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A constructivist theoretical proposition of cultural competence development in nursing
YNEDT-02977; No of Pages 7 Nurse Education Today xxx (2015) xxx–xxx
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A constructivist theoretical proposition of cultural competence development in nursing Amélie Blanchet Garneau 1, Jacinthe Pepin 2 Faculty of Nursing, University of Montreal, C.P. 6128, succ. Centre-Ville, Montréal, Québec H3C 3J7, Canada
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Article history: Accepted 25 May 2015 Available online xxxx Keywords: Cultural competence Competence development model Nursing education Constructivism Grounded theory Qualitative data analysis
s u m m a r y Cultural competence development in healthcare professions is considered an essential condition to promote quality and equity in healthcare. Even if cultural competence has been recognized as continuous, evolutionary, dynamic, and developmental by most researchers, current models of cultural competence fail to present developmental levels of this competence. These models have also been criticized for their essentialist perspective of culture and their limited application to competency-based approach programs. To our knowledge, there have been no published studies, from a constructivist perspective, of the processes involved in the development of cultural competence among nurses and undergraduate student nurses. The purpose of this study was to develop a theoretical proposition of cultural competence development in nursing from a constructivist perspective. We used a grounded theory design to study cultural competence development among nurses and student nurses in a healthcare center located in a culturally diverse urban area. Data collection involved participant observation and semi-structured interviews with 24 participants (13 nurses and 11 students) working in three community health settings. The core category, ‘learning to bring the different realities together to provide effective care in a culturally diverse context’, was constructed using inductive qualitative data analysis. This core category encompasses three dimensions of cultural competence: ‘building a relationship with the other’, ‘working outside the usual practice framework’, and ‘reinventing practice in action.’ The resulting model describes the concurrent evolution of these three dimensions at three different levels of cultural competence development. This study reveals that clinical experience and interactions between students or nurses and their environment both contribute significantly to cultural competence development. The resulting theoretical proposition of cultural competence development could be used not only to guide initial and continuing nursing education, but also to help redefine quality of care in a culturally diverse context. © 2015 Elsevier Ltd. All rights reserved.
Introduction The development of cultural competence among healthcare professionals and students is considered one of a series of solutions to improve quality of care in a culturally diverse context and to reduce health inequities (Calvillo et al., 2009). Many studies have explored cultural competence and its inclusion in nursing education programs. The vast majority of these studies are based on Leininger's conceptions of culture and culturally congruent care (Leininger and McFarland, 2006). Studies have also presented teaching strategies that foster the development of this competence and their effects on student learning (Kokko, 2011; Long, 2012). Most of these strategies are based on acquiring specific knowledge about given cultural groups, which denotes an essentialist understanding of the concept of culture and leaves little room for diversity E-mail addresses: [email protected] (A. Blanchet Garneau), [email protected] (J. Pepin). 1 Tel.: +1 514 343 6111 #38526. 2 Tel.: +1 514 343 7619.
within any one culture (Blanchet Garneau and Pepin, 2015). From a constructivist perspective, the concept of culture is considered to be fluid, dynamic, and constantly evolving in relation to historical, political, and social conditions. In this sense, culture is a relational process. A culturally diverse context thus encompasses diversity that can assume many forms in society—such as age, gender, sexual orientation or socioeconomic status—and is not limited to race and ethnicity. Moreover, even the notion of competence itself becomes problematic when it refers to know-how or behaviors to be adopted. Competence, understood from a constructivist perspective, refers rather to a systemic and holistic conception of learning (Tardif, 2006). Developing a competence involves challenging one's prior knowledge and developing new knowledge in a dialectic manner through an iterative cycling of reflection and action (Duke et al., 2009). Hence, the development of a competence requires long-term work and continues throughout life. Even if cultural competence has been recognized as continuous, evolutionary, dynamic, and developmental by most researchers (e.g. Andrews and Boyle, 2012; Campinha-Bacote, 2002; Jeffreys, 2010; Giger and Davidhizar, 2008; Papadopoulos, 2006; Purnell and Paulanka,
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Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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2003), current models of cultural competence fail to present developmental levels of this competence. Most models focus on cultural competence domains such as cultural sensitivity, awareness, skill, knowledge, and encounter (Shen, 2014) without presenting the learning processes involved in the concurrent evolution of these domains. Hence, they do not depict a profile of the progression of this competence that could be used in a competency-based approach to education. Thus, it becomes difficult to assess a progression in the development of this competence among students and nurses from another point of view than the one of the learner. Most models have also been criticized for their focus on ethnicity, on popular and stereotypical representations of cultural groups, and on cultural differences (Williamson and Harrison, 2010). Williamson and Harrison (2010) point out that emphasizing differences can reinforce ethnocentric approaches to care. Even though authors have recognized the systemic nature of cultural competence, models still focus on individual actions, thereby obscuring the influence of organizational and societal structures. Some recent studies have described the relation of cultural competence with the environment at a personal, organizational and global level (Soulé, 2014). However, these studies have not moved from a descriptive perspective to the integration of the resulting categories or concepts described into a unified theoretical proposition. Drawing from both the nursing (Calvillo et al., 2009; Duke et al., 2009; Goudreau et al., 2009; Lynam et al., 2007) and the education sciences literature (NRC, 2001; Tardif, 2006), Blanchet Garneau and Pepin (2015) have defined cultural competence as a “complex know-act3 grounded in critical reflection and action, which the healthcare professional draws upon to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care”. This definition highlights the interactional, dialogical, dynamic, contextual and evolutionary nature of cultural competence. The development of cultural competence is then understood as a lifelong ongoing process. While there is an abundance of literature on cultural competence and its domains in various health fields, there is little data on the learning processes involved in the development of this competence from a constructivist perspective. The aim of this study was to develop a constructivist theoretical proposition of the development of cultural competence in nursing. We wanted to answer the following research question: how do nurses develop their cultural competence in their learning and practicing environments?
Methods Methodologically, this research was informed by the constructivist perspective described by Guba and Lincoln (2005), who proposed a relativist ontology and a subjectivist and transactional epistemology. A constructivist perspective provides a theoretical lens to consider the development of cultural competence as a process that situates actors engaged in learning in constant interaction with their environment. We used Corbin and Strauss' (2008) grounded theory to document the process of cultural competence development among nurses and students in a health and social services center serving an urban population presenting substantial cultural and social diversity. The research project received ethical approval from the study setting and university of affiliation of the authors. Carrying out this study in the natural setting of the actors involved in the phenomenon allowed us to examine in detail the actual experience of people interacting with each other in their own social environments. The first author was the principal investigator of this research and undertook each step of sampling, data collection and analysis (Blanchet Garneau, 2013). The second author advised on
3
Translation of French “savoir-agir” that goes beyond know-how.
the research process and participated in the validation of data analysis and theoretical proposition. Sample The participants were nurses (n = 13) and students (n = 11) in the final year of a baccalaureate nursing program, all working in the study setting (encompassing three community health settings and home care) during the data collection period. According to Morse (2000), 20 to 30 participants are sufficient for theoretical saturation in grounded theory. Including both nurses and students offered the potential to understand cultural competence development through the various stages of learning. A purposive sampling strategy allowed recruiting nurses recognized by their peers as having a high level of proficiency in cultural competence, as well as nurses that were interested by culturally competent practice and senior undergraduate level students. Most of the participants were recruited at the beginning of data collection (n = 22). Two nurses were recruited during data collection to explore more deeply certain dimensions of the theoretical proposition under construction. The sampling, data collection, and analysis were only partially concurrent and were conducted from October 2011 to August 2012. Corbin and Strauss (2008) state that it is still possible to aim for theoretical saturation when most participants are selected at the start of data collection rather than over the course of developing the theoretical proposition. In such cases, it is important to remain attentive to variations in the participants and in the data collected (Corbin and Strauss, 2008). Thus, diversification and theoretical saturation principles guided the sampling in this study. The 24 participants' sociodemographic characteristics are presented in Table 1. It should be noted that by sharing their experience retrospectively, nurses identified by their peers as having a high level of development contributed to define not only the higher level of cultural competence development, but also the previous ones. Similarly, some students contributed to define not only the lower level of development but also the next levels. Data Collection A semi-structured interview was conducted with each of the 24 participants. Periods of participant observation (29 h) preceded the semistructured interviews of 16 of the 24 participants (13 nurses and three students). Observations focused on the physical environment of the participants, the different actors, actions and interactions taking place, the aims pursued and the feelings expressed by these actors. As the data collection progressed, observations became more specific to refine the theoretical proposition. Observational data provided a means of triangulating interview data, adding to the methodological rigor. Interviews focused on participants' experience with people from diverse cultures, situations in which they thought they expressed or witnessed cultural competence, and significant moments in their personal or
Table 1 Sociodemographic characteristics of the participants. Characteristics
Number of participants Students Nurses Total
Age (Years) Country of birth
Nursing experience (Years)
21 to 30 31 to 40 41 to 60 Canada Canada — 2nd generation immigrant Outside Canada 0 to 1 1 to 3 4 to 9 10+
8 0 3 4 2
3 6 4 8 2
11 6 7 12 4
5 11 0 0 0
3 0 3 5 5
8 11 3 5 5
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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professional experience that impacted on the development of their cultural competence. Written and verbal consent were obtained prior to conducting interviews or observations, and the voluntary nature of participation was reiterated frequently. Patient safety was a priority during this study. We remained sensitive to any adverse consequences for participants that can occur. Practice going against the nurses' Code of Ethics or causing possible harm to the person being cared for were not witnessed during the research process. Data Analysis The analysis was done in three phases: generating, developing, and verifying concepts (Corbin and Strauss, 2008). In each phase, open, axial, and selective coding, as well as constant comparison and questioning, were used to develop the concepts and categories making up the theoretical proposition for cultural competence development. Memos and diagrams were drafted to discern the relationships among the concepts and the processes in place. Two tools proposed by Corbin and Strauss (2008) facilitated the inclusion of context in the analysis: the paradigm model and the conditional matrix. Using inductive data analysis, the paradigm model helped situate learning as an ongoing active process; while the conditional matrix was useful to discern possible interactions between the learning environment and cultural competence development. The final step of the analysis consisted of summarizing and comparing the processes and contextual factors raised by each of the participants. In that phase, the analysis shifted to a more abstract and conceptual representation of the sequence of cultural competence development. We were able to delineate the interrelated stages of development and to position learnings in context from the beginning of cultural competence development to an expertise level. Hence, a theoretical proposition of the development of cultural competence among students and nurses was formulated. The credibility of analysis was continually evaluated by co-authors. They held regular meetings to ensure consistency between the data collected and the theoretical proposition being formulated and to strive for theoretical saturation. An audit trail of
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analytical insights and decisions was maintained throughout the research process. Results Based on in-depth analysis of the data, we formulated a theoretical proposition for cultural competence development. This proposition is summarized in Fig. 1 and comprises four key components: 1. The development of cultural competence is a process of reflection and action that consists of learning to bring the different realities together to provide effective care in a culturally diverse context. 2. This process involves developing the three dimensions of cultural competence: building a relationship with the other, working outside the usual practice framework, and reinventing practice in action. 3. This process involves three levels of development triggered by clinical immersion experience, whether local or international. 4. Students' or nurses' learning environment, which is represented by their personal trajectory and by social and political dimensions of care, fosters this process. Core Category: Learning to Bring the Different Realities Together to Provide Effective Care in a Culturally Diverse Context The participants considered the development of cultural competence as ‘learning to bring the different realities together to provide effective care in a culturally diverse context’. Following Corbin and Strauss' (2008) perspective, this represents the core category of the theoretical proposition. For the participants, bringing the different realities together meant finding common ground between cultures of the patient, the student or nurse, and the care facility, by overcoming barriers to effective and good-quality care. These barriers might be related, for example, to beliefs and values of the patient or the nurse, language spoken, professional standards of practice, organizational structures, and national policies.
Fig. 1. Blanchet Garneau's cultural competence development model ©Blanchet Garneau, 2013.
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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Learning to bring the different realities together is done through a process of reflection and action that enables the nurses or students to respond to complex situations they encounter and to overcome challenges they face in their nursing practice in a culturally diverse context. For the great majority of the participants, the desire to provide effective and good-quality care was a primary motivation for developing cultural competence. The participants considered care to be effective and of good-quality when it is provided equitably, i.e., when it meets the specific needs of each patient, whatever patient's age, gender, sexual orientation, social status, religious beliefs, or ethnicity. Dimensions of Cultural Competence Learning to bring the different realities together encompasses three dimensions that are at the center of the theoretical proposition for cultural competence development: building a relationship with the other, working outside the usual practice framework, and reinventing practice in action. In building a relationship with the other, the nurses or students learn to open up to the other as they perceive the difference to varying degrees between themselves and the patients. It is initially by being aware of their own culture that nurses or students find common ground with the patient and, ultimately, integrate the difference in the relationship. The difference is no longer a barrier to care, but an integral part of their nursing practice. They take into account patients' views by establishing a relationship of trust. Communication is also at the heart of building this relationship and was mentioned by all the participants. If I'm successful at adapting myself to the situation, it's because I'm able to go and get the items of information that I need to maintain a connection with the person. It's in your capacity to interact with the person that you maintain a relationship of trust. That's what a capacity for adapting to the client means to me (PN15, L514).4 Learning to bring together the different realities also pushes the nurses or students outside their usual practice framework. This dimension of cultural competence is about nurses or students interactions with patient's environment and socio-political dimensions of care, such as organizational or institutional practices and policies in their practice environment. Acknowledging that their current nursing practices and structures defining those practices are the result of a dominant perspective, bring the nurses or students to redefine their conception of care and expand the boundaries of nursing practice to address structural constraints. Among structural constraints mentioned by participants, the issue of insufficient time for provision of good-quality care to patients was a primary concern. Several participants stressed that lack of time did not allow in depth evaluation that is crucial for informed clinical judgment and intervention. They pointed out how exploring patients' needs in another language was time-consuming. In certain care settings, work schedules, priorities or organizational processes made it difficult to allocate more time to patients when required. When challenged with these constraints, participants realized their usual practice was inadequate to offer context-sensitive care. Some participants dealt with structural constraints by finding temporary solutions; others, more experienced, circumvent these constraints. I'm thinking especially of my practicum at [name of setting]. I think that's where we eliminated many, many barriers for patients; I found some inventive ways to get around them (PS21, L181). To bring different realities together, the nurses or students also need to reinvent their practice in action to make it appropriate to the culturally diverse context. Broadening their understanding of culture to the diversified experiences of a person in relation to its ethnicity, social status, gender, sexual orientation, and to the social and political context in 4 In the extracts from interviews or field notes, participants are identified by a code. ‘P’ indicates a participant, while ‘S’ indicates a student, and ‘N’, a nurse. Participants were each assigned a unique number, from 1 to 24, irrespective of whether they were nurses or students. L is the line number of the transcribed interview or field notes.
which he lives, bring the nurses or students to question their current nursing practice and take action to change it. To do this, they must actively develop their own care model. Participants mentioned the importance of changing their current practice in order to respect, and even protect, the cultural identity of patients. Students observed more experienced nurses and tried to imitate their approach. They were also more inclined than experienced nurses to use tools and guidelines to integrate culture in their nursing practice. Hence, they used external care models to guide their practice. Experienced nurses explained that they used their own various experiences and knowledge to develop their care model. They based their practice on patterns found in similar situations. To validate their approaches, these participants asked patients for their satisfaction or referred informally to colleagues to compare practices in specific situations. You work with people from other cultures, it's a constant adaptation. And it's something that develops with experience. You don't arrive and everything just falls into place! Your models, you make them up in your head, but you also need to be able to go outside your little model because, for sure, there will always be exceptions (PN17, L525). Each of these three dimensions of cultural competence comprises two to three indicators of progress presented in Fig. 2. This figure links the indicators of progress of each dimension to three levels of development. Indicators of progress are manifestations of learning achieved at each level of cultural competence development. They are essential developmental steps that correspond to “a cognitive reorganization or the integration of new rules or new principles” [authors' translation] (Tardif, 2006, p. 55). Levels of Cultural Competence Development Cultural competence is developed within the logic of growing complexity occurring on several fronts simultaneously. Thus, the three dimensions of cultural competence interact and influence each other at three different levels as cultural competence is developed. These three levels represent the trajectory generally followed by the participants in this study. All participants pointed to clinical immersion in a culturally diverse context as being the starting point for developing cultural competence. Some also emphasized that working or doing a practicum in a culturally diverse setting fostered a more rapid pace of learning compared with being in a more homogeneous setting. I would say that since I arrived here [clinical setting serving a culturally diverse population], my development has been exponential because I am constantly in contact with people from different cultures (PN15, L753). Some participants explained this exponential learning by the fact that they were confronted daily with cultural differences. Facing challenges of practice in this context, they necessarily had to adapt their practice to provide effective and good-quality care. A participant mentioned, “If there is a language barrier, well you have to make sure the patients understands you. In that case you have no choice but to find an interpreter so the patient can receive and participate in his care” (PN18, L824). Clinical immersion implies the impossibility for nurses or students to ignore cultural diversity. While having frequent and repeated contacts with patients from diverse cultural background, learning to bring the different realities together becomes a must to provide effective and good-quality care. ‘Being open to the different realities of practice in a culturally diverse context’ is a first level of cultural competence development. It consists of acquiring many insights into nursing practice in this context. For example, in building the relationship with the other, the nurses or students become aware of the different worldviews around them. They perceive a gap between their culture and that of the patient, but recognize the importance of taking their own perspective into account when providing care in a culturally diverse context. They also position themselves as the professional in this relationship, acknowledging the role that
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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LEVEL 3
LEVEL 1
Combining, in an integrated way, of practice in a culturally diverse context Building a relationship with the other - Perceive the gap between nurse and patient - Show openness - Be aware of the importance of commu nication Working outside the usual practice - Be aware of the challenges of care in a culturally diverse context - Be aware of structural limitations Reinventing one's practice in action - Be aware of the gap between theory and practice - Imitate approaches used by more experienced colleagues
Building a relationship with the other - Look for commonalities between nurse and patient - Focus on the patient - Use a variety of communication strategie Working outside the usual practice - Take the patient's environment into account when providing care - Work within the structural limitations Reinventing one's practice in action - Take the risk of changing - Create one's own practice model
a culturally diverse context
Building a relationship with the other relationship with the patient - Establish a partnership with the patient - Communicate with discernment Working outside the usual practice framework - Consider the patient and nurse as core components of a dynamic system - Circumvent structural limitations Reinventing one's practice in action - Act at the right time - Integrate one's model into practice
LEVEL 2 Challenging one’s practice in a culturally diverse context
Fig. 2. Three levels of cultural competence development (Blanchet Garneau, 2013).
their own preconceived notions can play in the relationship with the patient. Communication, and more specifically the language barrier, becomes a major challenge in building this relationship. At this first level, besides ‘building a relationship with the other’, the nurses or students also develop the dimensions of ‘working outside the usual practice framework’, and ‘reinventing practice in action’. Indicators of progress related to each of these three dimensions are detailed in Fig. 2. A second level of learning is ‘challenging one's practice in a culturally diverse context’. At this level, the nurses or students learn to question and modify their practice. In the relationship with the patient, they focus on looking for commonalities between their cultures, rather than differences. They understand that cultural practices are taken both from the patient's previous experience and its environment. When they have gone as far as they can, they call upon outside resources, such as colleagues, the patient's family, and occasionally the interpreter. At this level, the nurses or students have a better understanding of the living conditions and challenges that the patient faces on a daily basis. They work within the structural limitations to respond to patients' specific needs. Thus, they use their experience, by identifying successes and failures to guide their practice, or by turning to colleagues when the situation calls for it. ‘Combining, in an integrated way, the different realities of practice in a culturally diverse context’ is the third and last level of learning. Here, the nurses or students learn to feel at ease in their practice and to orchestrate the various challenges in an integrated way to provide effective and good-quality services for everyone. They integrate differences into the relationship building with the patient. They establish a care partnership and decide on its objectives together, which involves finding a middle ground between the nurse's aims and those of the patient in that situation and respecting each other's boundaries. Besides the relationship with the patient, the nurses or students take into consideration the overall care environment and understand the dynamic and contextual nature of each situation. The nurse–patient relationship is not limited to the immediate care situation. Providing good-quality care requires an understanding of socio-political environment and societal influences on nursing practice and relationships. Nurses or students circumvent structural impediments to practice by taking personal and professional initiatives, both for their own professional development and that of their colleagues in different disciplines. They present their knowledge effectively and are confident and at ease in their practice. They use their own practice model and adapt it to situations and
contexts as they arise. The nurses or students are also able to cope with the unexpected and applies critical thinking to different sources of knowledge. Learning Environment Several contextual elements related to the nurses' or students' personal trajectory as well as social and political dimensions of care at organization, community, and national levels can create a learning environment that fosters cultural competence development and the transition from one level to the next. In all the interviews, participants said that frequent and repeated contact with patients from other cultures helped raise their awareness of the challenges related to nursing practice in this context and facilitated changes to their practice. Thus, for the participants, the various measures for promoting contacts with ‘difference’, whether at the personal, organizational, community, or national levels, seemed to foster the development of cultural competence. For several participants, being an immigrant, having a spouse from another culture, or having traveled made it easier for them to be open to others, to examine their own preconceived notions, and to become more aware of the existence of different worldviews and of the impact of communication on interpersonal relationships. Most participants said that the characteristics of the care setting, and in particular, the support of colleagues and their cultural diversity, helped them progress toward a more culturally competent practice. Several participants also mentioned the need to pursue formal education, whether initial or continuing nursing education. They considered that such education could help them develop a knowledge base that would be essential for coping with the complexity of care in a culturally diverse context. Even so, most of them also said that theoretical course alone was not enough to produce action and concrete changes in practice. To achieve that, the participants felt that theoretical course should, for instance, be combined with formal or informal case discussions with colleagues when problematic situations arise or during the nurses' or students' reflexive review of their practice. Discussion This theoretical proposition is distinctive largely because it adopts a constructivist perspective of culture, competence, and cultural
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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competence. It is also grounded in empirical data and defines interrelated phases of development that involve combining different types of knowledge. It highlights interactions between the nurses or students and their learning environment from the earliest stages of learning through to an expert level. The results of this study are in line with those of other studies showing that cultural competence affects the cognitive, affective, behavioral, and environmental dimensions of the person, through awareness raising, knowledge, sensitivity, skills development, and cultural encounters (Suh, 2004; Zander, 2007). For Suh (2004), providing culturally competent care to different patients living with different health situations involves not just a way of doing, but also a way of being. The author adds that being knowledgeable about patients' cultures is not enough. The results of studies by Wilbur (2008) and Moulder (2011) also led to the conclusion that developing cultural competence is a process that requires more than just cultural awareness. The unique feature of our theoretical proposition for cultural competence development is that it presents indicators of progress of each dimension as competence developed. Hence, the development of the dimension “building a relationship with the other” is marked, for example, by going from “perceiving the gap between nurse and patient” to “looking for commonalities between nurse and patient” to “incorporating differences into the relationship with the patient”. By presenting the evolution of each dimension beyond its mere description, the theoretical proposition deepens the understanding of learning processes involved in cultural competence development. The results of this study highlight the importance of interactions between nurses or students and the environment, which is simultaneously restrictive and facilitative, in the development of cultural competence. It links the participants' subjective experience with the structural processes that influence both practice and learning. Indeed, organizational structures shape practice in a culturally diverse context because nurses must contend with them every day. These structures also frame the learning experience to the extent that they do or do not provide certain resources in care settings. Some authors have also examined the characteristics of organizations and work environments that foster culturally competent practice (Guerrero, 2012; Purnell et al., 2011; Taylor and Alfred, 2010). The results of theses studies are in line with the discourse of the participants in this study that highlights the role of organizational characteristics in cultural competence development. For example, Guerrero (2012), and Purnell et al. (2011) observed that cultural diversity among professionals and managers promoted culturally competent practice. Taylor and Alfred (2010) pointed out that culturally competent practice is fostered by hiring staff who are representative of the population served, as well as by the value attributed to it by the organization and by the accessibility of continuing education activities. This study also highlights the importance of clinical experience in the development of cultural competence. Such clinical experience provides the opportunity, either through local or international clinical immersion, to encounter diversity in ways that facilitate learning. Cultural encounter has been recognized as a central domain of cultural competence along with cultural sensitivity, awareness, skill and knowledge in most models of that competence in nursing (Shen, 2014). Based on empirical research, some authors also emphasize the essential contribution of clinical experience to professional development and, more specifically, to the capacity to provide adapted and effective services in a culturally diverse context (Long, 2012; Moulder, 2011; Wilbur, 2008). Wilbur (2008) and Moulder (2011) asserted that the cultural encounters, as well as years of experience, are all linked to cultural competence development. Long (2012) indicated that, in initial nurse education, repeated clinical experiences in a context of diversity allows students to develop confidence in their capacity to care for people from other cultures and to perform better. Our study also showed that such contact (learning in action) is important, but that it is equally important to be able to reflect with other colleagues on actions taken (reflexive
practice). Along the same line, Kokko (2011) concluded that international internships in nursing may help students develop this competence, but are not in themselves enough to advance their development to a higher level. According to this author, complementary strategies are needed to support learning, such as discussions with colleagues whose cultural competence is more advanced. While scientific rigor was maintained throughout the study, there are nevertheless certain limitations. Selecting a culturally diverse setting offered the advantage of being able to include students and nurses who were potentially undergoing the process of cultural competence development. The participants also presented a certain level of interest in nursing practice in a culturally diverse context. However, these participants do not represent all students or nurses who are expected to develop cultural competence. This may help to explain the fact that the theoretical proposition does not convey much about the different types of trajectories that might occur in cultural competence development. It was also difficult to describe the highest level of cultural competence development because of the small number of nurses in these settings who are at that third level of development, and even those nurses find it difficult to make their tacit knowledge explicit. Nevertheless, several periods of participant observation allowed us to watch these nurses in action and to uncover the particular features of their practice. Since the results of our study highlighted that the development of cultural competence is closely related to the learning environment of students and nurses, we must also remain careful about the application of the results of this study to other contexts. Further studies are needed to validate the theoretical proposition presented in this article to other contexts of practice. Conclusion This study will help advance nursing knowledge by furthering the understanding of how nurses and students develop cultural competence. The use of this theoretical proposition for cultural competence development has the potential to take nurses beyond the established structures of their practice to provide effective and good-quality services in a culturally diverse context. It could also be used to identify effective cultural competence development strategies that could be incorporated into initial and continuing nursing education. It is crucial that healthcare organizations, teaching institutions, and professional associations become involved in creating environments that foster the development of cultural competence and its application in practice. This first constructivist theoretical proposition for cultural competence development is expected to evolve in response to further research. The door is thus open for future studies that will bring greater precision and refinement to this theoretical proposition. Acknowledgments This work was supported by the Social Sciences and Humanities Research Council of Canada (SSHRC 767-2010-1287), the Ministère de l'Éducation du Loisir et du Sport of Quebec (MELS 195 975 475), and the team FUTUR funded by the Quebec Research Foundation, Society and Culture (FRQSC 171378). References Andrews, M.M., Boyle, J.S., 2012. Transcultural Concepts in Nursing Care. 6th ed. Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA. Blanchet Garneau, A., 2013. Constructivist Theoretical Proposition for the Development of Cultural Competence in Nursing [French] (Doctoral dissertation), University of Montreal, Montreal, Canada (Retrieved from http://hdl.handle.net/1866/10354). Blanchet Garneau, A., Pepin, J., 2015. Cultural competence: a constructivist definition. J. Transcult. Nurs. 26, 9–15. http://dx.doi.org/10.1177/1043659614541294. Calvillo, E., Clark, L., Ballantyne, J.E., Pacquiao, D., Purnell, L.D., Villarruel, A.M., 2009. Cultural competency in baccalaureate nursing education. J. Transcult. Nurs. 20, 137–145. Campinha-Bacote, J., 2002. The process of cultural competence in the delivery of healthcare services: a model of care. J. Transcult. Nurs. 13, 181–184.
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
A. Blanchet Garneau, J. Pepin / Nurse Education Today xxx (2015) xxx–xxx Corbin, J., Strauss, A., 2008. Basics of Qualitative Research. Techniques and Procedures for Developing Grounded Theory. 3rd ed. Sage Publications, Inc., Thousand Oaks, CA. Duke, J., Connor, M., McEldowney, R., 2009. Becoming a culturally competent health practitioner in the delivery of culturally safe care: a process oriented approach. J. Cult. Divers. 16, 40–49. Giger, J.N., Davidhizar, R.E., 2008. Transcultural Nursing: Assessment and Intervention. 5th ed. Mosby, St. Louis, MO. Goudreau, J., Pepin, J., Dubois, S., Boyer, L., Larue, C., Legault, A., 2009. A second generation of the competency-based approach to nursing education. Int. J. Nurs. Educ. Scholarsh. 6 (Article 15). Guba, E.G., Lincoln, Y.S., 2005. Paradigmatic controversies, contradictions, and emerging confluences. In: Denzin, N.K., Lincoln, Y.S. (Eds.), Handbook of Qualitative Research, 3rd ed. Sage Publications, Thousand Oaks, CA, pp. 191–215. Guerrero, E., 2012. Organizational characteristics that foster early adoption of cultural and linguistic competence in outpatient substance abuse treatment in the United States. Eval. Program Plann. 35, 9–15. Jeffreys, M.R., 2010. Teaching Cultural Competence in Nursing and Health Care: Inquiry, Action, and Innovation. 2nd ed. Springer, New York, NY. Kokko, R., 2011. Future nurses' cultural competencies: what are their learning experiences during exchange and studies abroad? A systematic literature review. J. Nurs. Manag. 19, 673–682. Leininger, M., McFarland, M.R., 2006. Transcultural Nursing: Concepts, Theories, and Practice. 4th ed. McGraw Hill, New York, NY. Long, T.B., 2012. Overview of teaching strategies for cultural competence in nursing students. J. Cult. Divers. 19, 102–108. Lynam, M.J., Browne, A.J., Reimer Kirkham, S., Anderson, J.M., 2007. Re-thinking the complexities of ‘culture’: what might we learn from Bourdieu? Nurs. Inq. 14, 23–34. Morse, J.M., 2000. Determining sample size. Qual. Health Res. 10, 3–5.
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Moulder, M., 2011. Senior Nursing Student Level of Preparation, Attitudes, Awareness, and Competence in Ethnocare. ProQuest, UMI Disseration Publishing, Ann Arbor, MI. National Research Council, 2001. Knowing What Students Know. The Science and Design of Educational Assessment. National Academy Press, Washington, DC. Papadopoulos, I. (Ed.), 2006. Transcultural Health and Social Care: Development of Culturally Competent Practitioners. Elsevier Health Sciences, New York, NY. Purnell, L.D., Paulanka, B.J., 2003. Transcultural Health Care: A Culturally Competent Approach. 2nd ed. Davis, Philadelphia, PA. Purnell, L., Davidhizar, R.E., Giger, J.N., Strickland, O.L., Fishman, D., Allison, D.M., 2011. A guide to developing a culturally competent organization. J. Transcult. Nurs. 22, 7–14. Shen, Z., 2014. Cultural competence models and cultural competence assessment instruments in nursing: a literature review. J. Transcult. Nurs. http://dx.doi.org/10.1177/ 1043659614524790. Soulé, I., 2014. Cultural competence in health care: an emerging theory. Adv. Nurs. Sci. 37, 48–60. Suh, E.E., 2004. The model of cultural competence through an evolutionary concept analysis. J. Transcult. Nurs. 15, 93–102. Tardif, J., 2006. L'évaluation des compétences: documenter le parcours de dévelopement. Les Éditions de la Chenelière Inc., Montréal, Canada. Taylor, R.A., Alfred, M.V., 2010. Nurses' perceptions of the organizational supports needed for the delivery of culturally competent care. West. J. Nurs. Res. 32, 591–609. Wilbur, V., 2008. Factors That Influence the Cultural Competence of Nurse Practitioner Students. ProQuest, UMI Disseration Publishing, Ann Arbor, MI. Williamson, M., Harrison, L., 2010. Providing culturally appropriate care: a literature review. Int. J. Nurs. Stud. 47, 761–769. Zander, P.E., 2007. Cultural competence: analyzing the construct. J. Theory Constr. Test. 11, 50–54.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
A constructivist theoretical proposition of cultural competence development in nursing Amélie Blanchet Garneau 1, Jacinthe Pepin 2 Faculty of Nursing, University of Montreal, C.P. 6128, succ. Centre-Ville, Montréal, Québec H3C 3J7, Canada
a r t i c l e
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Article history: Accepted 25 May 2015 Available online xxxx Keywords: Cultural competence Competence development model Nursing education Constructivism Grounded theory Qualitative data analysis
s u m m a r y Cultural competence development in healthcare professions is considered an essential condition to promote quality and equity in healthcare. Even if cultural competence has been recognized as continuous, evolutionary, dynamic, and developmental by most researchers, current models of cultural competence fail to present developmental levels of this competence. These models have also been criticized for their essentialist perspective of culture and their limited application to competency-based approach programs. To our knowledge, there have been no published studies, from a constructivist perspective, of the processes involved in the development of cultural competence among nurses and undergraduate student nurses. The purpose of this study was to develop a theoretical proposition of cultural competence development in nursing from a constructivist perspective. We used a grounded theory design to study cultural competence development among nurses and student nurses in a healthcare center located in a culturally diverse urban area. Data collection involved participant observation and semi-structured interviews with 24 participants (13 nurses and 11 students) working in three community health settings. The core category, ‘learning to bring the different realities together to provide effective care in a culturally diverse context’, was constructed using inductive qualitative data analysis. This core category encompasses three dimensions of cultural competence: ‘building a relationship with the other’, ‘working outside the usual practice framework’, and ‘reinventing practice in action.’ The resulting model describes the concurrent evolution of these three dimensions at three different levels of cultural competence development. This study reveals that clinical experience and interactions between students or nurses and their environment both contribute significantly to cultural competence development. The resulting theoretical proposition of cultural competence development could be used not only to guide initial and continuing nursing education, but also to help redefine quality of care in a culturally diverse context. © 2015 Elsevier Ltd. All rights reserved.
Introduction The development of cultural competence among healthcare professionals and students is considered one of a series of solutions to improve quality of care in a culturally diverse context and to reduce health inequities (Calvillo et al., 2009). Many studies have explored cultural competence and its inclusion in nursing education programs. The vast majority of these studies are based on Leininger's conceptions of culture and culturally congruent care (Leininger and McFarland, 2006). Studies have also presented teaching strategies that foster the development of this competence and their effects on student learning (Kokko, 2011; Long, 2012). Most of these strategies are based on acquiring specific knowledge about given cultural groups, which denotes an essentialist understanding of the concept of culture and leaves little room for diversity E-mail addresses: [email protected] (A. Blanchet Garneau), [email protected] (J. Pepin). 1 Tel.: +1 514 343 6111 #38526. 2 Tel.: +1 514 343 7619.
within any one culture (Blanchet Garneau and Pepin, 2015). From a constructivist perspective, the concept of culture is considered to be fluid, dynamic, and constantly evolving in relation to historical, political, and social conditions. In this sense, culture is a relational process. A culturally diverse context thus encompasses diversity that can assume many forms in society—such as age, gender, sexual orientation or socioeconomic status—and is not limited to race and ethnicity. Moreover, even the notion of competence itself becomes problematic when it refers to know-how or behaviors to be adopted. Competence, understood from a constructivist perspective, refers rather to a systemic and holistic conception of learning (Tardif, 2006). Developing a competence involves challenging one's prior knowledge and developing new knowledge in a dialectic manner through an iterative cycling of reflection and action (Duke et al., 2009). Hence, the development of a competence requires long-term work and continues throughout life. Even if cultural competence has been recognized as continuous, evolutionary, dynamic, and developmental by most researchers (e.g. Andrews and Boyle, 2012; Campinha-Bacote, 2002; Jeffreys, 2010; Giger and Davidhizar, 2008; Papadopoulos, 2006; Purnell and Paulanka,
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Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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2003), current models of cultural competence fail to present developmental levels of this competence. Most models focus on cultural competence domains such as cultural sensitivity, awareness, skill, knowledge, and encounter (Shen, 2014) without presenting the learning processes involved in the concurrent evolution of these domains. Hence, they do not depict a profile of the progression of this competence that could be used in a competency-based approach to education. Thus, it becomes difficult to assess a progression in the development of this competence among students and nurses from another point of view than the one of the learner. Most models have also been criticized for their focus on ethnicity, on popular and stereotypical representations of cultural groups, and on cultural differences (Williamson and Harrison, 2010). Williamson and Harrison (2010) point out that emphasizing differences can reinforce ethnocentric approaches to care. Even though authors have recognized the systemic nature of cultural competence, models still focus on individual actions, thereby obscuring the influence of organizational and societal structures. Some recent studies have described the relation of cultural competence with the environment at a personal, organizational and global level (Soulé, 2014). However, these studies have not moved from a descriptive perspective to the integration of the resulting categories or concepts described into a unified theoretical proposition. Drawing from both the nursing (Calvillo et al., 2009; Duke et al., 2009; Goudreau et al., 2009; Lynam et al., 2007) and the education sciences literature (NRC, 2001; Tardif, 2006), Blanchet Garneau and Pepin (2015) have defined cultural competence as a “complex know-act3 grounded in critical reflection and action, which the healthcare professional draws upon to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care”. This definition highlights the interactional, dialogical, dynamic, contextual and evolutionary nature of cultural competence. The development of cultural competence is then understood as a lifelong ongoing process. While there is an abundance of literature on cultural competence and its domains in various health fields, there is little data on the learning processes involved in the development of this competence from a constructivist perspective. The aim of this study was to develop a constructivist theoretical proposition of the development of cultural competence in nursing. We wanted to answer the following research question: how do nurses develop their cultural competence in their learning and practicing environments?
Methods Methodologically, this research was informed by the constructivist perspective described by Guba and Lincoln (2005), who proposed a relativist ontology and a subjectivist and transactional epistemology. A constructivist perspective provides a theoretical lens to consider the development of cultural competence as a process that situates actors engaged in learning in constant interaction with their environment. We used Corbin and Strauss' (2008) grounded theory to document the process of cultural competence development among nurses and students in a health and social services center serving an urban population presenting substantial cultural and social diversity. The research project received ethical approval from the study setting and university of affiliation of the authors. Carrying out this study in the natural setting of the actors involved in the phenomenon allowed us to examine in detail the actual experience of people interacting with each other in their own social environments. The first author was the principal investigator of this research and undertook each step of sampling, data collection and analysis (Blanchet Garneau, 2013). The second author advised on
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Translation of French “savoir-agir” that goes beyond know-how.
the research process and participated in the validation of data analysis and theoretical proposition. Sample The participants were nurses (n = 13) and students (n = 11) in the final year of a baccalaureate nursing program, all working in the study setting (encompassing three community health settings and home care) during the data collection period. According to Morse (2000), 20 to 30 participants are sufficient for theoretical saturation in grounded theory. Including both nurses and students offered the potential to understand cultural competence development through the various stages of learning. A purposive sampling strategy allowed recruiting nurses recognized by their peers as having a high level of proficiency in cultural competence, as well as nurses that were interested by culturally competent practice and senior undergraduate level students. Most of the participants were recruited at the beginning of data collection (n = 22). Two nurses were recruited during data collection to explore more deeply certain dimensions of the theoretical proposition under construction. The sampling, data collection, and analysis were only partially concurrent and were conducted from October 2011 to August 2012. Corbin and Strauss (2008) state that it is still possible to aim for theoretical saturation when most participants are selected at the start of data collection rather than over the course of developing the theoretical proposition. In such cases, it is important to remain attentive to variations in the participants and in the data collected (Corbin and Strauss, 2008). Thus, diversification and theoretical saturation principles guided the sampling in this study. The 24 participants' sociodemographic characteristics are presented in Table 1. It should be noted that by sharing their experience retrospectively, nurses identified by their peers as having a high level of development contributed to define not only the higher level of cultural competence development, but also the previous ones. Similarly, some students contributed to define not only the lower level of development but also the next levels. Data Collection A semi-structured interview was conducted with each of the 24 participants. Periods of participant observation (29 h) preceded the semistructured interviews of 16 of the 24 participants (13 nurses and three students). Observations focused on the physical environment of the participants, the different actors, actions and interactions taking place, the aims pursued and the feelings expressed by these actors. As the data collection progressed, observations became more specific to refine the theoretical proposition. Observational data provided a means of triangulating interview data, adding to the methodological rigor. Interviews focused on participants' experience with people from diverse cultures, situations in which they thought they expressed or witnessed cultural competence, and significant moments in their personal or
Table 1 Sociodemographic characteristics of the participants. Characteristics
Number of participants Students Nurses Total
Age (Years) Country of birth
Nursing experience (Years)
21 to 30 31 to 40 41 to 60 Canada Canada — 2nd generation immigrant Outside Canada 0 to 1 1 to 3 4 to 9 10+
8 0 3 4 2
3 6 4 8 2
11 6 7 12 4
5 11 0 0 0
3 0 3 5 5
8 11 3 5 5
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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professional experience that impacted on the development of their cultural competence. Written and verbal consent were obtained prior to conducting interviews or observations, and the voluntary nature of participation was reiterated frequently. Patient safety was a priority during this study. We remained sensitive to any adverse consequences for participants that can occur. Practice going against the nurses' Code of Ethics or causing possible harm to the person being cared for were not witnessed during the research process. Data Analysis The analysis was done in three phases: generating, developing, and verifying concepts (Corbin and Strauss, 2008). In each phase, open, axial, and selective coding, as well as constant comparison and questioning, were used to develop the concepts and categories making up the theoretical proposition for cultural competence development. Memos and diagrams were drafted to discern the relationships among the concepts and the processes in place. Two tools proposed by Corbin and Strauss (2008) facilitated the inclusion of context in the analysis: the paradigm model and the conditional matrix. Using inductive data analysis, the paradigm model helped situate learning as an ongoing active process; while the conditional matrix was useful to discern possible interactions between the learning environment and cultural competence development. The final step of the analysis consisted of summarizing and comparing the processes and contextual factors raised by each of the participants. In that phase, the analysis shifted to a more abstract and conceptual representation of the sequence of cultural competence development. We were able to delineate the interrelated stages of development and to position learnings in context from the beginning of cultural competence development to an expertise level. Hence, a theoretical proposition of the development of cultural competence among students and nurses was formulated. The credibility of analysis was continually evaluated by co-authors. They held regular meetings to ensure consistency between the data collected and the theoretical proposition being formulated and to strive for theoretical saturation. An audit trail of
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analytical insights and decisions was maintained throughout the research process. Results Based on in-depth analysis of the data, we formulated a theoretical proposition for cultural competence development. This proposition is summarized in Fig. 1 and comprises four key components: 1. The development of cultural competence is a process of reflection and action that consists of learning to bring the different realities together to provide effective care in a culturally diverse context. 2. This process involves developing the three dimensions of cultural competence: building a relationship with the other, working outside the usual practice framework, and reinventing practice in action. 3. This process involves three levels of development triggered by clinical immersion experience, whether local or international. 4. Students' or nurses' learning environment, which is represented by their personal trajectory and by social and political dimensions of care, fosters this process. Core Category: Learning to Bring the Different Realities Together to Provide Effective Care in a Culturally Diverse Context The participants considered the development of cultural competence as ‘learning to bring the different realities together to provide effective care in a culturally diverse context’. Following Corbin and Strauss' (2008) perspective, this represents the core category of the theoretical proposition. For the participants, bringing the different realities together meant finding common ground between cultures of the patient, the student or nurse, and the care facility, by overcoming barriers to effective and good-quality care. These barriers might be related, for example, to beliefs and values of the patient or the nurse, language spoken, professional standards of practice, organizational structures, and national policies.
Fig. 1. Blanchet Garneau's cultural competence development model ©Blanchet Garneau, 2013.
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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Learning to bring the different realities together is done through a process of reflection and action that enables the nurses or students to respond to complex situations they encounter and to overcome challenges they face in their nursing practice in a culturally diverse context. For the great majority of the participants, the desire to provide effective and good-quality care was a primary motivation for developing cultural competence. The participants considered care to be effective and of good-quality when it is provided equitably, i.e., when it meets the specific needs of each patient, whatever patient's age, gender, sexual orientation, social status, religious beliefs, or ethnicity. Dimensions of Cultural Competence Learning to bring the different realities together encompasses three dimensions that are at the center of the theoretical proposition for cultural competence development: building a relationship with the other, working outside the usual practice framework, and reinventing practice in action. In building a relationship with the other, the nurses or students learn to open up to the other as they perceive the difference to varying degrees between themselves and the patients. It is initially by being aware of their own culture that nurses or students find common ground with the patient and, ultimately, integrate the difference in the relationship. The difference is no longer a barrier to care, but an integral part of their nursing practice. They take into account patients' views by establishing a relationship of trust. Communication is also at the heart of building this relationship and was mentioned by all the participants. If I'm successful at adapting myself to the situation, it's because I'm able to go and get the items of information that I need to maintain a connection with the person. It's in your capacity to interact with the person that you maintain a relationship of trust. That's what a capacity for adapting to the client means to me (PN15, L514).4 Learning to bring together the different realities also pushes the nurses or students outside their usual practice framework. This dimension of cultural competence is about nurses or students interactions with patient's environment and socio-political dimensions of care, such as organizational or institutional practices and policies in their practice environment. Acknowledging that their current nursing practices and structures defining those practices are the result of a dominant perspective, bring the nurses or students to redefine their conception of care and expand the boundaries of nursing practice to address structural constraints. Among structural constraints mentioned by participants, the issue of insufficient time for provision of good-quality care to patients was a primary concern. Several participants stressed that lack of time did not allow in depth evaluation that is crucial for informed clinical judgment and intervention. They pointed out how exploring patients' needs in another language was time-consuming. In certain care settings, work schedules, priorities or organizational processes made it difficult to allocate more time to patients when required. When challenged with these constraints, participants realized their usual practice was inadequate to offer context-sensitive care. Some participants dealt with structural constraints by finding temporary solutions; others, more experienced, circumvent these constraints. I'm thinking especially of my practicum at [name of setting]. I think that's where we eliminated many, many barriers for patients; I found some inventive ways to get around them (PS21, L181). To bring different realities together, the nurses or students also need to reinvent their practice in action to make it appropriate to the culturally diverse context. Broadening their understanding of culture to the diversified experiences of a person in relation to its ethnicity, social status, gender, sexual orientation, and to the social and political context in 4 In the extracts from interviews or field notes, participants are identified by a code. ‘P’ indicates a participant, while ‘S’ indicates a student, and ‘N’, a nurse. Participants were each assigned a unique number, from 1 to 24, irrespective of whether they were nurses or students. L is the line number of the transcribed interview or field notes.
which he lives, bring the nurses or students to question their current nursing practice and take action to change it. To do this, they must actively develop their own care model. Participants mentioned the importance of changing their current practice in order to respect, and even protect, the cultural identity of patients. Students observed more experienced nurses and tried to imitate their approach. They were also more inclined than experienced nurses to use tools and guidelines to integrate culture in their nursing practice. Hence, they used external care models to guide their practice. Experienced nurses explained that they used their own various experiences and knowledge to develop their care model. They based their practice on patterns found in similar situations. To validate their approaches, these participants asked patients for their satisfaction or referred informally to colleagues to compare practices in specific situations. You work with people from other cultures, it's a constant adaptation. And it's something that develops with experience. You don't arrive and everything just falls into place! Your models, you make them up in your head, but you also need to be able to go outside your little model because, for sure, there will always be exceptions (PN17, L525). Each of these three dimensions of cultural competence comprises two to three indicators of progress presented in Fig. 2. This figure links the indicators of progress of each dimension to three levels of development. Indicators of progress are manifestations of learning achieved at each level of cultural competence development. They are essential developmental steps that correspond to “a cognitive reorganization or the integration of new rules or new principles” [authors' translation] (Tardif, 2006, p. 55). Levels of Cultural Competence Development Cultural competence is developed within the logic of growing complexity occurring on several fronts simultaneously. Thus, the three dimensions of cultural competence interact and influence each other at three different levels as cultural competence is developed. These three levels represent the trajectory generally followed by the participants in this study. All participants pointed to clinical immersion in a culturally diverse context as being the starting point for developing cultural competence. Some also emphasized that working or doing a practicum in a culturally diverse setting fostered a more rapid pace of learning compared with being in a more homogeneous setting. I would say that since I arrived here [clinical setting serving a culturally diverse population], my development has been exponential because I am constantly in contact with people from different cultures (PN15, L753). Some participants explained this exponential learning by the fact that they were confronted daily with cultural differences. Facing challenges of practice in this context, they necessarily had to adapt their practice to provide effective and good-quality care. A participant mentioned, “If there is a language barrier, well you have to make sure the patients understands you. In that case you have no choice but to find an interpreter so the patient can receive and participate in his care” (PN18, L824). Clinical immersion implies the impossibility for nurses or students to ignore cultural diversity. While having frequent and repeated contacts with patients from diverse cultural background, learning to bring the different realities together becomes a must to provide effective and good-quality care. ‘Being open to the different realities of practice in a culturally diverse context’ is a first level of cultural competence development. It consists of acquiring many insights into nursing practice in this context. For example, in building the relationship with the other, the nurses or students become aware of the different worldviews around them. They perceive a gap between their culture and that of the patient, but recognize the importance of taking their own perspective into account when providing care in a culturally diverse context. They also position themselves as the professional in this relationship, acknowledging the role that
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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LEVEL 3
LEVEL 1
Combining, in an integrated way, of practice in a culturally diverse context Building a relationship with the other - Perceive the gap between nurse and patient - Show openness - Be aware of the importance of commu nication Working outside the usual practice - Be aware of the challenges of care in a culturally diverse context - Be aware of structural limitations Reinventing one's practice in action - Be aware of the gap between theory and practice - Imitate approaches used by more experienced colleagues
Building a relationship with the other - Look for commonalities between nurse and patient - Focus on the patient - Use a variety of communication strategie Working outside the usual practice - Take the patient's environment into account when providing care - Work within the structural limitations Reinventing one's practice in action - Take the risk of changing - Create one's own practice model
a culturally diverse context
Building a relationship with the other relationship with the patient - Establish a partnership with the patient - Communicate with discernment Working outside the usual practice framework - Consider the patient and nurse as core components of a dynamic system - Circumvent structural limitations Reinventing one's practice in action - Act at the right time - Integrate one's model into practice
LEVEL 2 Challenging one’s practice in a culturally diverse context
Fig. 2. Three levels of cultural competence development (Blanchet Garneau, 2013).
their own preconceived notions can play in the relationship with the patient. Communication, and more specifically the language barrier, becomes a major challenge in building this relationship. At this first level, besides ‘building a relationship with the other’, the nurses or students also develop the dimensions of ‘working outside the usual practice framework’, and ‘reinventing practice in action’. Indicators of progress related to each of these three dimensions are detailed in Fig. 2. A second level of learning is ‘challenging one's practice in a culturally diverse context’. At this level, the nurses or students learn to question and modify their practice. In the relationship with the patient, they focus on looking for commonalities between their cultures, rather than differences. They understand that cultural practices are taken both from the patient's previous experience and its environment. When they have gone as far as they can, they call upon outside resources, such as colleagues, the patient's family, and occasionally the interpreter. At this level, the nurses or students have a better understanding of the living conditions and challenges that the patient faces on a daily basis. They work within the structural limitations to respond to patients' specific needs. Thus, they use their experience, by identifying successes and failures to guide their practice, or by turning to colleagues when the situation calls for it. ‘Combining, in an integrated way, the different realities of practice in a culturally diverse context’ is the third and last level of learning. Here, the nurses or students learn to feel at ease in their practice and to orchestrate the various challenges in an integrated way to provide effective and good-quality services for everyone. They integrate differences into the relationship building with the patient. They establish a care partnership and decide on its objectives together, which involves finding a middle ground between the nurse's aims and those of the patient in that situation and respecting each other's boundaries. Besides the relationship with the patient, the nurses or students take into consideration the overall care environment and understand the dynamic and contextual nature of each situation. The nurse–patient relationship is not limited to the immediate care situation. Providing good-quality care requires an understanding of socio-political environment and societal influences on nursing practice and relationships. Nurses or students circumvent structural impediments to practice by taking personal and professional initiatives, both for their own professional development and that of their colleagues in different disciplines. They present their knowledge effectively and are confident and at ease in their practice. They use their own practice model and adapt it to situations and
contexts as they arise. The nurses or students are also able to cope with the unexpected and applies critical thinking to different sources of knowledge. Learning Environment Several contextual elements related to the nurses' or students' personal trajectory as well as social and political dimensions of care at organization, community, and national levels can create a learning environment that fosters cultural competence development and the transition from one level to the next. In all the interviews, participants said that frequent and repeated contact with patients from other cultures helped raise their awareness of the challenges related to nursing practice in this context and facilitated changes to their practice. Thus, for the participants, the various measures for promoting contacts with ‘difference’, whether at the personal, organizational, community, or national levels, seemed to foster the development of cultural competence. For several participants, being an immigrant, having a spouse from another culture, or having traveled made it easier for them to be open to others, to examine their own preconceived notions, and to become more aware of the existence of different worldviews and of the impact of communication on interpersonal relationships. Most participants said that the characteristics of the care setting, and in particular, the support of colleagues and their cultural diversity, helped them progress toward a more culturally competent practice. Several participants also mentioned the need to pursue formal education, whether initial or continuing nursing education. They considered that such education could help them develop a knowledge base that would be essential for coping with the complexity of care in a culturally diverse context. Even so, most of them also said that theoretical course alone was not enough to produce action and concrete changes in practice. To achieve that, the participants felt that theoretical course should, for instance, be combined with formal or informal case discussions with colleagues when problematic situations arise or during the nurses' or students' reflexive review of their practice. Discussion This theoretical proposition is distinctive largely because it adopts a constructivist perspective of culture, competence, and cultural
Please cite this article as: Blanchet Garneau, A., Pepin, J., A constructivist theoretical proposition of cultural competence development in nursing, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.019
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competence. It is also grounded in empirical data and defines interrelated phases of development that involve combining different types of knowledge. It highlights interactions between the nurses or students and their learning environment from the earliest stages of learning through to an expert level. The results of this study are in line with those of other studies showing that cultural competence affects the cognitive, affective, behavioral, and environmental dimensions of the person, through awareness raising, knowledge, sensitivity, skills development, and cultural encounters (Suh, 2004; Zander, 2007). For Suh (2004), providing culturally competent care to different patients living with different health situations involves not just a way of doing, but also a way of being. The author adds that being knowledgeable about patients' cultures is not enough. The results of studies by Wilbur (2008) and Moulder (2011) also led to the conclusion that developing cultural competence is a process that requires more than just cultural awareness. The unique feature of our theoretical proposition for cultural competence development is that it presents indicators of progress of each dimension as competence developed. Hence, the development of the dimension “building a relationship with the other” is marked, for example, by going from “perceiving the gap between nurse and patient” to “looking for commonalities between nurse and patient” to “incorporating differences into the relationship with the patient”. By presenting the evolution of each dimension beyond its mere description, the theoretical proposition deepens the understanding of learning processes involved in cultural competence development. The results of this study highlight the importance of interactions between nurses or students and the environment, which is simultaneously restrictive and facilitative, in the development of cultural competence. It links the participants' subjective experience with the structural processes that influence both practice and learning. Indeed, organizational structures shape practice in a culturally diverse context because nurses must contend with them every day. These structures also frame the learning experience to the extent that they do or do not provide certain resources in care settings. Some authors have also examined the characteristics of organizations and work environments that foster culturally competent practice (Guerrero, 2012; Purnell et al., 2011; Taylor and Alfred, 2010). The results of theses studies are in line with the discourse of the participants in this study that highlights the role of organizational characteristics in cultural competence development. For example, Guerrero (2012), and Purnell et al. (2011) observed that cultural diversity among professionals and managers promoted culturally competent practice. Taylor and Alfred (2010) pointed out that culturally competent practice is fostered by hiring staff who are representative of the population served, as well as by the value attributed to it by the organization and by the accessibility of continuing education activities. This study also highlights the importance of clinical experience in the development of cultural competence. Such clinical experience provides the opportunity, either through local or international clinical immersion, to encounter diversity in ways that facilitate learning. Cultural encounter has been recognized as a central domain of cultural competence along with cultural sensitivity, awareness, skill and knowledge in most models of that competence in nursing (Shen, 2014). Based on empirical research, some authors also emphasize the essential contribution of clinical experience to professional development and, more specifically, to the capacity to provide adapted and effective services in a culturally diverse context (Long, 2012; Moulder, 2011; Wilbur, 2008). Wilbur (2008) and Moulder (2011) asserted that the cultural encounters, as well as years of experience, are all linked to cultural competence development. Long (2012) indicated that, in initial nurse education, repeated clinical experiences in a context of diversity allows students to develop confidence in their capacity to care for people from other cultures and to perform better. Our study also showed that such contact (learning in action) is important, but that it is equally important to be able to reflect with other colleagues on actions taken (reflexive
practice). Along the same line, Kokko (2011) concluded that international internships in nursing may help students develop this competence, but are not in themselves enough to advance their development to a higher level. According to this author, complementary strategies are needed to support learning, such as discussions with colleagues whose cultural competence is more advanced. While scientific rigor was maintained throughout the study, there are nevertheless certain limitations. Selecting a culturally diverse setting offered the advantage of being able to include students and nurses who were potentially undergoing the process of cultural competence development. The participants also presented a certain level of interest in nursing practice in a culturally diverse context. However, these participants do not represent all students or nurses who are expected to develop cultural competence. This may help to explain the fact that the theoretical proposition does not convey much about the different types of trajectories that might occur in cultural competence development. It was also difficult to describe the highest level of cultural competence development because of the small number of nurses in these settings who are at that third level of development, and even those nurses find it difficult to make their tacit knowledge explicit. Nevertheless, several periods of participant observation allowed us to watch these nurses in action and to uncover the particular features of their practice. Since the results of our study highlighted that the development of cultural competence is closely related to the learning environment of students and nurses, we must also remain careful about the application of the results of this study to other contexts. Further studies are needed to validate the theoretical proposition presented in this article to other contexts of practice. Conclusion This study will help advance nursing knowledge by furthering the understanding of how nurses and students develop cultural competence. The use of this theoretical proposition for cultural competence development has the potential to take nurses beyond the established structures of their practice to provide effective and good-quality services in a culturally diverse context. It could also be used to identify effective cultural competence development strategies that could be incorporated into initial and continuing nursing education. It is crucial that healthcare organizations, teaching institutions, and professional associations become involved in creating environments that foster the development of cultural competence and its application in practice. This first constructivist theoretical proposition for cultural competence development is expected to evolve in response to further research. The door is thus open for future studies that will bring greater precision and refinement to this theoretical proposition. Acknowledgments This work was supported by the Social Sciences and Humanities Research Council of Canada (SSHRC 767-2010-1287), the Ministère de l'Éducation du Loisir et du Sport of Quebec (MELS 195 975 475), and the team FUTUR funded by the Quebec Research Foundation, Society and Culture (FRQSC 171378). References Andrews, M.M., Boyle, J.S., 2012. Transcultural Concepts in Nursing Care. 6th ed. Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA. Blanchet Garneau, A., 2013. Constructivist Theoretical Proposition for the Development of Cultural Competence in Nursing [French] (Doctoral dissertation), University of Montreal, Montreal, Canada (Retrieved from http://hdl.handle.net/1866/10354). Blanchet Garneau, A., Pepin, J., 2015. Cultural competence: a constructivist definition. J. Transcult. Nurs. 26, 9–15. http://dx.doi.org/10.1177/1043659614541294. Calvillo, E., Clark, L., Ballantyne, J.E., Pacquiao, D., Purnell, L.D., Villarruel, A.M., 2009. Cultural competency in baccalaureate nursing education. J. Transcult. Nurs. 20, 137–145. Campinha-Bacote, J., 2002. The process of cultural competence in the delivery of healthcare services: a model of care. J. Transcult. Nurs. 13, 181–184.
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