores were similar for freshmen in all 3 types of culture programs. Freshmen scored in the culturally aware category (51-75 points of a possible 100), with a mean score of 67.94 in all 3 programs on the IAPCC-R. In self-efficacy (TSET), they scored between 6 and 7, which is considered mildly competent on a scale of 1 (not confident) to 10 (totally confident). Students who had the nursing culture course were the only group to attain a level of culturally competent (score 975 points) in the junior year, with mean scores of 75.10 and then to increase mean scores again in the senior year to 75.75, the highest level of the 3 programs. Students who had the nonnursing culture course reached a mean IAPCC-R score of 72.32 in the junior year (culturally aware) and had a mean score of 73.11 in the senior year (culturally aware). Students in the integrated group reached a mean score of 72.15 in the junior year and increased to 73.90 (culturally aware) in the senior year. The TSET scores increased in the nursing culture course group in the junior year to 7.72 and in the senior year to 7.82, which is moderate to high confidence. The nonnursing culture course group scores decreased slightly from junior (7.87) to senior (7.63) year and were the lowest of the 3 programs in this study. Scores for students who had integrated experiences increased from 7.28 to 8.11, which is the highest mean score for self-efficacy. Table 1 shows IAPCC-R scores based on program (nursing culture course, nonnursing culture course, and integrated programs) and academic level. Table 2 presents TSET scores. The ANOVA indicated significant differences across programs (F = 5.56, df = 2, P = .001) and academic level (F = 50.16, df = 2, P = .001) for cultural competence. Tukey HSD post hoc analysis revealed a significant difference in cultural competence between students who had nursing and nonnursing culture courses. Students in the programs with a nursing culture course scored significantly higher on the IAPCC-R than did those in the programs with a nonnursing culture course (P = .001). There also was a trend toward higher cultural competence between students who had a nursing culture course and those in the integrated program. Post hoc analysis (Tukey HSD) showed that in all 3 program types, IAPCC-R scores improved significantly from freshman to junior and freshman to senior year but did not improve significantly from junior to senior year. Volume 39 & Number 4 & July/August 2014
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Table 1. Mean IAPCC-Ra Scores for Program Type and Academic Year (N = 759) Academic Level Freshmen (n = 209) Mean (SD) n Junior (n = 322) Mean (SD) n Senior (n = 228) Mean (SD) n
Nursing Course (n = 363)
Nonnursing (n = 237)
Integrated (n = 159)
67.88 (6.60) 101
67.37 (7.15) 62
68.78 (6.67) 46
75.10 (6.98)b 164
72.32 (6.71)b 103
72.15 (7.73)b 55
75.63 (5.45)b 98
73.11 (6.62)b 72
73.90 (6.84)b 58
a
Transcultural CARE Associates.31 P G .05 from freshman to junior year and freshman to senior year in all 3 programs, not junior to senior year. Only programs with the Nursing Course reached Cultural Competence and sustained that level, even increasing slightly in senior year. This was a significant increase compared with Nursing Culture Course Program not Integrated. b
There were trends in self-efficacy across the 3 types of programs, although there were no significant differences in scores. Similar to cultural competence levels, ANOVA indicated significant differences in self-efficacy across academic levels (F = 35.17, df = 2, P = .001). Post hoc analysis (Tukey HSD) indicated significant differences from freshman to junior year and from freshman to senior year (P G .001) but not from junior to senior year in any of the 3 programs. In summary, IAPCC-R and TSET scores increased in a statistically significant manner in all 3 programs from freshman to junior year. They did not increase significantly from junior to senior year. Students in the nursing culture course program scored significantly higher (P G 0.05) on the IAPCC-R than did those on the nonnursing culture course program and higher, but not significantly, than did those on the integrated program. Students in the integrated program scored highest on the TSET, followed by those in the nursing culture course program and then those in the integrated program. These differences were not significant but may indicate a trend. Students in the nursing culture course program were the only ones to reach a level of cultural competence, which was achieved in the junior year and maintained in the senior year.
Discussion Demographic results were consistent with some of the findings from previous studies. As age and past academic degree increased, so did cultural competency, probably as
a result of more life experience. Students from nonmajority ethnic groups had significantly higher cultural competence, but not confidence. This suggests that although they were more culturally competent, they did not feel confident in their own ability. More research is necessary to explain these results. Students who believed that cultural competence education is important were significantly more culturally competent and confident. This reinforces both theoretical models discussed previously in that desire or motivation to become culturally competent is the foundation on which cultural competence is based. There were several significant findings from this study. Students who took a nursing culture course were the only ones to reach the level of cultural competence. Curricular changes should occur in schools of nursing such that they consider including a nursing culture course, taught by nursing faculty who are culturally competent practitioners. KardongEdgren32 found that nursing faculty are culturally competent, according to their scores on the IAPCC-R. This suggests that culturally competent nursing faculty may be more effective than nonnursing faculty at guiding nursing students to become culturally competent practitioners. Programs offering nonnursing culture courses and integrating culture content material should explore changing the way they teach to incorporate a nursing culture course as this has been shown in this study to prepare students with higher cultural competence levels. Nonnursing culture courses may
Table 2. Mean TSETa Scores for Program Type and Academic Year (N = 759) Academic Level Freshman (n = 209) Mean (SD) n Junior (n = 322) Mean (SD) n Senior (n = 228) Mean (SD) n
Nursing Course (n = 363)
Nonnursing (n = 237)
Integrated (n = 159)
6.86 (1.42) 101
6.87 (1.56) 62
6.57 (1.87) 46
7.72 (1.16)b 164
7.87 (1.32)b 103
7.28 (1.75)b 55
7.82 (1.04)b 98
7.63 (1.35)b 72
8.11 (1.34)b 58
a
10-point Likert scale.29 P G .05 in all programs between freshman and junior year and freshman and senior year, not between junior and senior year. No significant differences between programs. b
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be housed in departments such as philosophy, anthropology, and sociology and do not take into account nursing care and cultural implications in health and illness. Campinha-Bacote28 suggested that learning about cultures (cultural knowledge) without incorporating the other aspects of cultural competence (desire, encounters, skill, and awareness) may lead to stereotyping. It is suspected that in integrated programs cultural competence education may be in the ‘‘background’’ of courses, with an emphasis on theoretical knowledge focused on passing the National Council Licensure Examination for Registered Nurses.14,36 No literature was found that explored relationships between cultural competence scores and self-efficacy scores among baccalaureate nursing students, nor have any studies produced a baseline measure of cultural competence in entering baccalaureate nursing students. One way to address this lack of information would be to complete a longitudinal study and follow students through their educational program and into practice. More comparison studies using the same variables in other parts of the country are necessary. It would be beneficial to determine how more culturally and racially diverse areas compare with those that are not as diverse. Mean cultural competence and self-efficacy scores for students in all 3 program types had significant increases from freshman to junior year and freshman to senior year but not between the junior and senior years. This finding may be a result of the early data collection from seniors who were surveyed at the end of the first semester of their senior year. With more time, scores may have increased by the end of the senior year. Another factor is that the nursing and nonnursing culture courses were taken during the sophomore year, explaining the increase in scores from the freshman to junior years among students who had nursing and nonnursing culture courses. Evaluation of pseudo-immersion and immersion experiences in nursing clinical courses is necessary, as they have been shown in the literature16-21 to be effective in increasing cultural competence. There is a category called ‘‘culturally proficient’’ (scores of 91-100) on the IAPCC-R tool. This category is higher than the Culturally Competent category (75-90) on the tool and is rarely achieved by nursing students or faculty, according to the literature. More immersion experiences may enable nursing students and graduates to move above the level of cultural competence toward cultural proficiency. By evaluating the outcomes of using pseudoimmersion and immersion experiences in addition to the nursing culture courses, especially during the junior and senior years, it may be possible to increase students’ cultural competence and self-efficacy further. This was the first study to examine the cultural competence and self-efficacy levels of students in the freshman year to ascertain what the baseline levels are for incoming baccalaureate nursing students. Other studies have measured cultural competence and self-efficacy in graduating students or after an intervention, without knowing baseline data. Freshman baseline levels for cultural competence were in the culturally aware category (mean, 67.83). If they are ending their education at the same level, more needs to be done to graduate practitioners who are culturally competent and strive for cultural proficiency. Baseline freshman levels for self-efficacy were in the middle confidence area Nurse Educator
(mean, 6.80), but this increased significantly by the junior year. This can be explained for the students who had a culture course in the sophomore year, but exactly how this education was imparted in the integrated programs is unclear.
Study Limitations The limitations of this study are similar to those of other self-reported surveys. Students may have answered according to their own perceptions of what the researchers expected and not answered honestly about themselves. This was a convenience sample of baccalaureate nursing students attending 6 different colleges of nursing in a mid-Atlantic state. Senior nursing students were studied at the end of the first semester of their senior year, rather than at the end of their program, nearer to graduation in the second semester of their senior year. Had additional time been given to these senior students to further apply their knowledge, it is possible that their cultural competence and confidence would have increased to a significantly higher level by the end of the program when compared with junior year levels. There is no way to control for differences in the way cultural competence was taught between 3 programs (6 schools) that were included in this study. Data in this study were collected at singular points in time rather than longitudinally. It is possible that there were be differences in outcomes had a 4-year longitudinal study been designed instead, where students’ cultural competence and self-efficacy were followed over the length of their BSN programs. Lastly, the findings are generalizable only to the nursing programs included in this study. More research is necessary to see if these results hold true for other programs.
Conclusion Research has shown that nurses do not always practice in a culturally competent manner. This study suggests that we can improve the cultural competence of future nurses by changing the curriculum in which they learn. Culturally competent nurses provide holistic care for their patients, incorporating culture into their plan of care. Providing the most effective cultural competence education to nursing students is 1 way nurse educators can ensure better patient outcomes and less disparities in the future for a demographically changing healthcare system.
References 1. Quick Facts. US Census Bureau Web Site. Available at http:// www.census.gov/population/projections/data/national/ 2012/downloadablefiles.html. Published November 2012. Accessed February 14, 2014. 2. Betancourt J, Green A, Carrillo E, Park E. Cultural competence and health care disparities: key perspectives and trends. Health Aff. 2005;24(2):499-505. 3. Cortis JD. Meeting the needs of minority ethnic patients. J Adv Nurs. 2004;48(1):51-58. 4. Gerrish K. Individualized care: its conceptualization and practice within a multiethnic society. J Adv Nurs. 2000;32(1):91-99. 5. Gerrish K. The nature and effect of communication difficulties arising from interactions between district nurses and south Asian patients and their carers. J Adv Nurs. 2001;33(5):566-574. 6. Jirwe M, Gerrish K, Emani A. The theoretical framework of cultural competence. J Multicult Nurs Health. 2006;12(3):6-16. Volume 39 & Number 4 & July/August 2014
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7. McKinley D, Blackford J. Nurses’ experiences of caring for culturally and linguistically diverse families when their child dies. Int J Nurs Pract. 2001;7(4):251-256. 8. Preparing a culturally competent nursing workforce initiative. 2006. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/Media/NewsWatch/2006/ Dec.htm#1. Accessed December 28, 2009. 9. Cultural competency in baccalaureate nursing education. 2008. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/Education/pdf/competency.pdf. Accessed December 28, 2009. 10. Final draft of the revised baccalaureate essentials. 2008. American Association of Colleges of Nursing Web site. Available at http:// www.aacn.nche.edu/Education/pdf/DEdraft.pdf. Accessed December 28, 2009. 11. Toolkit of resources for cultural competence education for baccalaureate nurses. 2008. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/Education/ pdf/toolkit.pdf. Accessed December 28, 2009. 12. Green-Hernandez C, Quinn A, Denman-Vitale S, Falkenstern S, Judge-Ellis T. Making nursing care culturally competent. Holist Nurs Pract. 2004;18(4):215-218. 13. Principles and recommended standards for cultural competence education of healthcare professionals. 2003. California Endowment Web site. Available at http://www.calendow.org/uploadedfiles/ principles_standards_cultural_competence.pdf. Accessed February 14, 2014. 14. Lipson JG, Desantis LA. Current approaches to integrating elements of cultural competence in nursing education. J Transcult Nurs. 2007;18(1):10S-20S. 15. Calvillo E, Clark L, Ballantyne JE, Pacquiao D, Purnell L, Villarruel AM. Cultural competency in baccalaureate nursing education. J Transcult Nurs. 2009;20(2):137-145. 16. Amerson R. The impact of service learning on cultural competence. Nurs Educ Perspect. 2010;31(1):18-22. 17. Doutrich D, Storey M. Education and practice: dynamic partners for improving cultural competence in public health. Fam Community Health. 2004;27(4):298-307. 18. Kratzke C, Bertolo M. Enhancing students’ cultural competence using cross-cultural experiential learning. J Cult Divers. 2013;20(3):108-111. 19. Caffrey R, Neander W, Markle D, Stewart B. Improving the cultural competence of nursing students: results of integrating
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cultural content in the curriculum and an international immersion experience. J Nurs Educ. 2005;44(5):234-240. 20. Levine M, Perpetua E. International immersion programs in baccalaureate nursing education: professor and student perspectives. J Cult Divers. 2006;13(1):20-26. 21. Carpenter L, Garcia A. Assessing outcomes of a study abroad course for nursing students. Nurs Educ Perspect. 2012;33(2): 85-89. 22. Anderson K. Teaching cultural competence using an exemplar from literary journalism. J Nurs Educ. 2004;43(6):253-259. 23. Brennan S, Schulze M. Cultural immersion through ethnography: the lived experience. J Nurs Educ. 2004;43(6):285-288. 24. Cagle CS. Student understanding of culturally and ethically responsive care. Nurs Educ Perspect. 2006;27(6):308-314. 25. Sheerer R, Davidhizar R. Using role play to develop cultural competence. J Nurs Educ. 2003;42(6):273-276. 26. Slade D, Thomas-Connor I, Tsao TM. When nursing meets English: using a pathography to develop nursing students’ culturally competent selves. Nurs Educ Perspect. 2008;29(3):151-155. 27. Long T. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012;19(3):102-108. 28. Campinha-Bacote J. The process of cultural competency in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13:181-184. 29. Jeffreys MR. Teaching cultural competence in nursing and health care. 2nd ed. New York, NY: Springer; 2010. 30. Bandura A. Self-efficacy: The Exercise of Control. New York, NY: W.H. Freeman and Company; 1997. 31. Inventory for assessing the process of cultural competence among healthcare professionals—revised. 1999. Transcultural CARE Associates Web site. Available at http://www.transculturalcare .net/. Accessed April 28, 2011. 32. Kardong-Edgren S. Cultural competence of baccalaureate nursing faculty. J Nurs Educ. 2007;46(8):360-367. 33. Koempel V. Cultural Competence of Certified Nurse Practitioners [master’s thesis]. Mankato, MN: Minnesota State University; 2003. 34. Patsdaughter C. A streetcar named more than desire: cultural competence revisited. J Cult Divers. 2006;13(4):175-176. 35. Spencer W, Cooper-Braithwaite A. Reliability Analysis of the IAPCC-R. Toronto, ON, Canada: University of Toronto; 2003. 36. Boyle JS. Commentary on ‘‘Current Approaches to Integrating Elements of Cultural Competence in Nursing Education’’. J Transcult Nurs. 2007;18(1):21S-22S.
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Nurse Educator Vol. 39, No. 4, pp. 193-198 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
A Comparative Study of Cultural Competence Curricula in Baccalaureate Nursing Programs Donna M. Mesler, PhD, RN, CPNP This study evaluated the cultural competence and cultural confidence (self-efficacy) levels of baccalaureate nursing students in 3 types of programs: those with integrated cultural content, those with a required nonnursing culture course, and those with a culture course in nursing. A sample of 759 students participated. Only the students in the nursing culture course program reached a level of cultural competence. Cultural competence and confidence increased significantly from freshman to junior year in all 3 programs. Keywords: baccalaureate curriculum; cultural competence; nursing education; nursing students
H
ealthcare disparities have been well documented in reports generated about the current healthcare system in the United States. Ethnic minority groups do not have equal access and often do not receive equal care once they do access the healthcare system. The ethnic minority groups who are now experiencing these disparities are increasing in number and are expected to become the majority population by the year 2042.1 One way to address this potentially increasing healthcare disparity and engage minority populations more effectively in the evolving healthcare system is to provide more culturally competent healthcare. The goal of culturally competent care is to create a healthcare system and workforce that are capable of delivering the highest quality care to every patient regardless of race, religion, ethnicity, culture, or language proficiency.2 Nurses must be culturally competent to be effective in integrating their patients’ health beliefs and practices into plans of care. Studies have shown that nurses do not always practice in a culturally competent manner.3-7 In an effort to address the need for and lack of cultural competence in practice, nurse educators have an obligation to provide this education to their students to help them become culturally competent practitioners and provide more effective care and better outcomes for their patients.8-12 Author Affiliation: Assistant Professor, College of Nursing, Seton Hall University, South Orange, New Jersey. The author was a participant in the 2013 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education and Pocket Nurse. The author declares no conflicts of interest. Correspondence: Dr Mesler, College of Nursing, Seton Hall University, 400 S Orange Ave, South Orange, NJ 08802 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducator online.com). Accepted for publication: February 15, 2014 DOI: 10.1097/NNE.0000000000000040
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Some baccalaureate nursing programs integrate or thread culture content throughout the curriculum, whereas others require a nursing or nonnursing course on culture.13,14 No research has been found in the literature to support one program model over another.
Review of the Literature National Mandates for Cultural Competence in Nursing Programs In 2006, the American Association of Colleges of Nursing established the initiative Preparing a Culturally Competent Nursing Workforce. The purpose of this document was to create cultural competencies for baccalaureate nursing education.8 These competencies were developed in accordance with the Essentials of Baccalaureate Nursing Education,11 which provide direction and recommendations for nursing curricula. Calvillo et al15 predicted that these cultural competencies may become increasingly integrated into accreditation expectations and licensure examinations. The 5 cultural competencies are applying knowledge of social and cultural factors that affect nursing and healthcare; using relevant data sources and best evidence in providing culturally competent care; promoting achievement of safe and quality outcomes of care for diverse populations; advocating for social justice, including commitment to the health of vulnerable populations and eliminating health disparities; and participating in continuous self-cultural competence development.11 Cultural competence is a continuing practice that evolves over time and requires a lifelong commitment.15 Students should be encouraged to engage in self-awareness and self-reflection about values, prejudices, and stereotypes throughout their education and nursing careers. Current Trends in Cultural Competence Education A variety of innovative approaches to teaching cultural competence have been described in the literature and range Volume 39 & Number 4 & July/August 2014
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from integrating cultural material throughout the curriculum to entire courses devoted to cultural issues to pseudoimmersion and full immersion programs. Pseudo-immersion experiences take place when students, usually as part of their clinical education, visit cultural or ethnic communities for the day to care for patients and return back home or back to the campus at night.16-18 Other nursing programs offer international immersion experiences,19-21 where students live among the culture they are serving for a short period of time. For example, immersion studies have taken place in Honduras, Guatemala, Ireland, and Africa. Other teaching methodologies for cultural competence found in the literature are ethnographies, role play, works of literary journalism, and case studies.22-27 These teaching modalities may be used within any of the 3 forms of cultural competence programs previously identified (culture course, nonnursing culture course, or integrated).
Sample The sample consisted of 759 nursing students in 6 baccalaureate nursing programs. The 6 programs were chosen by convenience, as they were all within a reasonable driving distance from each other and those who had a nursing or nonnursing culture course required it during the sophomore year. The nursing culture course was a 3-credit required course taught by nursing faculty in both programs included in this study. The nonnursing culture course was also a 3-credit required course taught in the philosophy, sociology, or anthropology departments. Course objectives and syllabi were reviewed and were similar across programs. The programs that were integrated had culture content taught throughout the nursing courses. Culture content was included as a course objective and as required reading in the integrated programs.
Theoretical Foundation
Instruments Three instruments were used in the study: a demographic questionnaire, the Inventory to Assess the Process of Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R)31 to measure cultural competence, and the Transcultural Self-efficacy Tool (TSET)29 to measure self-efficacy or confidence. The demographic questionnaire asked respondents about gender, age, racial and ethnic background, highest academic degree, previous cultural competence education, and whether they valued cultural competence education. The IAPCC-R was developed by Campinha-Bacote31 and is based on her model of cultural competency. The IAPCC-R contains 25 items, 5 of which address each of 5 constructs inherent in this model. It is a self-administered tool that uses a 4-point Likert scale, with responses ranging from strongly agree to strongly disagree, very knowledgeable to not knowledgably, very comfortable to not comfortable, very aware to not aware, and very involved to not involved. There is no neutral scoring category, as there are only 4 points and some questions are negatively phrased for reverse scoring (1-to-4 or 4-to-1 point order). The total score, as summed across the 5 constructs, represents the level of cultural competence. There are 4 major score ranges: culturally incompetent (25-50), culturally aware (51-74), culturally competent (75-90), and culturally proficient (91-100). The higher the score, the higher level the level of cultural competence attained. The instrument has content validity and reliability, which was established by more than 10 previous studies with baccalaureate nursing students, nursing faculty, nurse practitioners, and registered community nurses.32-35 Reliability was assessed with Cronbach’s !, with coefficients of .85 or higher in each of these studies. Cronbach’s ! for the IAPCC-R in this study was .78, showing good reliability. The TSET was developed by Jeffreys29 to measure perceived self-efficacy or confidence in nursing students who were learning about or implementing the nursing process with diverse populations. This tool consists of 83 items designed to measure self-efficacy or confidence in performing general transcultural healthcare skills among diverse populations. The TSET is based on Bandura’s theory of self-efficacy and Jeffreys’ Model of Cultural Competence and Confidence.29
This study was based on 2 models of cultural competence. The 1st is the Process of Cultural Competency Model, which contains 5 constructs that should be addressed while seeking to become culturally competent: Cultural Desire, Awareness, Knowledge, Skill, and Encounters.28 According to this model, nurses must continuously strive to become culturally competent. Attaining cultural competence is a fluid, ongoing process. The second model that provided the foundation for this study was the Model of Cultural Competence and Confidence.29 This model is based on Bandura’s30 theory of selfefficacy, which states that individuals can learn if they are motivated and perceive that they are confident in learning. This motivation to learn is similar to Campinha-Bacote’s construct of desire, which is a necessary prerequisite to the 4 constructs. According to Jeffreys’ model, as individuals feel more confident in their own cultural competence, actual cultural competence increases. In the literature, within this model, the terms cultural competence and cultural confidence may be used interchangeably.
Purpose The primary purpose of this study was to evaluate the cultural competence and cultural confidence (self-efficacy) levels of baccalaureate nursing students in 3 different types of programs: those with integrated cultural content, those with a required nonnursing culture course, and those with a culture course in nursing. The secondary purpose was to determine how students transition across their academic journey to cultural competence, from freshman year (baseline) to juniors (after a culture course and preclinical education) to seniors (graduating practitioners).
Methodology Design This study used an exploratory, cross-sectional, betweengroups design. Nursing students’ cultural competence (measured directly) and self-efficacy or confidence (measured by how competent students perceived themselves to be) were compared in 3 different types of programs (nursing culture course, nonnursing culture course, and culture content integrated throughout the nursing programs) across 3 academic levels (freshman, junior, and senior). 194
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The TSET is a 10-point Likert scale ranging from 1 (not confident) to 10 (totally confident). There are 3 subscales of the TSET: cognitive, practical, and affective skills. The cognitive subscale contains 25 items and evaluates how confident students are with their cultural knowledge. The practical subscale contains 28 items and measures students’ confidence at interviewing patients of different cultural backgrounds to learn their values and beliefs. The affective subscale contains 30 items and addresses values, attitudes, and beliefs that students have related to cultural awareness. Previous research has established the validity and reliability of the TSET. The TSET is an effective tool that measures cultural competence of nursing students based on self-efficacy or confidence that students feel. Cronbach’s ! for this study was .986 for the TSET, showing good reliability. The level of cultural competence for nursing students was measured by calculating the individual and mean scores of the IAPCC-R, and the level of self-efficacy was measured by calculating the individual and mean scores of the TSET.
Data Collection The study had institutional review board approval. Data were collected during the first 2 weeks of the fall semester from freshmen and juniors. Students started clinical education during the junior year in all programs included in this study. Sophomores were excluded because students who took a culture course did so during the sophomore year. Because of time constraints, data were collected from seniors at the end of the fall semester instead of the end of the spring semester. Freshman data were considered baseline, junior-level data were considered post culture course (if there was one) as well as preclinical. Senior-level data were considered to be the final product. Data Analysis Frequency distributions were conducted on the demographic variables and correlations were done using Spearman >. A 2-way, 3 3 (3 academic levels and 3 program types) analysis of variance (ANOVA) was conducted to examine the relationships between the IAPCC-R and TSET scores and the type of program (nursing culture course, nonnursing culture course, and integrated program) and academic level (freshman, junior, and senior). Tukey honestly significant difference (HSD) test was conducted where significant differences were found on the ANOVA to show specific interactions. All the data were analyzed using Predictive Analysis Software, Version 18 (PASW 18) (SPSS Inc, Chicago, IL).
Results Demographics The Table, Supplemental Digital Content 1, shows the demographic frequencies and percentages (http://links.lww.com/NE/A130). As expected, about 90% of the participants were women, and most of the students were 18 to 27 years old. Most students in the nursing and nonnursing programs were white. Most students in the integrated program were black/African American. Otherwise, the demographics were similar between programs. Spearman > correlations were conducted on all demographic information and compared with the IAPCC-R and TSET scores. As age increased, IAPCC-R and TSET scores increased (P G .01). Students with past higher Nurse Educator
degrees scored significantly higher on both instruments (P G .01). Race/ethnicity also correlated with higher IAPCC-R but not TSET scores. The ethnic groups in the study scored significantly higher than the white group on the IAPCC-R (P G .05), and students with higher degrees also scored significantly higher (P G .01) on both instruments. Students who believed cultural competence education is important scored significantly higher (P G .05) on both instruments.
Overview of Cultural Competence and Self-efficacy Levels There were 363 subjects in the group with the nursing culture course, 237 subjects in the group with the nonnursing culture course, and 159 subjects in programs in which the cultural content was integrated. There was a significant positive correlation between the total survey scores on the IAPCC-R and TSET (r = 0.46, P = .001). As cultural competence increased, so did students’ self-efficacy or confidence. The mean IAPCC-R and TSET scores were similar for freshmen in all 3 types of culture programs. Freshmen scored in the culturally aware category (51-75 points of a possible 100), with a mean score of 67.94 in all 3 programs on the IAPCC-R. In self-efficacy (TSET), they scored between 6 and 7, which is considered mildly competent on a scale of 1 (not confident) to 10 (totally confident). Students who had the nursing culture course were the only group to attain a level of culturally competent (score 975 points) in the junior year, with mean scores of 75.10 and then to increase mean scores again in the senior year to 75.75, the highest level of the 3 programs. Students who had the nonnursing culture course reached a mean IAPCC-R score of 72.32 in the junior year (culturally aware) and had a mean score of 73.11 in the senior year (culturally aware). Students in the integrated group reached a mean score of 72.15 in the junior year and increased to 73.90 (culturally aware) in the senior year. The TSET scores increased in the nursing culture course group in the junior year to 7.72 and in the senior year to 7.82, which is moderate to high confidence. The nonnursing culture course group scores decreased slightly from junior (7.87) to senior (7.63) year and were the lowest of the 3 programs in this study. Scores for students who had integrated experiences increased from 7.28 to 8.11, which is the highest mean score for self-efficacy. Table 1 shows IAPCC-R scores based on program (nursing culture course, nonnursing culture course, and integrated programs) and academic level. Table 2 presents TSET scores. The ANOVA indicated significant differences across programs (F = 5.56, df = 2, P = .001) and academic level (F = 50.16, df = 2, P = .001) for cultural competence. Tukey HSD post hoc analysis revealed a significant difference in cultural competence between students who had nursing and nonnursing culture courses. Students in the programs with a nursing culture course scored significantly higher on the IAPCC-R than did those in the programs with a nonnursing culture course (P = .001). There also was a trend toward higher cultural competence between students who had a nursing culture course and those in the integrated program. Post hoc analysis (Tukey HSD) showed that in all 3 program types, IAPCC-R scores improved significantly from freshman to junior and freshman to senior year but did not improve significantly from junior to senior year. Volume 39 & Number 4 & July/August 2014
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Table 1. Mean IAPCC-Ra Scores for Program Type and Academic Year (N = 759) Academic Level Freshmen (n = 209) Mean (SD) n Junior (n = 322) Mean (SD) n Senior (n = 228) Mean (SD) n
Nursing Course (n = 363)
Nonnursing (n = 237)
Integrated (n = 159)
67.88 (6.60) 101
67.37 (7.15) 62
68.78 (6.67) 46
75.10 (6.98)b 164
72.32 (6.71)b 103
72.15 (7.73)b 55
75.63 (5.45)b 98
73.11 (6.62)b 72
73.90 (6.84)b 58
a
Transcultural CARE Associates.31 P G .05 from freshman to junior year and freshman to senior year in all 3 programs, not junior to senior year. Only programs with the Nursing Course reached Cultural Competence and sustained that level, even increasing slightly in senior year. This was a significant increase compared with Nursing Culture Course Program not Integrated. b
There were trends in self-efficacy across the 3 types of programs, although there were no significant differences in scores. Similar to cultural competence levels, ANOVA indicated significant differences in self-efficacy across academic levels (F = 35.17, df = 2, P = .001). Post hoc analysis (Tukey HSD) indicated significant differences from freshman to junior year and from freshman to senior year (P G .001) but not from junior to senior year in any of the 3 programs. In summary, IAPCC-R and TSET scores increased in a statistically significant manner in all 3 programs from freshman to junior year. They did not increase significantly from junior to senior year. Students in the nursing culture course program scored significantly higher (P G 0.05) on the IAPCC-R than did those on the nonnursing culture course program and higher, but not significantly, than did those on the integrated program. Students in the integrated program scored highest on the TSET, followed by those in the nursing culture course program and then those in the integrated program. These differences were not significant but may indicate a trend. Students in the nursing culture course program were the only ones to reach a level of cultural competence, which was achieved in the junior year and maintained in the senior year.
Discussion Demographic results were consistent with some of the findings from previous studies. As age and past academic degree increased, so did cultural competency, probably as
a result of more life experience. Students from nonmajority ethnic groups had significantly higher cultural competence, but not confidence. This suggests that although they were more culturally competent, they did not feel confident in their own ability. More research is necessary to explain these results. Students who believed that cultural competence education is important were significantly more culturally competent and confident. This reinforces both theoretical models discussed previously in that desire or motivation to become culturally competent is the foundation on which cultural competence is based. There were several significant findings from this study. Students who took a nursing culture course were the only ones to reach the level of cultural competence. Curricular changes should occur in schools of nursing such that they consider including a nursing culture course, taught by nursing faculty who are culturally competent practitioners. KardongEdgren32 found that nursing faculty are culturally competent, according to their scores on the IAPCC-R. This suggests that culturally competent nursing faculty may be more effective than nonnursing faculty at guiding nursing students to become culturally competent practitioners. Programs offering nonnursing culture courses and integrating culture content material should explore changing the way they teach to incorporate a nursing culture course as this has been shown in this study to prepare students with higher cultural competence levels. Nonnursing culture courses may
Table 2. Mean TSETa Scores for Program Type and Academic Year (N = 759) Academic Level Freshman (n = 209) Mean (SD) n Junior (n = 322) Mean (SD) n Senior (n = 228) Mean (SD) n
Nursing Course (n = 363)
Nonnursing (n = 237)
Integrated (n = 159)
6.86 (1.42) 101
6.87 (1.56) 62
6.57 (1.87) 46
7.72 (1.16)b 164
7.87 (1.32)b 103
7.28 (1.75)b 55
7.82 (1.04)b 98
7.63 (1.35)b 72
8.11 (1.34)b 58
a
10-point Likert scale.29 P G .05 in all programs between freshman and junior year and freshman and senior year, not between junior and senior year. No significant differences between programs. b
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be housed in departments such as philosophy, anthropology, and sociology and do not take into account nursing care and cultural implications in health and illness. Campinha-Bacote28 suggested that learning about cultures (cultural knowledge) without incorporating the other aspects of cultural competence (desire, encounters, skill, and awareness) may lead to stereotyping. It is suspected that in integrated programs cultural competence education may be in the ‘‘background’’ of courses, with an emphasis on theoretical knowledge focused on passing the National Council Licensure Examination for Registered Nurses.14,36 No literature was found that explored relationships between cultural competence scores and self-efficacy scores among baccalaureate nursing students, nor have any studies produced a baseline measure of cultural competence in entering baccalaureate nursing students. One way to address this lack of information would be to complete a longitudinal study and follow students through their educational program and into practice. More comparison studies using the same variables in other parts of the country are necessary. It would be beneficial to determine how more culturally and racially diverse areas compare with those that are not as diverse. Mean cultural competence and self-efficacy scores for students in all 3 program types had significant increases from freshman to junior year and freshman to senior year but not between the junior and senior years. This finding may be a result of the early data collection from seniors who were surveyed at the end of the first semester of their senior year. With more time, scores may have increased by the end of the senior year. Another factor is that the nursing and nonnursing culture courses were taken during the sophomore year, explaining the increase in scores from the freshman to junior years among students who had nursing and nonnursing culture courses. Evaluation of pseudo-immersion and immersion experiences in nursing clinical courses is necessary, as they have been shown in the literature16-21 to be effective in increasing cultural competence. There is a category called ‘‘culturally proficient’’ (scores of 91-100) on the IAPCC-R tool. This category is higher than the Culturally Competent category (75-90) on the tool and is rarely achieved by nursing students or faculty, according to the literature. More immersion experiences may enable nursing students and graduates to move above the level of cultural competence toward cultural proficiency. By evaluating the outcomes of using pseudoimmersion and immersion experiences in addition to the nursing culture courses, especially during the junior and senior years, it may be possible to increase students’ cultural competence and self-efficacy further. This was the first study to examine the cultural competence and self-efficacy levels of students in the freshman year to ascertain what the baseline levels are for incoming baccalaureate nursing students. Other studies have measured cultural competence and self-efficacy in graduating students or after an intervention, without knowing baseline data. Freshman baseline levels for cultural competence were in the culturally aware category (mean, 67.83). If they are ending their education at the same level, more needs to be done to graduate practitioners who are culturally competent and strive for cultural proficiency. Baseline freshman levels for self-efficacy were in the middle confidence area Nurse Educator
(mean, 6.80), but this increased significantly by the junior year. This can be explained for the students who had a culture course in the sophomore year, but exactly how this education was imparted in the integrated programs is unclear.
Study Limitations The limitations of this study are similar to those of other self-reported surveys. Students may have answered according to their own perceptions of what the researchers expected and not answered honestly about themselves. This was a convenience sample of baccalaureate nursing students attending 6 different colleges of nursing in a mid-Atlantic state. Senior nursing students were studied at the end of the first semester of their senior year, rather than at the end of their program, nearer to graduation in the second semester of their senior year. Had additional time been given to these senior students to further apply their knowledge, it is possible that their cultural competence and confidence would have increased to a significantly higher level by the end of the program when compared with junior year levels. There is no way to control for differences in the way cultural competence was taught between 3 programs (6 schools) that were included in this study. Data in this study were collected at singular points in time rather than longitudinally. It is possible that there were be differences in outcomes had a 4-year longitudinal study been designed instead, where students’ cultural competence and self-efficacy were followed over the length of their BSN programs. Lastly, the findings are generalizable only to the nursing programs included in this study. More research is necessary to see if these results hold true for other programs.
Conclusion Research has shown that nurses do not always practice in a culturally competent manner. This study suggests that we can improve the cultural competence of future nurses by changing the curriculum in which they learn. Culturally competent nurses provide holistic care for their patients, incorporating culture into their plan of care. Providing the most effective cultural competence education to nursing students is 1 way nurse educators can ensure better patient outcomes and less disparities in the future for a demographically changing healthcare system.
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7. McKinley D, Blackford J. Nurses’ experiences of caring for culturally and linguistically diverse families when their child dies. Int J Nurs Pract. 2001;7(4):251-256. 8. Preparing a culturally competent nursing workforce initiative. 2006. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/Media/NewsWatch/2006/ Dec.htm#1. Accessed December 28, 2009. 9. Cultural competency in baccalaureate nursing education. 2008. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/Education/pdf/competency.pdf. Accessed December 28, 2009. 10. Final draft of the revised baccalaureate essentials. 2008. American Association of Colleges of Nursing Web site. Available at http:// www.aacn.nche.edu/Education/pdf/DEdraft.pdf. Accessed December 28, 2009. 11. Toolkit of resources for cultural competence education for baccalaureate nurses. 2008. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/Education/ pdf/toolkit.pdf. Accessed December 28, 2009. 12. Green-Hernandez C, Quinn A, Denman-Vitale S, Falkenstern S, Judge-Ellis T. Making nursing care culturally competent. Holist Nurs Pract. 2004;18(4):215-218. 13. Principles and recommended standards for cultural competence education of healthcare professionals. 2003. California Endowment Web site. Available at http://www.calendow.org/uploadedfiles/ principles_standards_cultural_competence.pdf. Accessed February 14, 2014. 14. Lipson JG, Desantis LA. Current approaches to integrating elements of cultural competence in nursing education. J Transcult Nurs. 2007;18(1):10S-20S. 15. Calvillo E, Clark L, Ballantyne JE, Pacquiao D, Purnell L, Villarruel AM. Cultural competency in baccalaureate nursing education. J Transcult Nurs. 2009;20(2):137-145. 16. Amerson R. The impact of service learning on cultural competence. Nurs Educ Perspect. 2010;31(1):18-22. 17. Doutrich D, Storey M. Education and practice: dynamic partners for improving cultural competence in public health. Fam Community Health. 2004;27(4):298-307. 18. Kratzke C, Bertolo M. Enhancing students’ cultural competence using cross-cultural experiential learning. J Cult Divers. 2013;20(3):108-111. 19. Caffrey R, Neander W, Markle D, Stewart B. Improving the cultural competence of nursing students: results of integrating
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cultural content in the curriculum and an international immersion experience. J Nurs Educ. 2005;44(5):234-240. 20. Levine M, Perpetua E. International immersion programs in baccalaureate nursing education: professor and student perspectives. J Cult Divers. 2006;13(1):20-26. 21. Carpenter L, Garcia A. Assessing outcomes of a study abroad course for nursing students. Nurs Educ Perspect. 2012;33(2): 85-89. 22. Anderson K. Teaching cultural competence using an exemplar from literary journalism. J Nurs Educ. 2004;43(6):253-259. 23. Brennan S, Schulze M. Cultural immersion through ethnography: the lived experience. J Nurs Educ. 2004;43(6):285-288. 24. Cagle CS. Student understanding of culturally and ethically responsive care. Nurs Educ Perspect. 2006;27(6):308-314. 25. Sheerer R, Davidhizar R. Using role play to develop cultural competence. J Nurs Educ. 2003;42(6):273-276. 26. Slade D, Thomas-Connor I, Tsao TM. When nursing meets English: using a pathography to develop nursing students’ culturally competent selves. Nurs Educ Perspect. 2008;29(3):151-155. 27. Long T. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012;19(3):102-108. 28. Campinha-Bacote J. The process of cultural competency in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13:181-184. 29. Jeffreys MR. Teaching cultural competence in nursing and health care. 2nd ed. New York, NY: Springer; 2010. 30. Bandura A. Self-efficacy: The Exercise of Control. New York, NY: W.H. Freeman and Company; 1997. 31. Inventory for assessing the process of cultural competence among healthcare professionals—revised. 1999. Transcultural CARE Associates Web site. Available at http://www.transculturalcare .net/. Accessed April 28, 2011. 32. Kardong-Edgren S. Cultural competence of baccalaureate nursing faculty. J Nurs Educ. 2007;46(8):360-367. 33. Koempel V. Cultural Competence of Certified Nurse Practitioners [master’s thesis]. Mankato, MN: Minnesota State University; 2003. 34. Patsdaughter C. A streetcar named more than desire: cultural competence revisited. J Cult Divers. 2006;13(4):175-176. 35. Spencer W, Cooper-Braithwaite A. Reliability Analysis of the IAPCC-R. Toronto, ON, Canada: University of Toronto; 2003. 36. Boyle JS. Commentary on ‘‘Current Approaches to Integrating Elements of Cultural Competence in Nursing Education’’. J Transcult Nurs. 2007;18(1):21S-22S.
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