This article offers an overview of the GAIN (Greater Awareness in Idaho Nurses) Project which seeks to produce nursing graduates who are competent in providing culturally competent care. A description of the course will describe how interdisciplinary pedagogies have been utilized to provide an integrated course utilizing experiential leaming through Service Learning. Results of assessment of student outcomes illustrate the effectiveness of the project in developing cultural competence among participants

Black, Mikal

Soelberg, Terri

Springer, Pamela

Boise State University - ScholarWorks

Boise State UniversityScholarWorksNursing Faculty Publications and Presentations School of Nursing7-1-2008Cultural Competency in Nursing EducationMikal BlackBoise State UniversityTerri SoelbergBoise State UniversityPamela SpringerBoise State UniversityThis document was originally published by Academic Exchange Quarterly in Academic Exchange Quarterly. Copyright restrictions may apply.http://www.rapidintellect.com/AEQweb/I I I \ I I I ) j ! Cultural Competency in Nursing Education Mikal Black, Boise State University Terri Soelberg, Boise State University Pam Springer, Boise State University Black, MSN, RN, is Assistant Professor oj Nursing, Soelberg, MEd., is Grant Coordinator of the Greater Awareness in Idaho Nurses Project, and Springer, PhD, RN is Associate Dean, College of Health Sciences and Chair, Department a/Nursing. Abstract This article offers an overview of the GAIN (Greater Awareness in Idaho Nurses) Project which seeks to produce nursing graduates who are competent in providing culturally competent care. A description of the course will describe how interdisciplinary pedagogies have been utilized to provide an integrated course utilizing expcriential1eaming through Service Learning. Results of assessment of student outcomes illustrate the effectiveness of the project in deve10ping eultura1 competence among participants. Introduction & Background One aspect of nursing education includes instilling new graduates with the skill and sensitivity needed to provide culturally congruent care to diverse clients. Nurses serve clients from diverse backgrounds, many of whom face personal barriers to accessing healthcare services, limiting access to health care or diminishing the quality of healthcare received. By providing care that is responsive to cultural differences, nurses are able to support desired outcomes for clients of all cullores. The ability to provide culturally congruent care is referred to as cultural competence. Culloral competence is defined by Campinha-Bacote, (1999) as "the process in which the nurse continuously strives to achieve the ability and availability to effectively work within the culloral context of a client individual, family or community." (pg. 203) However, little has been studied about the success of cultural competence education. Christine Tanner (2007) asserts, "Like critical thinking, culloral competence is a vague concept. .. " witb "raging debate to which it is ever really possible for a healtb professional to be cultorally competent. .. We have yet to see the evidence." (pg. 7) The purpose of the GAIN (Greater Awareness in Idaho Nurses) Project is to offer the means for nursing students to gain cultural competence, as well as to evaluate and present the evidence of progression towards cultural competence through this project. The lack of culloral competency in healthcare delivery has been identified by Healtby People 2010 as a primary factor leading to healtb disparities (U.S. Dept. of Healtb and Human Services, 2000). Accrediting organizations expect nursing programs to produce graduates who are adequately prepared to interact with clients of culturally diverse backgrounds (National League for Nursing Accrediting Commission, Inc. 2006). Cultural competency in nursing practice incorporates cultural awareness through knowledge, cultural insight and sensitivity, and competence behaviors. Using this approach, healtbcare providers are called to celebrate diversity through a willinguess to build on their knowledge of cullore, explore the complexities of providing cullorally competent care to clients, and reduce disparities among cultural groups. Nursing educators are called to influence learning within the students' affective domain tlrrough synthesizing how culture, both their own and those of others, impacts and is utilized in 245 Academic Exchange Quarterly Summer 2008 Copyright © author(s) - details inside tbe back cover oftbe journal. nursing care. To date, schools of nursing have addressed the subject of culture and culturally responsible care in a number of ways, such as including cultural examples in delivery of content or in case studies. Up to this point, research has not been available to indicate specific educational strategies which had been effective for achieving significant changes in the cultural competence development of nursing students. The GAIN Project was designed to reduce cultural barriers by strengthening programs that provide basic nurse education through developing cultural competencies among nursing students. Staff of the GAIN Project sought to utilize a new approach by incorporating interdisciplinary pedagogies in an effort to overcome the difficulties for developing cultural competence among nursing students. Course Set-up Models of transcultural care and experientialleaming were utilized in providing the framework for the content delivery and throughout the study. Pedagogics that were used as frameworks for the course included Campinha-Bacote's (1999) Process of Cultural Competence in the Delivery of Healthcare Services Model and Service Learning. The course offered by the GAIN Project utilizes a tri-modal delivery, consisting of both live c1ass sessions and Internet based content, combined with the Service-Learning experience. The tri-modal approach allowed each of the constructs of Campinha-Bacotc's Model (1999) and thc activities of Service Learning to be fu11y integrated. Active participation in each of these three components is required in order to pass the course. Each course consists of four modules exploring the complexities of the constructs of Campinha-Bacote's Model delivered through a Web-based course-management system. Live classes are supplemented with materials posted on a website accessible via the Internet, which enables participants to complete self-directed activities. The learning modules delivered on line include the introduction of content through lectures, articles, and links to pertinent websites. Online activities are also available which inc1ude reinforcement of facts and concepts, practice of skills, exercises in personal awareness, and discussion forums which allow for reflection and response. In-class activities include reinforcement and application of the content through guest speakers and video presentations, in~class reflective activities and presentations, and group discussion. Campinha-Bacote's (1999) model of cultural competence is built on the process of becoming culturally competent through the constructs of cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounters. Cultural desire provides the motivation to undertake the process of cultural competence. Cultural awareness involves exploration and reflection of our own cultural beliefs, practices, and biases. This step in the process of cultural competence calls us to awareness of culture and cultural differences. In providing cultura11y competent hcalthcare, nurses often experience diversity that extends beyond the definition addressing etbnicity, but also includes those characteristics, beliefs, values, and experiences which shape the uniqueness of individuals, including such aspects as gender, religious affiliation, size, sexual orientation, age, ability, political orientation, class, socio-economic status, and occupation. The debate carries on whether these varieties of human diversity are regarded as multiculturalism, lifestyle, or simply groups found within the human existence (Canetto, Yang, Borrayo, & Timpson, 2003). For this project, a broad definition of culture is utilized to included human diversity across the whole range of human experience. The undergraduate course begins with exploring awareness of one's own culture and belief systems through in-class and online content and activities. Self-assessments, role-playing, and reflective discussion are among the activities students use to explore their own cultural identity, as well as biases. 246 Academic Exchange Quarterly Summer 2008 Copyright © author(s) - details inside the back cover of the journal. The focus then shifts to incorporating a broad view of culture by providing examples and identifying resources for cultural knowledge. Cultural knowledge is obtained through investigating the facts and concepts of different cultural views and biological vmiations of diverse ethnic groups in hope of gaining understanding. Speakers from diverse culhual groups are invited to relate relevant cultural information during class meetings. Cultural skill involves acquiting those practice behaviors which adapt to diverse cultures. Cultural skill is learned and practiced through the utilization of cultural assessment models and communication skills. Cultural assessments using cultural models such as Leininger's (1995) Theory of Culture Care Diversity and Universality Sunrise Model Cultural skill, Giger and Davidhizar's (1999) Transcultural Assessment Model, and Purnell and Paulanka's (2003) Model for Cultural Competence are applied to culhlral groups with whom the students arc working in their Service Learning experiences. Proper use of interpreters is demonstrated and role-played. Cultural encounter is realized through the opportunity to interact with individuals from culturally diverse groups (Campinha-Bacote, 2002). Interaction with individuals from cultural groups different from the shldents' own was realized through Service Learning opportunities. Service Learning is a "teaching method which blends community service and academic learning in such a way that the two reinforce each other to produce a greater impact than either could alone (Hale, 2007)." Service Learning is an experiential learning oPPOltunity designed to blend community service and the integration of course content. The foundation of Service Learning comes from Kolb's Model of Experiential Learning. Kolb's model (1984) describes the cyclical process of learning involving four stages, referred to as concrete experience (CE). reflective observation (RO), abstract conceptualization (Ae), and active experimentation (AE). These four stages are applied sequentially through experiential learning, the experiential activities provide occasion for feedback, initiation of new action, and ongoing evaluation. As a result, according to Kolb (1984, pg.38), "Learning is the process whereby knowledge is created through the transfonnation of experience. II Service Learning provides the basis for the understanding needed for a learning experience, the pursuit of understanding through directed reflection and the opportunity for interaction and application through experience. Experiential leaming opportunities through Service Learning activities allow students to explore cultures in the community. reinforcing skills and concepts covered in the course and providing a resource for reflection. Through their coursework, students were given both content as well as an opportunity to reflect on the meaning of culture, their own cultural backgrounds, and the manner in which the culture of biomedicine affects and is affected by the uniqueness of the cultures of individuals within the health care system. In this manner, nursing students gain knowledge about different cultures and skills necessary for competent practice and also are given opportunity to consider why and how it will affect their own lives and practice. Participation in the Service Learning activities allowed application of ideas and skills under study through direct experience with persons from different populations. Through assignments and class discussions, students clitically reflect on their service in order to increase their understanding of course content, gain a broader appreciation of the discipline, and enhance their sense of civic responsibility. In this course, the Service-Leaming experience is designed to allow the student to explore aspects of a culture that is different than their own, while reflecting on their service and community need. The students are oriented at the beginning ofthe course about Service Learning, the expectations, responsibilities, and benefits connected to Service Leaming opportunities. Preparation is given to the students during class times and through OIientation sessions to enhance cultural sensitivity when working among members of the diverse populations. Service Learning agencies pair students with members from both ethnic and social cultures including: veterans, homeless and at-risk citizens, persons with mental disabilities, homebound elders, at-risk for HIV/AIDS, elderly, marginalized ethnic groups including Hispanics, and refugees. 247 Academic Exchange Quarterly Summer 2008 Copyright © author(s) - details inside the back cover of the journal. Students participated in such activities as helping refugees to shop, assisting persons who speak another language with English classes, providing assistance to homebound persons with Alzheimer's disease, conducting fundrai~-;ng activities for and with marginalized groups, promoting health awareness campaigns among at-risk groups, and working with children of low-income and marginalized groups. Coordination with agencies is done through the university's Service Learning Office which matches appropriate agencies with students from the course and works to align agency projects with objectives of the cultural competency course.. Inshuctor facilitation is vital for providing information to the agencies, presenting foundational concepts and knowledge to students, guiding reflective activities, and monitOling the progress of the students' experiences. Course Outcomes This course has been offered at seven locations around the state of Idaho over the past 3 years. A total of 100 nursing students have completed the cultural competency course to date. The GAIN Project included data collection through pretests and postlests of participants to measure progression of cultural competency in nursing students. Pre-and post-tests were given to students using Campinha-Bacote's Inventory to Assess the Process of Cultural Competence among Healthcare Professionals (lAPCC-R). The IAPCC-R is a 20-item instrument based on Campinha-Bacote's Model and measures cultural awareness, cultural knowledge, cultural skill, and cultural encounters through reflective response (Campinha-Bacote, 1999). Reliability of the IAPCC-R has been established in a previous study (Salman, McCabe, Easter, Callahan, Goldstein, Smith, White, & Fitzpatrick, 2007) Cronbach's alpha coefficients were 0.74 for pretest assessment and 0.83 for posHest assessment in that study. During the GAIN Project, sixty-six students completed the pretest and posttest.;;, Post-lest scores showed a difference of 13.9 points, indicating a statistically significant impact in cultural competency. Students' comments also reflected that their awareness and skills in culhrral competency had been impacted. One student commented that "I plan to use this information to act more openly and be more willing to absorb information about other cultures I contact instead of always trying to act like I am able to communicate across the barriers."- Another commented, "This class is really helping me become aware of how to actually incorporate culturally-competent care into my future nursing practice. I think it is unrealistic to become knowledgeable ahout every group we will contact, but it is realistic to know how to recognize differences in culture and be able to utilize the resources we have to assist in treating diverse client." Discussion Findings of this project provided information about facilitating increased cultural competence in nursing students. Each time this course has been offered through the GAIN Project, pretest and posttest comparisons have shown that the students were significantly impacted in the area of cultural competency through the course. When inquiring about the success of cultural competence education among other nursing programs, mUltiple educators from other nursing schools indicated that their programs were unsuccessful in affecting the cultural competence of their student nurses. This fact is supported by the lack of evidence of success by traditional methods of teaching cultural competence through inclusion of content in coursework, but not inclusive of all of the constructs utilized by the GAIN Project. In particular, participation in the service learning experiences was emphasized by student participants as the key to true 248 Academic Exchange Quarterly Summer 2008 Copyright © author(s) - details inside the back cover of the journal. r I ) I I I I I I I I I I I I I I I I I I , understanding and practice of cultural competence principles. Faculty and students alike who have been participating in the GAIN Project admit that cultmal awareness in nursing practice can be facilitated through openness and the study of cultural information and skill. However, the practice of cultmal skill through the Service Learning activities, combined with opportunities for reflective discourse, make the difference in becoming culturally competent in caring for diverse populations. References Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. 10urnal of Nursing Education (38)5. 203-207. Campinha-Bacote, 1. (2002). The process of cultural competence in the delivery of healthcarc services: A model of care. 10urnal of Transcultural Nursing (13)3. 181-184. Canetto, Yan, BOlTayo, & Timpson, (2003). Teaching about human diversity: 111eoretical and epistemological issues. Teaching diversity: Challenges and complexities, identities and integrity. Timpson, Canetto, BOlTayo, & Yang, (Eds). Madison, WI: Atwood Publishing. Giger, 1. & Davidhizar, R. (1999). Transcultural nursing: Assessment and intervention (3rd ed.). Sl. Louis: Mosby. Hale, A. (2007, September). Service learning seminar. Seminar conducted at Boise State University. Leininger, M. (1995). Transcultural nursing: Concepts, theories, research & practices. USA: McGraw-Hili. Kolb, D. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, New Jersey: Prentice-Hall. National League for Nursing Accrediting Commission, Inc. (2006). Accreditation manual with interpretive guidelines by program type for postsecondary and higher degree programs in nursing. New York, NY: Author. Purnell, L. & Paulanka, B. (2003). Transcultural health care: A eultural1y competent approach (2nd ed.). Philadelphia: FA. Davis Company. Salman, A., McCabe, D., Easter, T., Callahan, B., Goldstein, D., Smith, T., White, M., & Fitzpatrick, J. (2007) Cultural competence among staff nurses who participated in a family-centered geliatric care program. lournal for Nurses in Staff Development 23(3), 103-111. Tanner, C. (2007). Nursing education: Current themes, puzzles and paradoxes. Communicating nursing research: Conference proceedings of the Western Institute of Nursing, 40,3-11. U.S. Depmtment of Health and Human Services (2000). Healthy People 2010. MacLean, VT: International Medical Publishing Inc. 249 Academic Exchange Quarterly Smnrner 2008 Copyright © author(s) - details inside the back cover of the journal. 

Cultural Competency in Nursing Education

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