Developing Cultural Competencies for Nurses

Evidence-Based and Best Practices

Cultural competencies refers to a set of congruent behaviors, knowledge, attitudes and policies that come together in a system, organization, or among health professionals that fosters effective interactions in cross-cultural situations (National Center for Cultural Competence, 2006).  It allows health care professionals to “increase their understanding and appreciation of cultural differences and similarities within, among, and between groups” (USDHHS, NEPR Program Guidance, 2006, p. 99).  Culture refers to integrated patterns of human behavior  that include the language, thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups.  It shapes values, attitudes, beliefs and practices of both patients and their care providers.  Cultural competence refers to the ability to respect the beliefs, language, interpersonal styles and behaviors of individuals, families, and communities receiving services as well as the health care professionals who are providing those services.  Cultural competence “requires a willingness and ability to draw on community-based values, traditions, and customs and to work with knowledgeable persons of and from the community in developing targeted interventions, communication, and other supports” (USDHHS, NEPR Program Guidance, 2006, p 99).  Striving to achieve cultural competence is a dynamic, ongoing, sustained developmental process that requires

1. a long-term commitment to mastery of specific knowledge and skills; and
2. constructively critical self-reflection on feelings, values, attitudes, beliefs, and motivations comprising the affective domain, including those related to prejudice, bigotry, discrimination, and racism (cf., National Center for Cultural Competence, for a comprehensive overview of definitions & references sources).

According to Leininger (2006), fewer than 40% of nurses and less than 25% of nursing faculty have had formal academic preparation or experience that qualifies them to teach students evidence-based and best practices in cultural competence.

With increasing frequency, state and national accreditation bodies governing nursing education and healthcare are requiring evidence that nurses and nursing students demonstrate cultural competencies when caring for diverse individuals, families, groups and communities.  In addition, nurses are expected to have knowledge and understanding of organizational and professional cultures.  The challenge is two-fold:

1. to assure that nurses, nurse practitioners, and nursing faculty-those who teach, mentor and serve as role models for the next generation of nurses keep abreast of evidence-based, best practices in cultural competencies when caring for those from similar and different backgrounds from their own;
2. to prepare nursing students who respect the unique health-related cultural beliefs and practices of various client populations, across the life span, and in a variety of settings so they can provide culturally congruent, competent and appropriate care in the context of an increasingly multicultural and diverse society.

In July, 2008, the primary federal agency for improving access to health care services, Health Resources and Services Administration (HRSA), awarded $1,004,461 to the University of Michigan-Flint and Madonna University to fund a three-year project (Developing Cultural Competencies for Nurses: Evidence-Based and Best Practices).  The purpose of the project is to offer culturally competent continuing educational programs for nurses, nurse practitioners, and nursing faculty that develop their cultural competencies by using evidence-based best practices to reduce or eliminate health disparities among selected racial/ethnic populations, and that prepare participants using a train-the-trainer model  to teach nurses, nursing faculty colleagues and students enrolled  in formal academic nursing programs (associate, baccalaureate, master’s and doctoral levels) to develop their cultural competence in the cognitive, affective and psychomotor domains.  This project was crafted in partnership with the Transcultural Nursing Society (TCNS) and other nursing and health care organizations committed to the development of nurses’ cultural competencies such as the National Black Nurses Association, National Hispanic Nurses Association, National Arab American Nurses Association, American Indian Alaska Native Nurses Association and the Asian American/Pacific Islander Nurses Association.  The relationship with these organizations has been used:

1. to identify faculty to teach the educational offerings;
2. to promote, foster and encourage trainees and students from diverse racial, ethnic, and cultural backgrounds to participate;
3. to provide an emic or “insider’s perspective” on health-related cultural beliefs and practices as they pertain to the pan-ethnic federal minority groups; and
4. to disseminate information about educational offerings on cultural competencies including printed materials, face-to-face presentations, and electronic resources on the  project website and on the University of Michigan-Flint’s Blackboard system.

Project personnel include the director, co-director, program manager, administrative/project coordinator, administrative assistant, site manager, and a reference librarian. The project also includes education, evaluation, statistical and web design consultants.  

Given that the primary focus of the project is educational in nature, faculty include some of the foremost leaders and scholars in transcultural nursing and other experts on culturally congruent and competent care.  All of the project faculty are TCNS members and many are transcultural nursing scholars.  Educational offerings provided focus on the relationship between nurses’ cultural competencies and the reduction or elimination of health disparities across the life span from infancy to old age.  Special emphasis is given to the following Healthy People 2010 risk factors and health disparities: obesity, depression, low birth weight infants, diabetes mellitus, hypertension, HIV/AIDS, and cancer.  The project also prepares nurses to become Certified Transcultural Nurses (CTN) and provides extensive online, print, and audiovisual resources on cultural competence and health disparities.  The educational offerings recognize culture as a central, predominant force influencing individuals, families, groups, and communities as well as the nursing profession itself, as key player in the larger health care delivery system.  Nurses are offered either online or face-to-face educational offerings.  Sessions are focused on the integration of cultural competence into nursing practice, advanced nursing practice, education, administration and research and teach nursing educators and clinical care nurses, theory- and evidence-based practices, and how to conduct cultural assessments in a way that is both respectful and understandable to students or clients of diverse backgrounds.  Participants are evaluated before and after each train-the-trainer session using the Jeffreys (2006) Transcultural Self Efficacy Tool (TSET), an 83-question survey, used to measure the respondents’ personal perception regarding cultural beliefs and confidence in their level of cultural competency.  The survey has three subscales with specific questions corresponding to:

1. cognitive;
2. practical and
3. affective aspects of cultural competence.

Participants are encouraged to train 5-10 nursing colleagues and/or students using the information received within 60 days of the session.  Tool kits consisting of references and resources pertaining to transcultural nursing, cultural competence and health disparities; pre- and post-tests to be used for evaluation purpose; audiovisual and computer software for teaching-learning purposes; and web-based resources are provided to trainers to facilitate their instruction of trainees.  

The three-year objectives set for this project are:

Objective 1: Prepare  nurses  to address the culture care needs of individuals, families, groups and communities at risk for health disparities by increasing the cognitive, affective, and psychomotor cultural competencies of 600 registered nurses and 100 nurse practitioners by offering a series of intensive continuing professional development programs using a train-the-trainer model, as measured by results on pre-test/post-test instruments for measuring cultural competencies.

Objective 2: Disseminate electronic and print resources on cultural competencies reflecting a theoretical foundation and evidence-based, best practices to at least 6,000 nurses and nurse practitioners to use when caring for diverse patients/clients.

Objective 3: Prepare 60 nurse educators with the knowledge and skills necessary to use cultural competencies in their practices, teaching, consultations, and research by completing a series of three train-the-trainer graduate level educational offerings that will prepare them for Transcultural Nursing Certification and for training faculty peers (60 nurse educators X 5 trainees = 300).

Objective 4: Improve the cultural competencies of 600 students in undergraduate and graduate nursing programs by at least 15% over a baseline, as measured by the scores of graduates on selected instruments for measuring cultural competencies.

To date, grant funds have been used to provide nine online and seventeen face-to-face educational offerings to over 1600 individuals (702 RNs, 91 NPs, 305 nurse educators and 503 nursing students).  The TTT participants have hailed from a variety of settings - acute care, community health, home health, long-term care facilities and university classrooms within 35 states.  During the July 1, 2008 to June 30, 2011 funding period, human and fiscal resources provided by the grant are and will continue to be used to support, in part, the TCNS annual conferences and regional workshops; update the credentialing process and Advanced TCN Certification (CTN-A) examination; create a new credentialing process and an examination leading to the CTN-B (Certified Transcultural Nurse-Basic). The project faculty and staff are currently in the process of writing a proposal for the continuation of the grant over the next three years (2011-2014).

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references

1. Jeffreys, M.  (2006). Teaching cultural competence in nursing and health care.  New York:  Springer.
2. Leininger, M.M., & McFarland, M.R. (2006). Culture care diversity and universality:  
   Worldwide nursing theory.  Boston:  Jones and Bartlett Publishers.
   
3. Michigan Center for Nursing. (2009). Profile of Michigan's Nursing Workforce 2009.
4. National Center for Cultural Competence.  (2006, October).  Conceptual frameworks/models, guiding values and principles.
5. U.S. Department of Health and Human Services, Health Resources and Services Administration.
   (2009). Nurse Education, Practice and Retention (NEPR) Program (HRSA-10-046).
6. U.S. Census Bureau (2009). Michigan QuickFacts from the US Census Bureau.
7. U.S. Census Bureau (2000). Flint QuickFacts from the US Census Bureau.