American Academy of Nursing Expert Panel report: developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations

Cultural competence in health care: an emerging theory

This study examined the current state of cultural competence in health care using a qualitative descriptive design. Interviews were conducted with 20 multidisciplinary experts in culture and cultural competence from the United States and abroad. Findings identified 3 themes; awareness, engagement, and application that crossed 4 domains of cultural competence; intrapersonal, interpersonal, system/organization, and global.

Cultural challenges and barriers through the voices of nurses

AIMS AND OBJECTIVES

To discover and describe challenges and barriers perceived by nurses in providing culturally competent care in their day-to-day encounters with diverse patient populations.

BACKGROUND

Nurses are challenged in today's healthcare environment to provide culturally competent care to a diverse patient population. To provide patient- and family-centred care, nurses must first acknowledge patient's and family's cultural differences, be willing to incorporate patient's and family's beliefs within the healthcare treatment plan, and respect the values and lifeways of differing cultures.

DESIGN

Qualitative description with thematic analysis was used to describe nurses' perceptions of barriers and challenges in providing culturally competent care. The qualitative component of the study was part of a larger research study that used a prospective, cross-sectional, descriptive survey. Participants responded to two open-ended questions about potential challenges and barriers to providing culturally competent health care.

METHODS

Nurses were recruited in a south-eastern state in the USA. Research surveys were mailed to 2000 nurses throughout the state using a stratified sampling method.

RESULTS

Three hundred and seventy-four nurses participated in the study. Three themes emerged from the qualitative description: great diversity, lack of resources, and prejudices and biases.

CONCLUSIONS

The provision of culturally competent patient- and family-centred care is an ethical imperative and professional mandate. Describing nurses' perspectives on challenges and barriers to providing culturally competent care is the first step in helping to redesign care delivery practices.

RELEVANCE TO CLINICAL PRACTICE

Challenges to providing culturally competent care included diversity in patient populations, lack of resources to provide culturally competent care and biases/prejudices. Strategies to address these challenges in the areas of nursing education, nursing research and nursing policy were proposed.

Validation of a patient-centered, culturally sensitive, clinic environment inventory using a national sample of adult patients

The purpose of this study was to determine the factor structure, internal consistency reliability, and validity of the Tucker Culturally Sensitive Health Care Clinic Environment Inventory-Patient Form (T-CSHCCEI-PF), a novel instrument designed to assess an aspect of health care often ignored in health care quality research: the cultural sensitivity of health care center policies and environment as perceived by adult, racially/ethnically diverse patients. Using ratings on this inventory by a culturally diverse national sample of adult patients (N = 1,639) from 67 health care sites across the United States, a confirmatory factor analysis of the T-CSHCCEI-PF was conducted, and its reliability and validity were determined. The T-CSHCCEI-PF was shown to be a reliable and valid inventory for culturally diverse patients to provide feedback to the administrators at their health care centers regarding the degree to which these centers have characteristics that are reflective of patient-centered culturally sensitive health care.

A Program to Enhance Recruitment and Retention of Disadvantaged and Ethnically Diverse Baccalaureate Nursing Students

Purpose: To describe and evaluate the use of a “Success in Learning: Individualized Pathways Program (SLIPP)” to retain and graduate disadvantaged and ethnically diverse nursing students. Design: A summative evaluative design was used with a population of 77 disadvantaged and ethnically diverse students who were accepted into a pre-entrance preparation quarter. The program based on an academic success model, included six pre-entrance classes, academic, social, and financial support, and seven faculty development workshops. Program outcomes were studied using student records, survey results, and interviews. Results: Following the pre-entrance quarter, all 77 students were accepted into the baccalaureate nursing program, 90.9% graduated with either a Bachelor in Science (75.3%) or Associate in Science (15.6%), and 98.6% of the graduates passed the state board registered nursing examination. Discussion: Outcomes are discussed in light of similar programs. Conclusions: Underprepared disadvantaged and ethnically diverse students can successfully become registered nurses. Implications for Education, Practice, and Research: Educators and recruiters for nursing practice should accept/hire culturally diverse students/nurses to expand the ethnic diversity of the nursing workforce to meet the needs of culturally diverse clients. Research is needed to determine the classes/components and length of the pre-entrance preparation program to successfully enhance success.

Measures of cultural competence in nurses: an integrative review

Background. There is limited literature available identifying and describing the instruments that measure cultural competence in nursing students and nursing professionals. Design. An integrative review was undertaken to identify the characteristics common to these instruments, examine their psychometric properties, and identify the concepts these instruments are designed to measure. Method. There were eleven instruments identified that measure cultural competence in nursing. Of these eleven instruments, four had been thoroughly tested in either initial development or in subsequent testing, with developers providing extensive details of the testing. Results. The current literature identifies that the instruments to assess cultural competence in nurses and nursing students are self-administered and based on individuals' perceptions. The instruments are commonly utilized to test the effectiveness of educational programs designed to increase cultural competence. Conclusions. The reviewed instruments measure nurses' self-perceptions or self-reported level of cultural competence but offer no objective measure of culturally competent care from a patient's perspective which can be problematic. Comparison of instruments reveals that they are based on a variety of conceptual frameworks and that multiple factors should be considered when deciding which instrument to use.

Mapping the concept of vulnerability related to health care disparities: a scoping review

Background

The aim of this paper is to share the results of a scoping review that examined the relationship between health care disparities and the multiplicity of vulnerability factors that are often clustered together.

Methods

The conceptual framework used was an innovative dynamic model that we developed to analyze the co-existence of multiple vulnerability factors (multi-vulnerability) related to the phenomenon of the ‘Inverse Care Law’. A total of 759 candidate references were identified through a literature search, of which 23 publications were deemed relevant to our scoping review.

Results

The review confirmed our hypothesis of a direct correlation between co-existing vulnerability factors and health care disparities. Several gaps in the literature were identified, such as a lack of research on vulnerable populations’ perception of their own vulnerability and on multimorbidity and immigrant status as aspects of vulnerability.

Conclusions

Future research addressing the revealed gaps would help foster primary care interventions that are responsive to the needs of vulnerable people and, eventually, contribute to the reduction of health care disparities in society.

Advancing genomic research and reducing health disparities: what can nurse scholars do?

PURPOSE

Advances in genomic research are improving our understanding of human diseases and evoking promise of an era of genomic medicine. It is unclear whether genomic medicine may exacerbate or attenuate extant racial group health disparities. We delineate how nurse scholars could engage in the configuration of an equitable genomic medicine paradigm.

ORGANIZING CONSTRUCT

We identify as legitimate subjects for nursing scholarship the scientific relevance, ethical, and public policy implications for employing racial categories in genomic research in the context of reducing extant health disparities.

FINDINGS

Since genomic research is largely population specific, current classification of genomic data will center on racial and ethnic groups. Nurse scholars should be involved in clarifying how putative racial group differences should be elucidated in light of the current orthodoxy that genomic solutions may alleviate racial health disparities.

CONCLUSIONS

Nurse scholars are capable of employing their expertise in concept analysis to elucidate how race is used as a variable in scientific research, and to use knowledge brokering to delineate how race variables that imply human ancestry could be utilized in genomic research pragmatically in the context of health disparities.

CLINICAL RELEVANCE

In an era of genomic medicine, nurse scholars should recognize and understand the challenges and complexities of genomics and race and their relevance to health care and health disparities.

Cultural competence: an evolutionary concept analysis

AIM

The purpose of this article is to explore the concept of cultural competence in the nursing and nursing education literature.

BACKGROUND

The RN workforce, the nurse faculty population, and the pre-licensure nursing student population do not reflect the country's changing demographics, and cultural competence is identified as key to preparing nurses to meet clients' needs.

METHOD

Using Rogers' method of evolutionary concept analysis, key words (cultural competence, nursing, and nursing education) were searched in two databases for a five-year period. Of 388 articles found, 137 met inclusion criteria; of these, 30 articles were randomly selected for nursing and nursing education.

RESULTS

Three dimensions of cultural competence (awareness, attitudes, and behaviors) and related concepts were identified.

CONCLUSION

Results of this concept analysis reveal congruency between nursing and nursing education with regard to cultural competence. Further research is recommended.

Model development for international nurse educator partnerships: relationship-building process and strategies

Cultural diversity and its impact on patient care contribute to persistent health care disparities. In attempts to enhance nursing  student  cultural  awareness  and  sensitivity,  nurse educators  seek  international  opportunities,  often  times  in low resource countries, as ways to expand upon culturally diverse experiences. A model that addresses relationship-building among faculty from different countries and cultures contributes  to enhanced professional relationships, minimizes  collaboration  barriers,  and  maximizes  shared teaching opportunities during  international experiences.  It  is critical  in  relationship-building  among  nurse  educators  to develop  implementation  strategies  that  facilitate comprehensive and effective student encounters. 

A Multicultural Approach to Health Psychology

The North American continent comprises a diverse array of individuals. Although the majority of them prescribe to the beliefs and treatments of Western biomedicine, a substantial number also practice diverse approaches to health. This article summarizes the basic tenets of major non-Western approaches to health, including the main beliefs and treatments. It bases this discussion in the context of health disparities, the existence of which presents a major problem for health care in America, and with an eye toward aiding the development of cultural competence for clinicians and health care providers nationwide.

Development of scales to assess patients' perception of physicians' cultural competence in health care interactions

This study describes the development of scales to measure patients' perception of physicians' cultural competence in health care interactions and thus contributes to promoting awareness of physician-patient intercultural interaction processes. Surveys were administrated to a total of 682 participants. Exploratory factor analyses were employed to assess emergent scales and subscales to develop reliable instruments. The first two phases were devoted to formative research and pilot study. The third phase was devoted to scale development, which resulted in a five-factor solution to measure patient perception of physicians' cultural competence for patient satisfaction.

Changing the face of nursing: reducing ethnic and racial disparities in health

This article reports on findings from a Nursing Diversity Workforce grant, BEST (Becoming Excellent Students in Transition to Nursing), designed to assist students from minority and educationally disadvantaged backgrounds to become culturally competent registered nurses. A program of retention strategies that included peer and faculty tutoring, counseling, and financial support helped to remove barriers to success in nursing. All but 3 of the enrolled students either have graduated or are on track to doing so. Most graduates are practicing in the city where they are helping to reduce health disparities through their contributions to improved health care for vulnerable populations.

Oncology nursing: educating advanced practice nurses to provide culturally competent care

More than 37 million persons or 12.4% of the U.S. population are older than 65 years. These numbers are expected to reach 71.5 million (20% of the population) by 2030. This older population is becoming more racially and ethnically diverse as the overall minority and culturally diverse populations increase. Although the incidence and mortality rates from several major cancers have declined due to advances in cancer care, these advances have lagged among the underserved and more vulnerable racially and culturally diverse populations. Moreover, the disparity between the gender and the racial mix of nurses and the overall population continues to widen. Thus, a growing need for professional nurses and advanced practice nurses with formal educational preparation in all areas of oncology nursing exists. This article (a) highlights significant cancer disparities among diverse populations, (b) describes how cultural belief systems influence cancer care and decision making, and (c) explicates the need to prepare advanced practice nurses for careers that include cancer care of diverse and vulnerable populations through formal oncology educational programs. The "Top 10" reasons for becoming an advanced practice nurse specializing in the oncologic care of patients from diverse and underserved populations are presented.

Evaluation findings from genetics and family health history community-based workshops for African Americans

The purpose of this study was to examine the implementation and effectiveness of community education workshops to change genetics and health-related knowledge, intentions, and behavior of urban African Americans. Eight workshops were held and 183 participants consented to participate in the study. A majority of the participants were African American (97%) and female (84%) and just over half were 65 years and older (60%), and had some high school or were high school graduates (52%). The community-based workshops were standardized and comprised a 45-min PowerPoint presentation that included group discussions and interactive activities. The evaluation used a pre-post design with a 2-month follow-up. The group as a whole (and the subgroups by age and education level) significantly improved their knowledge of race and genetics from pretest to posttest as measured by their scores on the "Race", Genetics, and Health knowledge questions. Findings around intentions showed that the largest number of participants pledged to collect family health history information from family members. Findings around behavior changes showed that, along the stages of change continuum, there were more participants at maintenance (stage 5) at the 2-month follow-up than at the pre-workshop for three health-related activities. Feedback was positive as participants indicated they appreciated the information they received and audience involvement. The article discusses local and global implications for practice and research among community health educators.

Cultural competencies for graduate nursing education

Nursing is challenged to meet the health needs of ethnic and socioculturally diverse populations. To this end, American Association of Colleges of Nursing (AACN) charged an expert nursing faculty advisory group to formulate competencies for graduate nursing education, expanding them to integrate leadership and scholarship. The Cultural Competency in Baccalaureate Nursing Education served as the springboard for the initiative. In formulating the graduate cultural competencies and the toolkit, the advisory group reviewed all AACN Essentials documents and the cultural competency literature, drew upon their collective experiences with cultural diversity, and used cultural humility as the supporting framework. Six core competencies were formulated and endorsed by the AACN board of directors and key professional nursing organizations. A companion toolkit was compiled to provide resources for the implementation of the competencies. A 1-day conference was held in California to launch the cultural competencies and toolkit. Dissemination to graduate nursing programs is in process, with emphasis on faculty readiness to undertake this graduate educational transformation. The AACN Cultural Competencies for Graduate Nursing Education set national standards to prepare culturally competent nurses at the graduate level who will contribute to the elimination of health disparities through education, clinical practice, research, scholarship, and policy.

Psychometric evaluation of the perceived prejudice in health care scale-modified (PPHC-M) among baccalaureate student nurses

PURPOSE

Discrepancy in quality of health care for patients with diverse backgrounds contributes to health outcome disparities. BSN students reveal surprise regarding the presence of health care disparities. Critical social theory guided this study. The psychometric properties of the Perception of Prejudice in Health Care Scale–Modified (PPHC-M) were evaluated,and the relationship between perceived discrimination in health care delivery and cultural sensitivity awareness was explored.

DESIGN

A descriptive, cross-sectional survey of 146 Midwest BSN students was conducted using Cultural Competence Assessment (CCA), PPHC-M, and the Marlowe–Crowne Social Desirability Scale.

RESULTS

PPHC-M demonstrated reliability(α = .781.) Cronbach’s alphas for General Perception of Prejudice (GPP) and Personal Experience of Prejudice (PEP) were.759 and .756, respectively. Construct validity was supported by contrasted groups. The PPHC was not significantly correlated with the CCA scores.

DISCUSSION/CONCLUSION

PPHC-M shows promise in measuring perceived prejudice in health care.

Lost in translation: student perceptions of cultural competence in undergraduate and graduate nursing curricula

The rapidly changing demographics of the United States require nurses who are equipped with knowledge and skills to meet the needs of an increasingly diverse patient population. Nurse educators seek to meet this challenge through integrating cultural competence into nursing course curricula. Few studies have examined student perceptions of the integration of this material. As part of a larger school-wide assessment, this qualitative descriptive study used focus groups of doctoral and bachelor of science in nursing students to evaluate their perceptions of the integration of cultural competence in the nursing curriculum. We sought to answer two questions: (a) what the students' perceptions were and (b) what recommendations they had for improvement. The results of the focus groups yielded three themes: (a) broadening definitions, (b) integrating cultural competence, and (c) missed opportunities. Student suggestions and recommendations for enhancing cultural competence in the curricula are provided.

A Guide to Developing a Culturally Competent Organization

The journey to organizational cultural competence for a health care organization, educational setting, freestanding clinic, or long-term-care organization is a process that requires the collaborative efforts from people at all levels in every department as well as external consumers such as public policy officials, students, and community leaders. Broadly speaking, four main but overlapping areas must be considered in institute activities and strategies to accomplish a comprehensive culturally competent organization. These four areas are (a) administration and governance, (b) orientation and education, (c) language, and (d) staff competencies. This article presents key content areas and activities to consider on the journey to cultural competence. Tables with suggested departmental responsibilities for implementation are included. In some cases, the journey may best be facilitated by a consultant who is well versed in cultural competence and organizational dynamics.

Nurses' perceptions of the organizational supports needed for the delivery of culturally competent care

The purpose of this study was to determine nurses' views on the organizational supports needed for the delivery of culturally competent care. The research design was qualitative, with a case study approach. Data collection included face-to-face interviews with 23 registered nurses, document analysis, and reports of critical incidents. The findings of this study revealed that caring for culturally diverse clients was challenging and frustrating for most participants. Major themes emerging from the data included language barriers, lack of training, difficulty with cultural differences, lack of organizational support, and reliance on culturally diverse staff members. Few organizational supports existed for delivering culturally competent care. Expectations were not explicit, and culturally competent care was not rewarded or supported. Recommendations for organizations, nursing practice, theory, and future research are made.

Cultural competence among nurse practitioners working with asylum seekers

Asylum seekers often have complex medical needs. Little is known about the cultural competences health care providers should have in their contact with asylum seekers in order to meet their needs. Cultural competence is generally defined as a combination of knowledge about certain cultural groups, as well as attitudes towards and skills for dealing with cultural diversity. Given asylum seekers' specific care needs, it may be asked whether this set of general competences is adequate for the medical contact with asylum seekers. We explored the cultural competences that nurse practitioners working with asylum seekers thought were important. A purposive sample of 89 nurse practitioners in the Netherlands completed a questionnaire. In addition, six group interviews with nurse practitioners were also conducted. A framework analysis was used to analyse the data of the questionnaires and the interviews. From the analysis, several specific competences emerged, which were required for the medical contact with asylum seekers: knowledge of the political situation in the country of origin; knowledge with regard to diseases common in the country of origin; knowledge of the effects of refugeehood on health; awareness of the juridical context in the host country; ability to deal with asylum seekers' traumatic experiences; and skills to explain the host country's health care system. Apart from these cultural competences specific for the situation of asylum seekers, general cultural competences were also seen as important, such as the ability to use interpretation services. We conclude that insight into these cultural competences may help to develop related education and training for health care providers working with asylum seekers.

Nursing's silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts

The purpose of this study was to selectively review the nursing literature for publications related to lesbian, gay, bisexual, and transgender health, using (1) a key word search of CINAHL, the database of nursing and allied health publications; (2) from the top-10 nursing journals by 5-year impact factor from 2005 to 2009, counting articles about lesbian, gay, bisexual, and transgender issues; and (3) content analysis of the articles found in those journals. Only 0.16% of articles focused on lesbian, gay, bisexual, and transgender health (8 of nearly 5000 articles) and were biased toward authors outside of the United States. We discuss the impact of this silence.

An Integrative Approach to Cultural Competence Education for Advanced Practice Nurses

A project funded by Health Resources and Services Administration (HRSA) provided the impetus for the development of four cultural competence modules taught in a graduate program at a university-based school of nursing. These modules have been consistently taught for 6 years. The authors describe the modules’ content, educational strategies, required faculty training, and evaluation and measurement of outcomes. The authors recommend use of the modules and make suggestions for future implementation. Cultural competence is essential for 21st-century practice. The impending national and global health care crises require educational approaches that are cost-effective and tested. These modules are recommended to meet this educational challenge.

Disparidad en Salud: Un Fenómeno Multidimensional

La Disparidad en Salud (DS) ha llamado la atención pública desde el siglo pasado, ha sido analizada desde diversas perspectivas y enfoques incluso variados términos han sido utilizados como sinónimos pudiendo llevar a confusión e inequidades al momento de su operacionalización. Sin embargo es importante señalar que las publicaciones coinciden en que la DS es uno de las determinantes esenciales a considerar al momento de definir polĺticas públicas. El propósito de esta publicación es analizar la disparidad en salud incorporando; a) los aspectos claves de su conceptualización, b) la evolución histórica del concepto, c) las estrategias que se han generado para enfrentarla, d) los factores considerados determinantes, y e) los aspectos éticos y la contribución de la investigación en la disminución de la DS.Health Disparities (HD) have been at the center of public attention for the past century. They have been analyzed from diverse perspectives utilizing various terms as synonyms that can lead to confusion and inequality at the moment of operationalization. Despite this, it is important to indicate that publications agree that HD are essential determinants that must be considered in the definition of public policy. The objective of this publication is to analyze health disparities incorporating; (a) key aspects in their conceptualization, (b) the historic evolution of the concept, (c) strategies that have been generated to confront them, (d) determining factors, and (e) ethical aspects and the contribution of research in decreasing HD.

Health disparities in the forensic sexual assault examination related to skin color

Little is known about the role of skin color in the forensic sexual assault examination. The purpose of this study was to determine whether anogenital injury prevalence and frequency vary by skin color in women after consensual sexual intercourse. The sample consisted of 120 healthy (63 Black, 57 White) women who underwent a forensic sexual assault examination following consensual sexual intercourse. Experienced sexual assault forensic examiners using visual inspection, colposcopy technique with digital imaging, and toluidine blue application documented the number, type, and location of anogenital injuries. Although 55% of the total sample was observed to have at least one anogenital injury of any type following consensual intercourse, the percentages significantly differed for White (68%) and Black (43%) participants (p= 0.02). When the presence of anogenital injury was analyzed by specific anatomical region, a significant difference between White and Black participants was only evident for the external genitalia (White = 56%, Black = 24%, p= .003), but not for the internal genitalia (White = 28%, Black = 19%, p= .20) or anus (White = 9%, Black = 10%, p= 0.99). A one standard deviation-unit increase in L* values (lightness) was related to a 150% to 250% increase in the odds of external genitalia injury prevalence (p < 0.001). While Black and White participants had a significantly different genital injury prevalence, dark skin color rather than race was a strong predictor for decreased injury prevalence. Sexual assault forensic examiners, therefore, may not be able to detect injury in women with dark skin as readily as women with light skin, leading to health disparities for women with dark skin.

Transcultural nursing courses online: implications for culturally competent care

Cultural diversity must be taken seriously by both faculty and students, and requires action by both parties for successful integration into online learning. Limited diversity in the nursing workforce or student population creates a need for learning cultural competence. Online transcultural nursing courses meet this learning need and provide opportunities for a variety of students and faculty participation from around the world. Successful online learning experiences can contribute to the provision of culturally competent nursing care.

Development and testing of the Blueprint for Integration of Cultural Competence in the Curriculum Questionnaire

The 31-item Blueprint for Integration of Cultural Competence in the Curriculum Questionnaire (BICCCQ) was developed to measure student reports of components of content on cultural competence taught in undergraduate and graduate nursing programs. BICCCQ items were derived from the Tool for Assessing Cultural Competence Training, which was developed to measure faculty report of components of content on cultural competence in medical school curricula. Additional items were added by a task force of members of a nursing faculty. Five factors were found by principal components factor analysis with varimax rotation: Attitudes and Skills, Knowledge of Basics, Cultural Communication, Knowledge of Theory, and Knowledge of Key Concepts, which accounted for 62.64% of the variance and included all 31 items. Mean scores for freshmen, seniors, and master's students were statistically significantly different for each factor, with freshmen scoring lower than the other two groups. Internal consistency using Cronbach's alpha ranged from .73 to .94 across factors and was .96 overall. The BICCCQ has satisfactory preliminary construct validity and internal consistency reliability. Further testing in other schools to cross-validate the stability of our findings is recommended.

Of goldfish tanks and moonlight tricks: can cultural competency ameliorate health disparities?

Within nursing, cultural competency is seen as an important mechanism for reducing racial and ethnic health disparities; however, after years of attempted implementation of "cultural competence," minimal evidence exists demonstrating a relationship between culturally competent interventions and improved health outcomes or reduced disparities. We examine how cultural competency as an intervention for tackling health disparities is undertheorized and misguided, and deflects attention and efforts needed to address broader social determinants of health. We provide a historical overview of cultural competency, critiques of the concept, and recommendations for moving beyond cultural competency as a means of diminishing health disparities.