Cultural competence and cultural safety in Canadian schools of nursing: a mixed methods study

Adapting the Donabedian model in undergraduate nursing education: a modified Delphi study

BACKGROUND

Donabedian conceptual and multidimensional framework has been used in several studies in an educational context. In this study, we aimed to adapt the Donabedian three-component model (structure, process, and outcome) in undergraduate nursing education. This conceptual framework provides a comprehensive image of nursing education institutions and can help to evaluate institutions by measuring different aspects of their performance. A comprehensive understanding of the various elements of an educational institution helps to develop a complete, appropriate relevant set of performance indicators.

METHODS

This was a modified Delphi study. It had three rounds. The expert panel consisted of nursing faculty members and nursing Ph.D. students. In the first round, a questionnaire was designed based on interviews, focus groups, and a literature review. Experts rated their agreement with each element on a 5-point Likert scale in rounds two and three. The consensus level was set as 75%. The stability between rounds was also determined by calculating kappa coefficients. One Sample T-Test was also calculated for new items in round three.

RESULTS

All 55 items of the questionnaire were confirmed in the second round based on the consensus percentage of 75. Five new items were added to the third round based on comments in round two. Eventually, all elements except one were confirmed according to the consensus level, kappa values, means, and One-Sample T-Test in round three. The structure's key elements include staff (academic and non-academic); equipment; guidelines; resources and facilities; and students' demographics and characteristics. Process key elements include communication; education; evaluation; cooperation; and consultation. Outcome key elements include knowledge development; nursing image; alumni's outcome; students' outcome; related medical centers' performance; accreditation and evaluation results; and satisfaction.

CONCLUSIONS

Different elements of a nursing education institution at the bachelor's level were determined. The results of this study can help related bodies to develop and implement a comprehensive and systematic evaluation. These results can also be a basis for making this model useful in other nursing courses or education in other fields.

Culturally Safe Mentoring for American Indian Nursing Students

Being the least-represented ethnic/racial group in college settings, American Indian students may experience loneliness and self-doubt related to the challenges of adapting to an environment that embodies values, norms, and culture so different from those represented in their traditional culture. Ongoing health disparities and psychosocial inequities, and persisting impacts of historical colonization, have led to additional hardships for these students that further complicate their academic experiences. Fostering culturally safe learning environments where compassionate and caring faculty provide culturally aligned teaching is important in addressing these complex disparities. Derived from American Indian values and teachings, we present a culturally safe intergenerational mentoring approach that emphasizes the nursing mentors' responsibility to support the growth and success of American Indian nursing students. This approach, drawn from the wisdom of American Indian teachings, focuses on students' strengths and culturally based protective factors. Culturally informed faculty who are aware of the historical impacts of colonization and who have adequate mentoring capacity (time, interest, and commitment) contribute to safe and effective learning environments. Culturally safe mentoring is one approach to promoting American Indian students' potential for academic and professional success.

Indigenous Cultural Safety Training for Applied Health, Social Work, and Education Professionals: A PRISMA Scoping Review

Anti-Indigenous racism is a widespread social problem in health and education systems in English-speaking colonized countries. Cultural safety training (CST) is often promoted as a key strategy to address this problem, yet little evidence exists on how CST is operationalized and evaluated in health and education systems. This scoping review sought to broadly synthesize the academic literature on how CST programs are developed, implemented, and evaluated in the applied health, social work and education fields in Canada, United States, Australia, and New Zealand. MEDLINE, EMBASE, CINAHL, ERIC, and ASSIA were searched for articles published between 1996 and 2020. The Joanna Briggs Institute's three-step search strategy and PRISMA extension for scoping reviews were adopted, with 134 articles included. CST programs have grown significantly in the health, social work, and education fields in the last three decades, and they vary significantly in their objectives, modalities, timelines, and how they are evaluated. The involvement of Indigenous peoples in CST programs is common, but their roles are rarely specified. Indigenous groups must be intentionally and meaningfully engaged throughout the entire duration of research and practice. Cultural safety and various related concepts should be careful considered and applied for the relevant context.

Cultural Competence of Turkish Nurses and Nursing Students: An Integrative Literature Review

INTRODUCTION

Turkish population is characterized by its great cultural diversity, thus, Turkish nurses and nursing students often interact with patients of different cultural backgrounds from theirs. Cultural competence is needed to provide qualified contemporary nursing care. This study aimed to explore the literature on the cultural competence of Turkish nurses and nursing students.

METHODOLOGY

The Whittemore and Knafl review methodology was used to extract, summarize, and synthesize data of 15 primary research articles published between January 2011 and January 2021. The search was done in the Turkish Academic Network and Information Center-ULAKBIM (PubMed, TRDizin, DergiPark).

RESULTS

Three themes were identified: cultural competence, cultural-related problems, and importance of training on transcultural nursing.

DISCUSSION

Appropriate educational courses on transcultural nursing should be implemented in Turkish nursing schools as well as in continuing education programs for Turkish nurses.

Exploring cultural competence of nurses and associated barriers in Ethiopian tertiary hospitals: A qualitative study

BACKGROUNDS

Cultural diversities in both patients and health professionals possess difficulties in cultural care. Such cultural diversities can lead to culturally inappropriate care and health disparities. Delivering culturally competent nursing care is a powerful tool to provide care equally for all patients and eliminate health disparities among culturally diverse people. The present study aimed to explore the cultural competence of nurses and associated barriers in Ethiopian tertiary hospitals.

METHODS

The study was conducted on eight purposively selected key informants from March 1 to April 30, 2018. Data was collected using semi-structured questions through face to face in-depth interview. The collected data analyzed using thematic analysis and presented in the form of text and table.

RESULTS

Eight (n = 3 females and n = 5 males) participants were involved in the study. After extensive analysis, four themes emerged: cultural competence, linguistic competence, cultural competence education and training, and barriers to cultural competence. Another six subthemes of barriers encountered by participants identified and consisted of the language barrier, trained interpreter and translator limitation, lack of knowledge of the patient's culture, lack of multicultural nursing workforce, and shortage of nursing staff, cultural and linguistic stereotypes.

CONCLUSIONS

Nurses less focused on cultural aspects of patients, and they focused more on biological factors and patients' disease. Interestingly, they expressed respect for the cultural and religious practice of patients and showed an interest to learn about cultural care nursing. Cultural competence of participants was hindered by several barriers that need nurses to overcome it.

Undergraduate nursing students' perceptions about creating culturally safe classrooms: Living the epistemology, ontology and pedagogy

Cultural Safety is a means of empowerment through antiracist actions, decolonising praxis, an understanding of the effects of a colonial history, and reconciliation to an equitable and inclusive place. The purpose of this paper is to share the perceptions of undergraduate students in northern Canada about the creation of culturally safe classrooms. A secondary analysis was conducted on archived data from undergraduate nursing student-led research. The findings illuminated four themes: sharing with genuineness, disrupting dissonance, addressing history and transforming through relationality. The themes inform a model that offers a beginning understanding of how culturally safe classrooms transpired in the Canadian north to enable students to become inclusive, relational, critical, and informed.

Integrating equity and social justice for indigenous peoples in undergraduate health professions education in Canada: a framework from a critical review of literature

Understanding how to create structural change by actively counteracting racialized ways of interacting with Indigenous peoples at an individual and organizational level within health care systems and health professions education is essential for creating a more inclusive, equitable, and healthier society. In health professions education, the primary means of teaching about health inequities has been to frame them as stemming from culturally or ethnically based issues. While attention to culturally specific practices can be valuable to health and healing in some contexts, education that solely focuses on Indigenous cultures risks perpetuating cultural stereotypes and othering, rather than focusing on how Eurocentric systems continue to exert oppressive effects on Indigenous peoples. We present an organizational transformation framework grounded in equitable partnerships from a comprehensive critical review of the literature on the integration of equity and social justice in undergraduate health professions education with a focus on Indigenous health. We did a thematic analysis of the results and discussions presented in the 26 selected articles to identify promising practices and challenges associated with the integration of equity and social justice in undergraduate health professions education. The framework resulting from this analysis is composed of three interrelated components: 1) adopt critical pedagogical approaches that promote Indigenous epistemologies; 2) partner with Indigenous students, educators and communities; 3) engage educators in critical pedagogical approaches and health equity issues. This framework could guide the development of contextually tailored interventions that contribute to decolonizing health professions education.

Nursing Lecturers' Perception and Experience of Teaching Cultural Competence: A European Qualitative Study

Cultural competence is an essential component in providing effective and culturally responsive healthcare services, reducing health inequalities, challenging racism in health care and improving patient safety, satisfaction and health outcomes. It is thus reasonable that undergraduate nursing students can develop cultural competency through education and training. The aim of this paper was to investigate nursing lecturers' perception and experience of teaching cultural competence in four undergraduate nursing programs. A phenomenological approach was selected to illicit nursing lecturers' perception of culture and experience of teaching cultural competence. Semi-structured personal interviews were held with a sample of 24 lecturers from four European universities. The anonymized transcripts were analyzed qualitatively following Braun and Clark's phases for thematic analysis. Six themes and fifteen subthemes emerged from thematic analysis of the transcripts. Cultural competence was not explicitly integrated in the nursing curricula. Instead, the lecturers used mainly examples and case studies to illustrate the theory. The integration of cultural content in the modules was unplanned and not based on a specific model. Nursing programs should be examined to establish how cultural content is integrated in the curricula; clear guidelines and standards for a systematic integration of cultural content in the nursing curriculum should be developed.

Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury

OBJECTIVE

To explore health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries.

BACKGROUND

As a discipline, nursing espouses ideologies of inclusion, equity and valuing diversity. However, little is known about how these ideologies translate into clinical care. Pressure injury prevention is a routine aspect of nursing care; yet, there is evidence of inequity in relation to clinical care and patient assessment, as people with darker skin tones have a higher prevalence of severe pressure injuries before detection of damage occurs. Despite limited literature being available surrounding the topic of pressure injuries and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health disparity within the nursing curriculum.

DESIGN

A multiple method collective case study. The STROBE checklist was followed in reporting this study.

METHODS

Documentary and observational data of lectures regarding pressure injuries were collected during 2017 and 2018 from five Higher Education Institutes in England delivering approved nursing undergraduate programmes.

RESULTS

Documentary analysis confirmed all Higher Education Institutes overwhelmingly directed teaching and learning activities about pressure injury towards people with Caucasian skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with pressure injuries and darker skin tones. There was no discursive language or awareness of colour or colour blindness.

CONCLUSION

Radical critique of all teaching and learning activities needs to occur, to help explore, improve and meaningfully and authentically include diversity and inclusivity in nurse education, and in particular, how people across the skin tone spectrum are included and represented in teaching and learning activities.

RELEVANCE TO CLINICAL PRACTICE

Critical examination of current teaching practice is crucial to address disparity and ensure care for people with darker skin tones is optimised. Nurse educators have a responsibility to educate for the care needs of all, as the quality of nurse education has a direct impact on care delivery and health disparity. This paper highlights the importance of addressing skin tone diversity and offers the opportunity for reflective practice, not just in formal education, but in clinical settings by preceptors and senior staff.

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition

Background

Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them.

Methods

A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA.

Results

Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.

Conclusions

A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Educational Model to Increase the Number and Diversity of RN to BSN Graduates From a Resource-Limited Rural Community

Increasing the number of BSN-prepared nurses at the bedside is directly linked to improved health care outcomes. However, employers are challenged to find enough BSN graduates to meet workforce demands. This article presents an educational model that uses evidence-based practices to increase enrollment, retention, and graduation rates of RN students in a BSN program (RN-BSN) in a resource limited rural community. This exemplar may equip nurse educators with strategies to adopt in their own communities.

Lean thinking in health and nursing: an integrative literature review

Objectives:

to demonstrate the scientific knowledge developed on lean thinking in health, highlighting the impact and contributions in health care and nursing.

Method:

an integrative literature review in the PubMed, CINAHL, Scopus, Web of Science, Emerald, LILACS and SciELO electronic library databases, from 2006 to 2014, with syntax keywords for each data base, in which 47 articles were selected for analysis.

Results:

the categories were developed from the quality triad proposed by Donabedian: structure, process and outcome. Lean thinking is on the rise in health surveys, particularly internationally, especially in the USA and UK, improving the structure, process and outcome of care and management actions. However, it is an emerging theme in nursing.

Conclusion:

this study showed that the use of lean thinking in the context of health has a transforming effect on care and organizational aspects, promoting advantages in terms of quality, safety and efficiency of health care and nursing focused on the patient.

Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing

Although nursing has a unique contribution to advancing social justice in health care practices and education, and although social justice has been claimed as a core value of nursing, there is little guidance regarding how to enact social justice in nursing practice and education. In this paper, we propose a critical antidiscriminatory pedagogy (CADP) for nursing as a promising path in this direction. We argue that because discrimination is inherent to the production and maintenance of inequities and injustices, adopting a CADP offers opportunities for students and practicing nurses to develop their capacity to counteract racism and other forms of individual and systemic discrimination in health care, and thus promote social justice. The CADP we propose has the following features: it is grounded in a critical intersectional perspective of discrimination, it aims at fostering transformative learning, and it involves a praxis-oriented critical consciousness. A CADP challenges the liberal individualist paradigm that dominates much of western-based health care, and the culturalist and racializing processes prevalent in nursing education. It also situates nursing practice as responsive to health inequities. Thus, a CADP is a promising way to translate social justice into nursing practice and education through transformative learning.

Building Collaboration: A Scoping Review of Cultural Competency and Safety Education and Training for Healthcare Students and Professionals in Canada

Phenomenon: This scoping literature review summarizes current Canadian health science education and training aimed to lessen health gaps between Aboriginal and non-Aboriginal peoples.

APPROACH

Keyword searches of peer-reviewed and gray literature databases, websites, and resources recommended by local Aboriginal community members identified 1,754 resources. Using specific inclusion and exclusion criteria, 26 resources relevant to education and training of healthcare professionals and students in Canada were selected. Information included self-assessment for cultural competency/safety skills, advocacy within Canadian healthcare, and descriptions of current programs and training approaches.

FINDINGS

In spite of increasing awareness and use of cultural competency and safety concepts, few programs have been successfully implemented. Insights: A concerted effort among health science education and training bodies to develop integrated and effective programs could result in comprehensive processes that hasten the Canadian culturally safe healthcare provision, thus reducing the gaps among populations.

REM

The well-documented health disparities between the Australian Indigenous and non-Indigenous population mandates a comprehensive response from health professionals. This article outlines the approach taken by one faculty of health in a large urban Australian university to enhance cultural competence in students from a variety of fields. Here we outline a collaborative and deeply respectful process of Indigenous and non-Indigenous university staff collectively developing a model that has framed the embedding of a common faculty Indigenous graduate attribute across the curriculum. Through collaborative committee processes, the development of the principles of “Respect; Engagement and sharing; Moving forward” (REM) has provided both a framework and way of “being and doing” our work. By drawing together the recurring principles and qualities that characterize Indigenous cultural competence the result will be students and staff learning and bringing into their lives and practice, important Indigenous cultural understanding.