CULTURAL COMPETENCE IN NURSING FACULTY: A JOURNEY, NOT A DESTINATION SUSAN M. MONTENERY, DNP,⁎ ANGELA D. JONES, DNP,† NANCY PERRY, DNP,‡ DEBRA ROSS, DNP,§ AND RICK ZOUCHA, PHD ‖ Nurse educators work with the intention of empowering students to provide holistic and comprehensive care. One concept that is essential in the delivery of patient-centered comprehensive care is cultural competence. The process of cultural competence is an imperative for nurses, faculty, and students. Little research exists to substantiate cultural desire in nursing faculty. Subsequently, questions arise about the faculty's desire to teach and promote nursing care that is culturally competent. Therefore, are nursing faculty committed to the process of culturally competence for themselves, students, and the profession? This article reviews the literature on cultural competency as it applies to nursing faculty. Campinha-Bacote's model of cultural competence provides the theoretical underpinning for the discussion and implications of enhancing cultural competence for nursing faculty. Cultural competency among nursing faculty could yield a significant impact by facilitating achievement and provision of culturally competent care for nurses at the local, national, and global level. (Index words: Nursing; Transcultural nursing; Cultural competence; Nursing education; Faculty) J Prof Nurs 29:e51–e57, 2013. © 2013 Elsevier Inc. All rights reserved.
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HE PROCESS OF cultural competence is an imperative for the profession of nursing and for nursing students. National accrediting bodies identify cultural competence as a standard in education because caring for patients requires cultural competence (NLNAC Standards, n.d.; Cultural competency, 2008). Little research exists on cultural competency of faculty. Many schools of nursing have a transcultural nursing course or thread transcultural nursing concepts throughout their curriculum, yet few nurse educators have taken courses in transcultural nursing or hold international transcultural nursing certification. With an increased focus on cultural competence in nursing students, consideration should be given to cultural competence among nursing faculty. In order to have a significant impact on creating ∗Assistant Professor of Nursing, Ohio Northern University, Ada, OH. †Nursing Faculty, Angelina College, Lufkin, TX. ‡Director of Nursing, Carroll Community College, Westminster, MD. §School Nurse, Benton Area School District, Benton, PA. ‖Professor of Nursing, Duquesne University, Pittsburgh, PA. Address correspondence to Susan M. Montenery: 525 South Main Street, Ada, OH 45810. E-mail: [email protected] 8755-7223/13/$ - see front matter
an atmosphere of cultural competence and congruence in nursing education, nurse educators can model the behaviors expected of the students. This leads to the question, in academic settings, is cultural competence encouraged among nursing faculty? The purpose of this article is to review the literature on competency and consider the need to provide opportunities to promote cultural competence and potentially cultural desire for nursing faculty. In particular, the authors discuss faculty commitment to personal and professional cultural competence.
Conceptual Orientation Campinha-Bacote's conceptual model of cultural competence serves as the theoretical framework for this article. Campinha-Bacote (2002) describes cultural competence not as an event or a result but as an ongoing and neverending process. Health care providers are continually learning and growing while attempting to engage in the process of cultural competency when working with diverse populations. Health care providers and the educators must acknowledge this ongoing process to meet the needs of individuals, families, and communities
Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp e51–e57 © 2013 Elsevier Inc. All rights reserved.
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with various cultural values while encouraging nursing students to adopt the same values. Campinha-Bacote's model addresses the concepts of cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounter. These five distinct concepts were not meant to stand alone but, rather, work together as interlocking puzzle pieces to reveal the mosaic of cultural competence. The first concept of Campinha-Bacote's (2002) model is cultural desire. Cultural desire is an essential component of establishing cultural competence. Without a desire to engage in the process of cultural competence, the process therefore may become fragmented at best. Lack of cultural desire may impede the ability to meet the cultural needs of others. Cultural awareness is one part of the process where the nurse self-examines his or her own culture and beliefs. Self-awareness is an enlightening process, which allows the nurse to be more aware of the cultural needs of others. Nurses can develop cultural knowledge as part of the process in seeking and obtaining information about the values of a culture. A health care provider must also be knowledgeable in obtaining data on various cultures of the clients that they are caring for because cultural skills are acquired and advanced. The last identified concept by Campinha-Bacote in regard to the procession to cultural competence is the face-to-face encounters that health care providers have with those from various cultures. These concepts are continually evolving with each new cultural encounter, therefore, encouraging and enriching cultural desire for the individual. Actual engagement with individuals, families, and communities continues to stimulate knowledge, data collection, and learning, therefore increasing awareness, which leads to cultural competency (Kirkpatrick & Brown, 1999).
Background Nursing has been described as an art and a science, with caring as the central value. Nurse educators operationalize the caring value in teaching students, but how can nurse educators display this value and assist in this process when teaching students? A literature search using multiple databases including Cumulative Index to Nursing and Allied Health Literature, ProQuest, Medline, Scopus, and Education Resources Information Center yielded minimal results for terms including cultural competence, nursing faculty, nurse educators, field experience, and cultural immersion. The literature is vast regarding the need for students and nurses to be culturally competent, yet nursing faculty literature is vague. With the primary responsibility of role modeling, nurturing, and developing nurses who provide holistic, effective, comprehensive, and culturally appropriate care, nurse educators can be proficient and dedicated in all facets. Nurse educators have the potential for meaningful influences on students regarding the process of cultural competence. If the educators lack cultural desire and are unwilling to engage in the process of cultural awareness, humility and, ultimately, promotion of culturally con-
gruent care, then students may assume those same characteristics, thus negatively impacting patient care. From the literature, questions regarding the educational expectations and opportunities for nursing faculty emerged. Nurse educators can demonstrate cultural competence when interacting with students but also in delivery of patient care in order to foster an attitude of cultural desire in the students they serve. Hospitals require yearly training and have resource manuals available for nursing staff. Educators are responsible for grooming cultural competence in students, yet there is no a predetermined plan for updates, training, or educational requirements; it is left to the discretion of individual faculty members. In many cases, there are particular faculty members responsible for teaching the transcultural nursing courses and are the official resources for anything related to culture or diversity. Cultural competence should thread throughout the nursing curriculum; therefore, all faculty members can be responsible for demonstrating cultural competency, but the question remains, is this actually occurring in nursing education? Nursing faculty, who function as both didactic and clinical educators, impact students, families, and other health care providers. Because nurses have the opportunity to impact a vast segment of society, the impact can be positive and meaningful. Across the country, nursing students and faculty participate in a cultural immersion experiences. These experiences allow for examination of one's own culture and the immersion culture. These experiences often place students in an uncomfortable environment similar to what many people who are culturally different might feel when receiving health and nursing care in the United States. Nurse educators need to be sensitive and empathetic about the unique cultural experiences of others and instill these values in students. Byrne, Weddle, Davis, and McGinnis (2003) identified that most nurses have not spent an extended time frame (over 7 days) out of their own environment and embedded in another culture. Nurse educators may also be unaware that educational materials may contain stereotypes or omit important cultural content (Byrne et al., 2003). Cultural immersion experiences stress the importance of focusing on the strengths of a culture that can contribute to health promotion (Mkandawire-Valhmu & Doehring, 2012). Students and faculty alike are able to draw on these experiences to enhance their nursing practice. In order to understand the impact of culture on nursing education, specifically nurse educators, a review of existing literature is necessary and presented.
Literature Review Since the inception of the idea of cultural competence as part of nursing curricula, the emphasis has been on future nurses becoming culturally competent. However, the literature on nursing faculty and cultural competency is limited. Over 15 years ago, Tanner (1996) asked the very important question in an editorial, “How culturally
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competent are we as faculty?” (p. 291). Tanner linked student retention of minority students and education of culturally competent future nurses as the responsibility of faculty. She recommended that all nursing faculty assume responsibility for this, not just the sole minority faculty. Prior to Tanner questioning the competency of nursing faculty, Leininger (1995) acknowledged that nursing faculty must be educated prior to transferring the knowledge to nursing students. Leininger (1995) stated, “It is essential to educate faculty about the nature, scope, goals, theories, practices, and desired outcomes of transcultural nursing” (p. 11). Leininger stated that there are no adequate numbers of nursing faculty prepared at the doctoral level equipped with the tools to teach future nurses to be culturally competent and stressed that additional funding be mandated to accomplish this goal. Sealey, Burnett, and Johnson (2006) explored faculty competence in teaching cultural components in a study of baccalaureate programs in Louisiana. Participants (n = 163) reported subscales of cultural awareness as the highest criterion (4.14 out of 5), cultural desire (3.67), cultural knowledge (3.65), cultural skill (3.65), and cultural encounter (3.56). Each subscale was statistically significant (P b .001) related to overall cultural competence (3.73). A panel of experts established content validity, yet reliability of the instrument was not reported. Highest mean scores on the survey included “I accept that male-female roles may vary significantly among different cultures and ethnic groups” (4.35) and “I am personally and professionally committed to providing (or teaching to provide) nursing care that is culturally competent” (4.33). Lowest scoring items included “I am knowledgeable about variations in drug metabolism among specific cultural groups” (2.79) and “I have spent extended periods of time living (i.e. at least seven consecutive days) among people from cultural/racial/ethnic groups different than me” (2.91). Faculty also reported insufficient preparation and understanding of key words and phrases necessary for communication (3.00) and screening materials (books, movies, and media) for negative stereotypes (3.28). The authors recommended faculty development, certification in transcultural nursing, and inclusion of theory on cultural competence for nursing faculty education. Furthermore, nurse educators need to expand boundaries and opportunities for exposure to people of diverse backgrounds. Kardong-Edgren et al. (2005) surveyed nursing faculty (n = 94) using a convenience sample of attendees of two national nursing conferences. Participants were surveyed on cultural attitudes and cultural knowledge. The Cultural Attitudes Scale (CAS) was administered following four cultural vignettes. Mean scores ranged from 64 to 68 out of 100 respectively indicating a moderately positive attitude toward ethnic groups. CAS reliabilities were low with the highest subscale of .76. Further studies need to be completed to assess reliability of this
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instrument. The Cultural Self-Efficacy Scale determined faculty confidence in caring for different ethnic groups. Participants reported moderate to high responses in feeling confident in their knowledge and skill with diverse groups. There was a moderate correlation between knowledge and attitude that was statistically significant (P b .01). The alpha coefficient for skills in transcultural care was .92, and confidence in knowledge of cultural concepts was .87. The majority of faculty identified teaching cultural concepts in the nursing curriculum, yet only one third reported having cultural components in their own schooling, and no specifics were provided on how students perceive cultural competence. Narrative comments expressed the need for repeated exposure to clients of different cultures. Although these findings cannot be generalized to all nursing faculty, it does represent a small population of faculty that is engaging in the process of cultural competence. Because this convenience sample was taken from national nursing conferences, it may be a reason for their strong commitment to the profession. Sargent, Sedlak, and Martsolf (2005) studied students and nursing faculty at a baccalaureate college in Ohio, using Camphina-Bacote's tool, the Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals. Transcultural health care experts established content and construct validity of the instrument. Reliability analysis using Chronbach's alpha yielded a result of .76. Faculty members were selected based on their responsibility for teaching cultural concepts with students. Of the 51 faculty members surveyed, 29 were found to be culturally aware, 20 were culturally competent, and 2 were culturally proficient. Curriculum threads of cultural components were established for each year of the nursing program. This suggests faculty commitment and cultural desire, yet not all faculty were surveyed. Suggestions for improvement include acknowledging that it is a long-term process to achieve cultural competence but that the reward is great in the end. Ume-Nwagbo (2012) compared the cultural competence of nursing faculty in accredited bachelor of science in nursing programs with the admission and graduation of minority students within the past 5 years. UmeNwagbo used Sealy's tool, The Cultural Diversity Questionnaire for Nurse Educators, to survey 173 faculty members. Content validity was established by a panel of four experts in cultural diversity. Reliability for the five constructs were cultural awareness (.63), cultural desire (.82), cultural knowledge (.69), cultural skill (.68), and cultural encounter (.76), respectively. Sixty-six questionnaires were grouped as school responses and analyzed individually as well. The findings were classified as low cultural competence if the respondent scored between 55 and 130, moderate 131 to 201, and high cultural competence if the scores were 202 to 275. School's competency rating scores were 199.7 to 229.8; individual faculty member competency rating scores ranged from 168 to 262. A significant positive correlation existed
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between school's cultural competency rating and the percentage of minority students graduating (P b .01). Ume-Nwagbo stressed the importance of nursing faculty becoming highly culturally competent to facilitate a culturally diverse future nursing workforce. Although the study was limited to institutions in Tennessee, UmeNwagbo recommended faculty training and support to achieve higher levels of cultural commitment. Bedharz, Schim, and Doorenbos (2010) discuss faculty and student cultural competency addressing threats, strategies, and pitfalls. Language is a major factor in communicating between faculty and students, whether spoken or written. Faculty must be aware of their mode of communication and be culturally sensitive. In order for people to improve personal cultural capacity, the authors propose five areas to address: know thy self, think globally, act locally, find the keys, and listen and learn. Find the keys refers to faculty responsibility to understand terms such as acculturation, racism, ageism, and appreciate how they influence behavior. Listen and learn addresses shifting to active teaching/learning methods to reach all learners. While this article addressed many teaching and communication strategies for culturally diverse students, Bedharz et al. (2010) also stressed the importance of individual cultural development. Wilson, Sanner, and McAllister (2010) completed a study of health science faculty (n = 28). This longitudinal study included a cultural competency pretest followed by a cultural training series. Followup testing was completed at 3, 6, and 12 months. Internal consistency reliability for this study was reported on the pretest as .86 and posttest .81, respectively. Faculty scores revealed increases in cultural awareness, cultural skill, cultural knowledge, and cultural encounters when comparing pretest and posttest (P b .06). Results were not statistically significant at 3 months (P b .08), yet were significant at 6 months (P b .03) and 12 months (P b .03). These findings validate the benefits and needed reinforcement of cultural components for nurse educators. Cultural competence is a continual process, and faculty must be engaged in the process to expand their own cultural growth and facilitate development in students. The concept of cultural safety is an additional component of cultural competency. Cultural safety is the power disparity between patient and nurse (Mkandawire-Valhmu & Doehring, 2012). When considering culturally safe care, nurses must assess the current social, economic, and political differences between themselves and the patient (McEldowney & Connor, 2011; Mkandawire-Valhmu & Doehring, 2012). Patients become at risk for culturally unsafe care when nurses “disempower, diminish, demean or compromise cultural identity” (Bidzinski, Boustead, Gleave, Russo, & Scott, 2012, p. 43). A strategy to assist the nurse with understanding power differences is for the nurse to complete a cultural heritage reflection (Gerlach, 2012). Unfortunately, the review and synthesis of literature
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revealed no studies that specifically addressed cultural safety and nursing faculty. In addition to cultural sensitivity and cultural safety, nurses can also possess and practice cultural humility. Cultural humility entails providing care to individuals from other cultures without stereotyping or passing judgment (Broome & McGuiness, 2007). This is a lifelong process that demands self-reflection and critique and the willingness to learn from others and build partnerships in patient care (Chang, Simon, & Dong, 2012; Foster, 2009). Furthermore, cultural humility demands that individuals recognize one's own beliefs and values and take responsibility for interactions with others while accepting differences and being responsive to the needs of others. This self-reflection and awareness allows the culturally competent health care provider to go beyond identifying and responding to specific cultural traits, allowing for a partnership with the client (Levi, 2009; Tervalon & Murray-Garcia, 1998). This process encourages respect and requires responsible interactions beyond sensitivity to differences (Levi, 2009). One process for practicing cultural humility proposed by Chang et al. (2012) includes self-questioning, cultural immersion, active listening, and negotiation. These skills and opportunities strengthen self-reflection and diverse interactions. In essence, examining oneself is a key to conscientiously communicating with others. Again, no studies were found in the literature addressing cultural humility and nursing faculty. The concept of service learning in promoting cultural competence is a growing area, yet the majority of literature discusses the impact of service learning on students. No studies were found in the literature specifically addressing the impact on faculty cultural competence. Community-based curriculums integrate service learning components with students (Amerson, 2010; Hamner, Wilder, & Byrd, 2007; Zoucha, Mayle, & Colliza, 2011). Faculty involved with these courses may develop cultural competence, yet this opportunity is limited to only those faculty directly involved. In one program, the community stakeholders expressed the need for a consistent supervising faculty member (Hamner et al., 2007). This provides only a small population of faculty connection to cultural competence through service learning. Studies need to be conducted to evaluate service learning as an avenue to promote cultural competence of faculty.
Discussion Nurses display the attributes of caring and respect in addition to having the knowledge and skills necessary to deliver quality patient care. Cultural competency for the profession of nursing relates to being sensitive to and respectful of the client's values and traditions that make up their culture (de Chesnay, Hart, & Brannan, 2012). Cultural differences thread through nursing education programs at all levels and continue to be a relevant issue post licensure in that cultural competency is included in annual staff training in the
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majority of health care facilities. The question remains, where should the emphasis on cultural desire begin? In order to achieve the greatest effect, cultural competency must begin with nursing education, specifically with nurse educators. One of the fundamental values of nursing education focuses on caring for culturally diverse individuals and populations. Nurse educators should seek to impart and encourage cultural desire, awareness, knowledge, assessment, and encounter to the nursing students with the ultimate goal of developing cultural competence. However, no exact plan exists for how this should unfold with all nursing programs. Nurse educators need to ensure that cultural content is incorporated in existing curricula (Waite & Calamaro, 2010). Nurses must be able to take the knowledge that they have and transfer it to practice (DeSantis & Lipson, 2007). There is ample evidence to support integration of cultural content within nursing curricula; however, little addresses cultural competency of nursing faculty. Without nursing educators transferring their knowledge of cultural competence into the practice setting of nursing education, nursing students will lack a fundamental dimension of learned behavior. According to McMillan (2012), professional development for nurse educators is one way to promote cultural competence in nursing education. Professional development is appropriate for faculty continuing education; however, this is inefficient when used as the sole means of developing cultural competency in nursing faculty (Waite & Calamaro, 2010). Nursing faculty need to incorporate a dynamic approach to attaining cultural competence. Educators must become the student and employ many of the same teaching and learning strategies used in their classroom and clinical experiences. Nurse educators use the teaching methodology of reflection with students to have the students evaluate and analyze their personal reactions of meaningful experiences (Rowles & Russo, 2009; Waite & Calamaro, 2010). Nurse educators should be encouraged to employ the technique of reflection in relation to their experiences with culturally diverse students, individuals, families, and communities to evaluate their personal strengths and identify weaknesses. It is through identifying weaknesses that nursing faculty can become more engaged in the process of cultural competence. Cultural immersion is one method for developing and supporting the process of cultural competence. According to Vaughan (2005), submersion into situations or environments different from your own is instrumental for developing cultural competence. Being immersed in a different culture promotes selfreflection of personal views, beliefs, and even personal biases. Cultural immersion experiences are often expensive and time consuming; however, immersion experiences of a smaller scale could be beneficial as well. Nursing faculty must be creative and capitalize on any opportunities that provide diverse didactic,
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clinical, and immersion experiences locally, nationally, and globally.
Implications Nursing faculty members have frequent, direct contact with nursing students, thus should role model expected professional behavior including cultural competence. One method for developing cultural competence with a student body is through the recruitment and retention of culturally diverse faculty and students (Wellman, 2009). Wellman (2009) goes on to state that faculty can further assist with cultural competence attainment by modeling a sound commitment to competence development and by including cultural concepts in didactic and clinical courses. Having the knowledge that cultural competency is essential is only the beginning of the process. Cultural desire must come from within the individual faculty member and institutional commitment in order to demonstrate the true process of cultural competence. “Cultural desire is the motivation of the health care provider to want to, rather than have to, engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and familiar with cultural encounters” (Campinha-Bacote, 2002, p.182). Two important facets of cultural competency apply to faculty and curricular planning for nursing students. It is essential that nursing faculty “know yourself and show respect for others” (de Chesnay, 2012, p.446). A beginning exercise could be to examine your student population, neighborhood, and region for the demographic breakdown. Sharing cultural icons, such as photographs, jewelry, or clothing, during a faculty development session can also assist with knowing yourself. Appreciating the culture of each nursing faculty is a beginning step to respecting others. The Office of Minority Health is responsible for the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards). These standards set the stage for health care provider's awareness about transcultural practices. Many continuing education opportunities are available on the Think Cultural Health Web page (Office of Minority Health, 2012, https://ccnm. thinkculturalhealth.hhs.gov). While faculty must have the cultural desire, students also identify with faculty and clinical instructors with certain qualities. Key elements of an effective educator include being a source of support, being a role model, personal traits (e.g., empathy, affection for the nursing profession, and reflective thinking), metacognition, and making clinical learning enjoyable (Heshmati-Nabavi & Vanaki, 2009). Waite and Calamaro (2010) argue that educators need more than a 1-day inservice or faculty simply interested in teaching cultural courses without formal education in this arena. They question if nursing faculty demonstrate the knowledge, skills, and experiences to educate students on diverse populations. As nurse educators, we must take responsibility for our own
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cultural competence, mentor new faculty, and role model positive behaviors that are culturally sensitive.
Conclusion As our culture in the United States becomes more diverse, nurses must meet the challenge of providing culturally competent care to all. Cultural competence is a dynamic process that occurs on a continuum. The concept of cultural competence is introduced to nursing students in the nursing curricula and continues post licensure. In order to have the greatest impact on cultural knowledge, awareness, skill, and cultural diversity, nurse educators must be culturally competent and model culturally sensitive behaviors with each student encounter. Current literature offers a variety of teaching and learning methodologies to support achievement of cultural competence by nursing students. However, when the question was posed regarding cultural competency in nurse educators, the literature is lacking. More research needs to be conducted on nursing faculty cultural desire, including educators from all program types. CampinhaBacote's (2002) conceptual model of cultural competence provides a sound framework for evaluating the concept of cultural competence in nursing education, specific to nursing faculty. It is the hope that all nurse educators develop cultural desire and foster the development of cultural competency in the students they mentor. This responsibility does not default only to faculty teaching a transcultural nursing course, rather teaching cultural competence is the responsibility of all nurse educators. As nurse educators become more aware of their role in the development and impact of cultural competence in the nurses of tomorrow, the rewards are innumerable. Nurse educators are assisting in the hope of tomorrow because they teach, mentor, and foster the development of the next generation of nurses. What greater impact can nurse educators have than teaching future nurses by example to care for all people while appreciating our differences?
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HE PROCESS OF cultural competence is an imperative for the profession of nursing and for nursing students. National accrediting bodies identify cultural competence as a standard in education because caring for patients requires cultural competence (NLNAC Standards, n.d.; Cultural competency, 2008). Little research exists on cultural competency of faculty. Many schools of nursing have a transcultural nursing course or thread transcultural nursing concepts throughout their curriculum, yet few nurse educators have taken courses in transcultural nursing or hold international transcultural nursing certification. With an increased focus on cultural competence in nursing students, consideration should be given to cultural competence among nursing faculty. In order to have a significant impact on creating ∗Assistant Professor of Nursing, Ohio Northern University, Ada, OH. †Nursing Faculty, Angelina College, Lufkin, TX. ‡Director of Nursing, Carroll Community College, Westminster, MD. §School Nurse, Benton Area School District, Benton, PA. ‖Professor of Nursing, Duquesne University, Pittsburgh, PA. Address correspondence to Susan M. Montenery: 525 South Main Street, Ada, OH 45810. E-mail: [email protected] 8755-7223/13/$ - see front matter
an atmosphere of cultural competence and congruence in nursing education, nurse educators can model the behaviors expected of the students. This leads to the question, in academic settings, is cultural competence encouraged among nursing faculty? The purpose of this article is to review the literature on competency and consider the need to provide opportunities to promote cultural competence and potentially cultural desire for nursing faculty. In particular, the authors discuss faculty commitment to personal and professional cultural competence.
Conceptual Orientation Campinha-Bacote's conceptual model of cultural competence serves as the theoretical framework for this article. Campinha-Bacote (2002) describes cultural competence not as an event or a result but as an ongoing and neverending process. Health care providers are continually learning and growing while attempting to engage in the process of cultural competency when working with diverse populations. Health care providers and the educators must acknowledge this ongoing process to meet the needs of individuals, families, and communities
Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp e51–e57 © 2013 Elsevier Inc. All rights reserved.
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with various cultural values while encouraging nursing students to adopt the same values. Campinha-Bacote's model addresses the concepts of cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounter. These five distinct concepts were not meant to stand alone but, rather, work together as interlocking puzzle pieces to reveal the mosaic of cultural competence. The first concept of Campinha-Bacote's (2002) model is cultural desire. Cultural desire is an essential component of establishing cultural competence. Without a desire to engage in the process of cultural competence, the process therefore may become fragmented at best. Lack of cultural desire may impede the ability to meet the cultural needs of others. Cultural awareness is one part of the process where the nurse self-examines his or her own culture and beliefs. Self-awareness is an enlightening process, which allows the nurse to be more aware of the cultural needs of others. Nurses can develop cultural knowledge as part of the process in seeking and obtaining information about the values of a culture. A health care provider must also be knowledgeable in obtaining data on various cultures of the clients that they are caring for because cultural skills are acquired and advanced. The last identified concept by Campinha-Bacote in regard to the procession to cultural competence is the face-to-face encounters that health care providers have with those from various cultures. These concepts are continually evolving with each new cultural encounter, therefore, encouraging and enriching cultural desire for the individual. Actual engagement with individuals, families, and communities continues to stimulate knowledge, data collection, and learning, therefore increasing awareness, which leads to cultural competency (Kirkpatrick & Brown, 1999).
Background Nursing has been described as an art and a science, with caring as the central value. Nurse educators operationalize the caring value in teaching students, but how can nurse educators display this value and assist in this process when teaching students? A literature search using multiple databases including Cumulative Index to Nursing and Allied Health Literature, ProQuest, Medline, Scopus, and Education Resources Information Center yielded minimal results for terms including cultural competence, nursing faculty, nurse educators, field experience, and cultural immersion. The literature is vast regarding the need for students and nurses to be culturally competent, yet nursing faculty literature is vague. With the primary responsibility of role modeling, nurturing, and developing nurses who provide holistic, effective, comprehensive, and culturally appropriate care, nurse educators can be proficient and dedicated in all facets. Nurse educators have the potential for meaningful influences on students regarding the process of cultural competence. If the educators lack cultural desire and are unwilling to engage in the process of cultural awareness, humility and, ultimately, promotion of culturally con-
gruent care, then students may assume those same characteristics, thus negatively impacting patient care. From the literature, questions regarding the educational expectations and opportunities for nursing faculty emerged. Nurse educators can demonstrate cultural competence when interacting with students but also in delivery of patient care in order to foster an attitude of cultural desire in the students they serve. Hospitals require yearly training and have resource manuals available for nursing staff. Educators are responsible for grooming cultural competence in students, yet there is no a predetermined plan for updates, training, or educational requirements; it is left to the discretion of individual faculty members. In many cases, there are particular faculty members responsible for teaching the transcultural nursing courses and are the official resources for anything related to culture or diversity. Cultural competence should thread throughout the nursing curriculum; therefore, all faculty members can be responsible for demonstrating cultural competency, but the question remains, is this actually occurring in nursing education? Nursing faculty, who function as both didactic and clinical educators, impact students, families, and other health care providers. Because nurses have the opportunity to impact a vast segment of society, the impact can be positive and meaningful. Across the country, nursing students and faculty participate in a cultural immersion experiences. These experiences allow for examination of one's own culture and the immersion culture. These experiences often place students in an uncomfortable environment similar to what many people who are culturally different might feel when receiving health and nursing care in the United States. Nurse educators need to be sensitive and empathetic about the unique cultural experiences of others and instill these values in students. Byrne, Weddle, Davis, and McGinnis (2003) identified that most nurses have not spent an extended time frame (over 7 days) out of their own environment and embedded in another culture. Nurse educators may also be unaware that educational materials may contain stereotypes or omit important cultural content (Byrne et al., 2003). Cultural immersion experiences stress the importance of focusing on the strengths of a culture that can contribute to health promotion (Mkandawire-Valhmu & Doehring, 2012). Students and faculty alike are able to draw on these experiences to enhance their nursing practice. In order to understand the impact of culture on nursing education, specifically nurse educators, a review of existing literature is necessary and presented.
Literature Review Since the inception of the idea of cultural competence as part of nursing curricula, the emphasis has been on future nurses becoming culturally competent. However, the literature on nursing faculty and cultural competency is limited. Over 15 years ago, Tanner (1996) asked the very important question in an editorial, “How culturally
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competent are we as faculty?” (p. 291). Tanner linked student retention of minority students and education of culturally competent future nurses as the responsibility of faculty. She recommended that all nursing faculty assume responsibility for this, not just the sole minority faculty. Prior to Tanner questioning the competency of nursing faculty, Leininger (1995) acknowledged that nursing faculty must be educated prior to transferring the knowledge to nursing students. Leininger (1995) stated, “It is essential to educate faculty about the nature, scope, goals, theories, practices, and desired outcomes of transcultural nursing” (p. 11). Leininger stated that there are no adequate numbers of nursing faculty prepared at the doctoral level equipped with the tools to teach future nurses to be culturally competent and stressed that additional funding be mandated to accomplish this goal. Sealey, Burnett, and Johnson (2006) explored faculty competence in teaching cultural components in a study of baccalaureate programs in Louisiana. Participants (n = 163) reported subscales of cultural awareness as the highest criterion (4.14 out of 5), cultural desire (3.67), cultural knowledge (3.65), cultural skill (3.65), and cultural encounter (3.56). Each subscale was statistically significant (P b .001) related to overall cultural competence (3.73). A panel of experts established content validity, yet reliability of the instrument was not reported. Highest mean scores on the survey included “I accept that male-female roles may vary significantly among different cultures and ethnic groups” (4.35) and “I am personally and professionally committed to providing (or teaching to provide) nursing care that is culturally competent” (4.33). Lowest scoring items included “I am knowledgeable about variations in drug metabolism among specific cultural groups” (2.79) and “I have spent extended periods of time living (i.e. at least seven consecutive days) among people from cultural/racial/ethnic groups different than me” (2.91). Faculty also reported insufficient preparation and understanding of key words and phrases necessary for communication (3.00) and screening materials (books, movies, and media) for negative stereotypes (3.28). The authors recommended faculty development, certification in transcultural nursing, and inclusion of theory on cultural competence for nursing faculty education. Furthermore, nurse educators need to expand boundaries and opportunities for exposure to people of diverse backgrounds. Kardong-Edgren et al. (2005) surveyed nursing faculty (n = 94) using a convenience sample of attendees of two national nursing conferences. Participants were surveyed on cultural attitudes and cultural knowledge. The Cultural Attitudes Scale (CAS) was administered following four cultural vignettes. Mean scores ranged from 64 to 68 out of 100 respectively indicating a moderately positive attitude toward ethnic groups. CAS reliabilities were low with the highest subscale of .76. Further studies need to be completed to assess reliability of this
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instrument. The Cultural Self-Efficacy Scale determined faculty confidence in caring for different ethnic groups. Participants reported moderate to high responses in feeling confident in their knowledge and skill with diverse groups. There was a moderate correlation between knowledge and attitude that was statistically significant (P b .01). The alpha coefficient for skills in transcultural care was .92, and confidence in knowledge of cultural concepts was .87. The majority of faculty identified teaching cultural concepts in the nursing curriculum, yet only one third reported having cultural components in their own schooling, and no specifics were provided on how students perceive cultural competence. Narrative comments expressed the need for repeated exposure to clients of different cultures. Although these findings cannot be generalized to all nursing faculty, it does represent a small population of faculty that is engaging in the process of cultural competence. Because this convenience sample was taken from national nursing conferences, it may be a reason for their strong commitment to the profession. Sargent, Sedlak, and Martsolf (2005) studied students and nursing faculty at a baccalaureate college in Ohio, using Camphina-Bacote's tool, the Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals. Transcultural health care experts established content and construct validity of the instrument. Reliability analysis using Chronbach's alpha yielded a result of .76. Faculty members were selected based on their responsibility for teaching cultural concepts with students. Of the 51 faculty members surveyed, 29 were found to be culturally aware, 20 were culturally competent, and 2 were culturally proficient. Curriculum threads of cultural components were established for each year of the nursing program. This suggests faculty commitment and cultural desire, yet not all faculty were surveyed. Suggestions for improvement include acknowledging that it is a long-term process to achieve cultural competence but that the reward is great in the end. Ume-Nwagbo (2012) compared the cultural competence of nursing faculty in accredited bachelor of science in nursing programs with the admission and graduation of minority students within the past 5 years. UmeNwagbo used Sealy's tool, The Cultural Diversity Questionnaire for Nurse Educators, to survey 173 faculty members. Content validity was established by a panel of four experts in cultural diversity. Reliability for the five constructs were cultural awareness (.63), cultural desire (.82), cultural knowledge (.69), cultural skill (.68), and cultural encounter (.76), respectively. Sixty-six questionnaires were grouped as school responses and analyzed individually as well. The findings were classified as low cultural competence if the respondent scored between 55 and 130, moderate 131 to 201, and high cultural competence if the scores were 202 to 275. School's competency rating scores were 199.7 to 229.8; individual faculty member competency rating scores ranged from 168 to 262. A significant positive correlation existed
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between school's cultural competency rating and the percentage of minority students graduating (P b .01). Ume-Nwagbo stressed the importance of nursing faculty becoming highly culturally competent to facilitate a culturally diverse future nursing workforce. Although the study was limited to institutions in Tennessee, UmeNwagbo recommended faculty training and support to achieve higher levels of cultural commitment. Bedharz, Schim, and Doorenbos (2010) discuss faculty and student cultural competency addressing threats, strategies, and pitfalls. Language is a major factor in communicating between faculty and students, whether spoken or written. Faculty must be aware of their mode of communication and be culturally sensitive. In order for people to improve personal cultural capacity, the authors propose five areas to address: know thy self, think globally, act locally, find the keys, and listen and learn. Find the keys refers to faculty responsibility to understand terms such as acculturation, racism, ageism, and appreciate how they influence behavior. Listen and learn addresses shifting to active teaching/learning methods to reach all learners. While this article addressed many teaching and communication strategies for culturally diverse students, Bedharz et al. (2010) also stressed the importance of individual cultural development. Wilson, Sanner, and McAllister (2010) completed a study of health science faculty (n = 28). This longitudinal study included a cultural competency pretest followed by a cultural training series. Followup testing was completed at 3, 6, and 12 months. Internal consistency reliability for this study was reported on the pretest as .86 and posttest .81, respectively. Faculty scores revealed increases in cultural awareness, cultural skill, cultural knowledge, and cultural encounters when comparing pretest and posttest (P b .06). Results were not statistically significant at 3 months (P b .08), yet were significant at 6 months (P b .03) and 12 months (P b .03). These findings validate the benefits and needed reinforcement of cultural components for nurse educators. Cultural competence is a continual process, and faculty must be engaged in the process to expand their own cultural growth and facilitate development in students. The concept of cultural safety is an additional component of cultural competency. Cultural safety is the power disparity between patient and nurse (Mkandawire-Valhmu & Doehring, 2012). When considering culturally safe care, nurses must assess the current social, economic, and political differences between themselves and the patient (McEldowney & Connor, 2011; Mkandawire-Valhmu & Doehring, 2012). Patients become at risk for culturally unsafe care when nurses “disempower, diminish, demean or compromise cultural identity” (Bidzinski, Boustead, Gleave, Russo, & Scott, 2012, p. 43). A strategy to assist the nurse with understanding power differences is for the nurse to complete a cultural heritage reflection (Gerlach, 2012). Unfortunately, the review and synthesis of literature
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revealed no studies that specifically addressed cultural safety and nursing faculty. In addition to cultural sensitivity and cultural safety, nurses can also possess and practice cultural humility. Cultural humility entails providing care to individuals from other cultures without stereotyping or passing judgment (Broome & McGuiness, 2007). This is a lifelong process that demands self-reflection and critique and the willingness to learn from others and build partnerships in patient care (Chang, Simon, & Dong, 2012; Foster, 2009). Furthermore, cultural humility demands that individuals recognize one's own beliefs and values and take responsibility for interactions with others while accepting differences and being responsive to the needs of others. This self-reflection and awareness allows the culturally competent health care provider to go beyond identifying and responding to specific cultural traits, allowing for a partnership with the client (Levi, 2009; Tervalon & Murray-Garcia, 1998). This process encourages respect and requires responsible interactions beyond sensitivity to differences (Levi, 2009). One process for practicing cultural humility proposed by Chang et al. (2012) includes self-questioning, cultural immersion, active listening, and negotiation. These skills and opportunities strengthen self-reflection and diverse interactions. In essence, examining oneself is a key to conscientiously communicating with others. Again, no studies were found in the literature addressing cultural humility and nursing faculty. The concept of service learning in promoting cultural competence is a growing area, yet the majority of literature discusses the impact of service learning on students. No studies were found in the literature specifically addressing the impact on faculty cultural competence. Community-based curriculums integrate service learning components with students (Amerson, 2010; Hamner, Wilder, & Byrd, 2007; Zoucha, Mayle, & Colliza, 2011). Faculty involved with these courses may develop cultural competence, yet this opportunity is limited to only those faculty directly involved. In one program, the community stakeholders expressed the need for a consistent supervising faculty member (Hamner et al., 2007). This provides only a small population of faculty connection to cultural competence through service learning. Studies need to be conducted to evaluate service learning as an avenue to promote cultural competence of faculty.
Discussion Nurses display the attributes of caring and respect in addition to having the knowledge and skills necessary to deliver quality patient care. Cultural competency for the profession of nursing relates to being sensitive to and respectful of the client's values and traditions that make up their culture (de Chesnay, Hart, & Brannan, 2012). Cultural differences thread through nursing education programs at all levels and continue to be a relevant issue post licensure in that cultural competency is included in annual staff training in the
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majority of health care facilities. The question remains, where should the emphasis on cultural desire begin? In order to achieve the greatest effect, cultural competency must begin with nursing education, specifically with nurse educators. One of the fundamental values of nursing education focuses on caring for culturally diverse individuals and populations. Nurse educators should seek to impart and encourage cultural desire, awareness, knowledge, assessment, and encounter to the nursing students with the ultimate goal of developing cultural competence. However, no exact plan exists for how this should unfold with all nursing programs. Nurse educators need to ensure that cultural content is incorporated in existing curricula (Waite & Calamaro, 2010). Nurses must be able to take the knowledge that they have and transfer it to practice (DeSantis & Lipson, 2007). There is ample evidence to support integration of cultural content within nursing curricula; however, little addresses cultural competency of nursing faculty. Without nursing educators transferring their knowledge of cultural competence into the practice setting of nursing education, nursing students will lack a fundamental dimension of learned behavior. According to McMillan (2012), professional development for nurse educators is one way to promote cultural competence in nursing education. Professional development is appropriate for faculty continuing education; however, this is inefficient when used as the sole means of developing cultural competency in nursing faculty (Waite & Calamaro, 2010). Nursing faculty need to incorporate a dynamic approach to attaining cultural competence. Educators must become the student and employ many of the same teaching and learning strategies used in their classroom and clinical experiences. Nurse educators use the teaching methodology of reflection with students to have the students evaluate and analyze their personal reactions of meaningful experiences (Rowles & Russo, 2009; Waite & Calamaro, 2010). Nurse educators should be encouraged to employ the technique of reflection in relation to their experiences with culturally diverse students, individuals, families, and communities to evaluate their personal strengths and identify weaknesses. It is through identifying weaknesses that nursing faculty can become more engaged in the process of cultural competence. Cultural immersion is one method for developing and supporting the process of cultural competence. According to Vaughan (2005), submersion into situations or environments different from your own is instrumental for developing cultural competence. Being immersed in a different culture promotes selfreflection of personal views, beliefs, and even personal biases. Cultural immersion experiences are often expensive and time consuming; however, immersion experiences of a smaller scale could be beneficial as well. Nursing faculty must be creative and capitalize on any opportunities that provide diverse didactic,
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clinical, and immersion experiences locally, nationally, and globally.
Implications Nursing faculty members have frequent, direct contact with nursing students, thus should role model expected professional behavior including cultural competence. One method for developing cultural competence with a student body is through the recruitment and retention of culturally diverse faculty and students (Wellman, 2009). Wellman (2009) goes on to state that faculty can further assist with cultural competence attainment by modeling a sound commitment to competence development and by including cultural concepts in didactic and clinical courses. Having the knowledge that cultural competency is essential is only the beginning of the process. Cultural desire must come from within the individual faculty member and institutional commitment in order to demonstrate the true process of cultural competence. “Cultural desire is the motivation of the health care provider to want to, rather than have to, engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and familiar with cultural encounters” (Campinha-Bacote, 2002, p.182). Two important facets of cultural competency apply to faculty and curricular planning for nursing students. It is essential that nursing faculty “know yourself and show respect for others” (de Chesnay, 2012, p.446). A beginning exercise could be to examine your student population, neighborhood, and region for the demographic breakdown. Sharing cultural icons, such as photographs, jewelry, or clothing, during a faculty development session can also assist with knowing yourself. Appreciating the culture of each nursing faculty is a beginning step to respecting others. The Office of Minority Health is responsible for the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards). These standards set the stage for health care provider's awareness about transcultural practices. Many continuing education opportunities are available on the Think Cultural Health Web page (Office of Minority Health, 2012, https://ccnm. thinkculturalhealth.hhs.gov). While faculty must have the cultural desire, students also identify with faculty and clinical instructors with certain qualities. Key elements of an effective educator include being a source of support, being a role model, personal traits (e.g., empathy, affection for the nursing profession, and reflective thinking), metacognition, and making clinical learning enjoyable (Heshmati-Nabavi & Vanaki, 2009). Waite and Calamaro (2010) argue that educators need more than a 1-day inservice or faculty simply interested in teaching cultural courses without formal education in this arena. They question if nursing faculty demonstrate the knowledge, skills, and experiences to educate students on diverse populations. As nurse educators, we must take responsibility for our own
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cultural competence, mentor new faculty, and role model positive behaviors that are culturally sensitive.
Conclusion As our culture in the United States becomes more diverse, nurses must meet the challenge of providing culturally competent care to all. Cultural competence is a dynamic process that occurs on a continuum. The concept of cultural competence is introduced to nursing students in the nursing curricula and continues post licensure. In order to have the greatest impact on cultural knowledge, awareness, skill, and cultural diversity, nurse educators must be culturally competent and model culturally sensitive behaviors with each student encounter. Current literature offers a variety of teaching and learning methodologies to support achievement of cultural competence by nursing students. However, when the question was posed regarding cultural competency in nurse educators, the literature is lacking. More research needs to be conducted on nursing faculty cultural desire, including educators from all program types. CampinhaBacote's (2002) conceptual model of cultural competence provides a sound framework for evaluating the concept of cultural competence in nursing education, specific to nursing faculty. It is the hope that all nurse educators develop cultural desire and foster the development of cultural competency in the students they mentor. This responsibility does not default only to faculty teaching a transcultural nursing course, rather teaching cultural competence is the responsibility of all nurse educators. As nurse educators become more aware of their role in the development and impact of cultural competence in the nurses of tomorrow, the rewards are innumerable. Nurse educators are assisting in the hope of tomorrow because they teach, mentor, and foster the development of the next generation of nurses. What greater impact can nurse educators have than teaching future nurses by example to care for all people while appreciating our differences?
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