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bs_bs_banner AN INDEPENDENT VOICE FOR NURSING Culture and Cultural Competence in Nursing Education and Practice: The State of the Art Linda Harkess, MSN, RN, and Mahmoud Kaddoura, PhD, CAGS, APRN, NP-C
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bs_bs_banner AN INDEPENDENT VOICE FOR NURSING Culture and Cultural Competence in Nursing Education and Practice: The State of the Art Linda Harkess, MSN, RN, and Mahmoud Kaddoura, PhD, CAGS, APRN, NP-C Linda Harkess, MSN, RN, is Staff Nurse, Brigham and Women s Hospital, Boston, MA; and Mahmoud Kaddoura, PhD, CAGS, APRN, NP-C, is Assistant Professor, Duke University, Durham, NC. Keywords Cultural competence, cultural diversity, education, nursing research Correspondence Mahmoud A. Kaddoura, PhD, CAGS, APRN, NP-C, School of Nursing, Duke University, Durham, NC duke.edu PROBLEM. The concept of cultural competency has developed a substantial presence in nursing education and practice since first attracting widespread attention in the 1990s. While several theories and corresponding measures of cultural competency have been advanced and tried, much work remains, as many nursing professionals continue to call for greater evidence-based research and attention to patient perspectives and outcomes. METHODS. Using a method provided by Hawker et al. to appraise articles, this paper compares nine recent ( ) studies (including two composite studies) related to cultural competency, undergraduate curricula, and teaching strategies in nursing to assess the state of the art in this important area of care. FINDINGS. The studies applied phenomenological, study abroad, online, and service learning strategies, four of which relied on some version of Campinha-Bacote s IAPCC model. These studies reported a general improvement in competency among students, though generally only to a level of cultural awareness, and admitted being constrained by several common limitations. CONCLUSION. Improved results and more realistic expectations in this area may require a closer understanding of the nature of the culture that underlies cultural competence. Introduction The development of the concept of cultural competence in nursing may be linked to the emergence of several broader trends, including the embrace of multicultural education, educational reform emphasizing critical thinking skills, and trends toward experiential, practical, and applied training in the field. Although the embrace of the term cultural competence is not entirely universal (e.g., Thackrah and Thompson [2013] proposed a notion of cultural humility ), today it has a foothold in many nursing school curricula and general discourse. The basics of what cultural competence has come to mean in relation to nursing first emerged in the 1970s with theories of transcultural nursing (Leininger, 1978). The concept gained much greater attention in the mid-1990s, at which time the American Academy of Nursing attempted a standard definition for it as a complex integration of knowledge, attitudes, and skills that enhances cross-cultural communication and appropriate effective interactions with others (Kaddoura, 2012; Kaddoura & Williams, 2012; Long, 2012). By 2004, the term had gathered enough steam to engender a substantial bibliography, and set of influential proposed models, including Leininger s Cultural Care and Diversity and Universality theory, Purnell s Model for Cultural Competence/Transcultural Health Care, Spector s Health Traditions Model, Giger and Davidhizar s Model of Transcultural Nursing, and Campinha-Bacote s Cultural Competency model (American Association of Colleges of Nursing, 2008b; Shen, 2004), among others. Yet, Kardong-Edgren and 1 Cultural Competence in Nursing Education L. Harkess and M. Kaddoura Campinha-Bacote s observation remains true today: A universally agreed-upon definition of what cultural competency is, is still lacking (Kardong-Edgren & Campinha-Bacote, 2008, p. 38). This is reflected in the varied approaches to integrate the concept into nursing education, as illustrated in the productive engagement generated by Lipson and DeSantis s (2007) treatment, which called attention to important issues such as debates about content, standards and tools for evaluating effectiveness, coursework on culture, the nurse patient encounter, and faculty support. As various theories of cultural competence have emerged, some have been more influential than others. The National CLAS Standards (National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care) have served as a guideline for some nursing schools and healthcare institutions (CLAS, 2014; Koh et al., 2014). Another, Campinha- Bacote s Cultural Competency model, defines cultural competency as an ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, community) (Harris, Purnell, Fletcher, & Lindgren, 2013, p. 135). This model relies on the pillar constructs of cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters. Common training methods for cultural competency in nursing schools include group discussion, lectures, case scenarios, clinical experiences, cultural immersion and presentations by ethnic minority speaker (Long, 2012, p. 104). The frequently referenced Toolkit of Resources for Cultural Competent Education for Baccalaureate Nurses (American Association of Colleges of Nursing, 2008b) lists a varied set of classroom learning strategies to help achieve cultural competence, everything from more inward and classroom reliant activities (performing a cultural self-assessment, guest presentations by indigenous healers, role playing), to more outward directed ones (developing culturally specific nursing plans, community health fairs, faith-based wellness programs). Lipson and DeSantis (2007) grouped common approaches to implementing cultural competence education in nursing education in the categories: specialty focus, required courses, models, immersion experiences, and distance learning or simulation. In their implementation, the strategy designed to teach cultural competences varies from a few dedicated courses to integrated curriculum approaches that incorporate it as an essential element across numerous courses in a program. Regardless of strategy, the experiential component of cultural competency courses and programs varies and deserves delineation. While immersion is often referenced as a strategy to satisfy the pillar of cultural encounter, the immersion element, as Ballestas and Roller (2013) point out, can take various forms, including study abroad, exchange programs, local cultural immersion, or in service learning. Study abroad and exchange programs predate more recent understandings of cultural competence, and though they inherently might serve to partly promote cultural competence (e.g., through language instruction), such programs per se are not automatically fully geared to this purpose. The same may be said for the experientially grounded approach of service learning, or academic service learning (Kaddoura, Puri, & Dominick, 2014; Puri, Kaddoura, & Dominick, 2013). Academics and professionals draw from various models in what by now is a vast literature on service learning to define it, but Thackrah and Thompson s (2013) definition contains its typical features: service learning is an educational experience in which students participate in service based on community need, and reflect on their involvement to gain understanding of the course content, a broader perspective on their discipline, and an enhanced sense of civic responsibility (Curtin et al., p. 549). This can overlap with study abroad and exchange programs in the form of international service learning. Thus, study abroad, exchange programs, and service learning opportunities should not be presumed to support cultural competence, but they may overlap with the goal of enhancing cultural competence only in the extent to which they involve an intercultural encounter and apply sound principles of a cultural competence strategy. The relationship between ethnicity/race, language, and cultural competency is also an interesting one that deserves scrutiny and careful attention to presumptions. The Inventory for Assessing the Process of Cultural Competency Among Healthcare Professionals-Revised (IAPCC-R ) has been a commonly referenced instrument for gauging achievements in cultural competency: The IAPCC-R is frequently used because of its length, ease of use, and reliability and validity (Kardong-Edgren & Campinha-Bacote, 2008, p. 42). A rationale for adopting cultural competence as a goal in nursing education and practice can rest on the pragmatic consideration that it has been adopted as a requirement: Since 1986 teaching cultural competence in the delivery of nursing care is an expectation of accreditation and approval boards for schools of 2 L. Harkess and M. Kaddoura Cultural Competence in Nursing Education nursing by bodies like the American Nurses Credentialing Center, American Nurses Association, National League for Nurses Accreditation Commission, Joint Commission, among others (Long, 2012, p. 103). To date, while many schools and medical institutions have adopted it into their discourse and integrated its recommendations to some extent, adoption remains a largely dynamic and voluntary process, with much room for interpretation and innovation. Thus, Although much has been defined about cultural competence, it is left to each school of nursing to choose the definition and methods to teach students about cultural competence (Long, 2012, p. 103). Differences in definition and approach can be telling with regard to the acceptance and potential future development of the concept of cultural competence. This paper does an integrative review of nine systematically appraised studies involving cultural competence, as presented in Table 1, to gauge what we can learn about its status and potential benefit to nursing education and practice. Methodology A comprehensive, computer-assisted search was conducted using the Cumulative Index to Nursing and Allied Health Literature, Educational Research Information Clearinghouse, Health Source/Academic Edition and Professional Development Collection, Ovid Nursing Journal Collection, Science Direct, and Google Scholar. The keywords cultural competence, teaching strategies, undergraduate curricula, nursing education, faculty knowledge, cultural competency, nursing, and cultural sensitivity were used as search terms, which yielded 139 research studies. The works selected were research studies published in peer-reviewed journals, written in English, dated from January 2008 through December 2013, and pertained to undergraduate nursing student populations. The time frame for the search was selected based upon the establishment of The Essentials of Baccalaureate Education for Professional Practice (American Association of Colleges of Nursing, 2008a). Only studies done in the United States were included. Studies that did not pertain to cultural competence, undergraduate nursing curricula, teaching strategies, undergraduate nursing students, or were from different disciplines such as medicine or pharmaceuticals were excluded. Studies pertaining to graduate nursing students, medical, and pharmaceutical students were also excluded, as were nonpublished research and theoretical studies. After this selection, the remaining 12 original research studies were then appraised using a modified version of Hawker, Payne, Kerr, Hardey, and Powell s (2002) quality appraisal tool. The nine areas graded were abstract and title, introduction and aim, method and data, sampling, data analysis, ethics and bias, results, transferability or generalizability, and implication and usefulness. Each of these areas was divided into four subcategories similar to that of a 4-point Likert scale: good, fair, poor, and very poor. The subcategories were then assigned a numerical number rating: for example, good warranted a 4, with cumulative points from all 9 sections. Fair equals 3, or cumulative points Poor equals 2, or cumulative points 10 18, and very poor equals 1, or cumulative points 9, for a total of 36 points for each article (Hawker et al., 2002). The remaining 9 studies with scores of 28 36, or good, were then selected for this integrative review. Table 2 provides a summary of the appraisal process. Results The selected focus studies varied in their approaches, although five out of nine (Adamshick & August-Brady, 2012; Ballestas & Roller, 2013; Carpenter & Garcia, 2012; Curtin, Martins, Schwartz-Barcott, DiMaria, & Ogando, 2013; Larson, Ott, & Miles, 2010) could be described as study abroad. Two studies were self-described as cultural immersion experience classes (Adamshick & August-Brady, 2012; Larson et al., 2010) and were held abroad; two as study abroad (Ballestas & Roller, 2013; Carpenter & Garcia, 2012); two as service learning (one conducted domestically; Chen, McAdams-Jones, Tay, & Packer, 2012, and another held abroad described as international service learning ; Curtin et al., 2013); and one took the form of an online-only summer class (Harris et al., 2013). Two of the articles (Kardong-Edgren & Campinha-Bacote, 2008; Kardong-Edgren et al., 2010) represented composite studies that culled data from more than one class/ program (four in one case; Kardong-Edgren & Campinha-Bacote, 2008, and six in another; Kardong-Edgren et al., 2010). Of the seven noncomposite studies, class size varied from 8 students (Adamshick & August-Brady, 2012) to 35 students (Carpenter & Garcia, 2012), with a mean of 18 students. Consistent with the demographics of nursing 3 Cultural Competence in Nursing Education L. Harkess and M. Kaddoura Table 1. Summary of Studies Reviewed Study a Purpose Teaching strategy Instrument /framework Sample Findings Limitations References [1] Uncover the meaning of a week-long immersion for RN students and its impact on their clinical practice post experience [2] To measure level of CC before and after a study abroad program [3] Assess the impact of a study abroad program on developing CC, cultural awareness, sensitivity, knowledge, and skills Cultural immersion Study abroad Study abroad Hermeneutic phenomenological reflection Van Manen s approach IAPCC-R Per/posttest data collection Campinha-Bacote s Cultural Competency Model Modified version of the Cultural Awareness Survey (CAS) Interviews Reflective journals Written responses to open-ended questions Eight BSN students Male n = 1 Female n = 7 Latino = 2 White n = 6 Ages Years of experience 2 16 Traveled outside the United States on mission trip n = 1 BSN students Sample size n = 18 Ages Predominantly female Ethnicity African American n = 3 White n = 8 Asian n = 2; Hispanic/Latino n = 1 Other n = 4 35 undergraduate nursing students Ages Female 85.7% White 63% 75% of students tested into the beginner levels of Spanish. No significant difference between the two cohorts in the studies. More male students participated in 2008 than in Chi-square = 7.78, df = 1, p =.005) Students were actively engaged in practice prior to and post trip. Themes From the outside looking in Struggling with dissonance Searching for meaning From the inside looking out CC score increase on 16 of the 18 students. Mean pre-score 66.3% of 100 Mean post-score increase to 78.8% t = 5.62; p .000. Experiential teaching such as field trips, post conferences, and reflective journaling may be more effective than classroom content. Themes Cultural awareness Cultural sensitivity Cultural knowledge Cultural skills Effects of the experience of nursing practice Sample characteristics Lack globalization Small sample size, focus group attendance varied but was saturated Small sample size Limits generalizability No follow-up post-test beyond the immediate post experience SV of the instrument would have been more suitable to use. Unknown prior content on cultural elements threaded throughout the four year curriculum. % of Hispanic students in sample compared to the school s population Hispanic culture may have reflected a specific interest in these students also. Small sample size Lack generalization Need longitudinal studies to evaluate the long-term impact of culture on nursing students education Adamshick and August-Brady (2012) Ballestas and Roller (2013) Carpenter and Garcia (2012) Cultural immersion Study abroad Study abroad 4 L. Harkess and M. Kaddoura Cultural Competence in Nursing Education Table 1. Continued Study a Purpose [4] Enhance students CC through a service learning project in a community clinic [5] Describe a short-term international service learning program to meet the needs of senior baccalaureate students [6] Employ an alternative learning strategy while addressing issues relevant to develop CC Teaching strategy Service learning (domestic) Service learning Online learning Instrument /framework Sample Findings Limitations References IAPCC-SV Pre-/post-test Control group Design Campinha-Bacote s Cultural Competency Model Thematic analysis Daily reflective and post-experience seminars Onsite group debriefing sessions Audit trail Interactive comparison of themes by researchers Riner s Framework Thematic analysis Reflection stimulated by five key questions Creative PowerPoint class presentation, online assessment, blackboard discussion Campinha-Bacote s Cultural Competency Model 26 ASN students volunteer 13 per group 2 speak conversational Spanish Comparison group Male n = 3 Female n = 10 Married n = 6 Employed n = 12 White n = 12 Experimental group Male n = 4 Female n = 9 Married n = 7 Employed n = 10 White n = 13 No significant difference in demographic in comparison group 10 senior female BSN students Ages Five students traveled to European Countries for vacation but not developing countries. Six students had minimal to some Spanish language skills, and one spoke Spanish fluently. All 10 students expressed interest in studying abroad and being immersed in the culture. 16 BSN students Female n = 15 Ages Caucasian n = 12 African American n = 2 American Indian n = 1 Asian n = 1 2nd semester n = 6 3rd semester n = 5 4th semester n = 4 5th semester n = 1 Experimental group improved their CC from cultural awareness to being culturally competent throughout the service-learning project. Themes Learned their culture Learned their language Transferability: information was shared at national conferences by nursing faculty. Themes Adapting physically Encountering frustration in the ability to fully meet patients needs Increasing confidence in speaking Spanish and assessing health problems Increase cultural awareness Shifting focus from self to others Positive feedback from all students Awareness of own biases and importance for being prepared to provide culturally sensitive care to diverse patient population Appreciation for hardships experienced by others Small sample size Limit globalization Randomization was impossible due to voluntary participation. Did not surmise how students translate cultural competence into clinical practice Needs consistent psychometric evaluation of IAPCC-SV Small sample size Highly motivated participants Chen et al. (2012) Curtin et al. (2013) None discussed Harris et al. (2013) Service learning (domestic) Service learning Online learning 5 Cultural Competence in Nursing Education L. Harkess and M. Kaddoura Table 1. Continued Study a Purpose Teaching strategy Instrument /framework Sample Findings Limitations References [7] Evaluate CC of graduating nursing students from programs using different curricular approaches Two used a well-known transcultural theory One used an integrative approach, no specific model One program utilized a free-standing two-credit culture course [8] Evaluate curricular methodology for teaching CC Six programs were evaluated for curricular integration [9] To explore the impact of a cultural immersion experience on student nurses cultural competence Composite IAPCC-R Data were analyzed using ANOVA F, 3214 = 1.24, p .05) Campinha-Bacote s Cultura
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