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Assessment of cultural competence in Texas nursing faculty
Nurse Education Today 45 (2016) 225–229
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Assessment of cultural competence in Texas nursing faculty Collen Marzilli, PhD, DNP, MBA, RN-BC, CCM, APHN-BC, CNE, Assistant Professor The University of Texas at Tyler, Braithwaite Building 2170, 3900 University Blvd., Tyler, TX 75799, United States
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Article history: Received 27 April 2016 Received in revised form 2 August 2016 Accepted 16 August 2016 Keywords: Purnell model of cultural competence Nursing Health Culture Values Nursing education Nurses' cultural competence scale
a b s t r a c t Background: Cultural competence [CC] is an essential component of nursing education and nursing practice yet there is a gap in the research evaluating CC in faculty and how to practically develop this skillset for faculty members. Objectives: To explore CC in faculty as evaluated with the Nurses' Cultural Competence Scale [NCCS] and apply the findings to the Purnell Model of Cultural Competence [PMCC] to guide professional development opportunities for faculty members. Design: This was a concurrent mixed-methods study. Setting: Faculty members teaching in Texas nursing programs were recruited for the study. Quantitative data was collected using an online survey tool and qualitative data was collected over the phone. Participants: 89 Texas faculty members completed the quantitative strand and a subset of 10 faculty members completed the qualitative strand. Methods: Descriptive statistics were used to examine the quantitative data and Strauss and Corbin's methodology guided the evaluation of the qualitative data. These two strands were used to support the results. Results: Faculty in Texas are moderately culturally competent. The qualitative findings support the application of the PMCC to the areas identified by the NCCS. Conclusion: The PMCC may be applied to the application of culture and values in nursing professional education as supported by the NCCS. Recommendations are to include the PMCC as a structure for the creation of professional development opportunities for faculty. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction Cultural competence [CC], which is acting in a manner that acknowledges the cultural background of another individual and tailoring the attitudes and behaviors of the individual providing care towards the culturally diverse individual (Marzilli, 2014), is of paramount importance to address health disparities in the United States (U.S.). As U.S. CC education needs to be integrated into the nursing curriculum, it is important to understand the level of CC in faculty members as they are responsible for teaching this important skill. Applying this understanding to Purnell's Model of Cultural Competence [PMCC] provides opportunities for faculty development to better prepare nurse educators to advance their own cultural competency and model this behavior for students. By framing faculty understanding of culture and faculty development sessions in the PMCC, pedagogically faculty members may be better prepared to understand and address this for students. Faculty members' perceptions of CC are not well-documented. Therefore, the purpose of this mixed-methods study was to determine the level of CC in pre-licensure faculty in Texas and explore faculty perceptions of what it means to be culturally competent while
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applying these findings to the PMCC. The research question was: In pre-licensure faculty members, what is their level of CC and their perceptions of CC? Ultimately, faculty are paramount in teaching necessary skills. Considering the challenges related to fear in the general public (Cook, 2015), faculty members should understand their own level of cultural competency, seek opportunities to improve this, and actively model and teach these skills to students. 2. Background/Literature 2.1. CC in Nursing Education CC in nursing education has been studied through qualitative methodologies like interviews. Studies have identified many resources for the development of CC, such as experiential learning (Harris et al., 2013; Harrowing et al., 2012; Gillund et al., 2013; Kratzke and Bertolo, 2013; Michael et al., 2012). These studies, while essential to the body of knowledge regarding CC in students do not provide quantitative data to evaluate or identify means to improve CC in nursing students. Campinha-Bacote (2006) found that nursing students who expressed a desire to be culturally competent achieved a higher level of CC than their peers who did not express such a desire (Fitzgerald et al., 2009).
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Quantitative studies found that knowledge gained in an immersion environment or a classroom setting was essential to increasing CC (Michajlyszyn et al., 2012. Wilson et al. (2010) found that providing knowledge through a CC workshop had lasting benefits. 2.2. CC in Faculty Faculty members are role models for pre-licensure nursing students (Felstead, 2013). Warner and Esposito (2009) studied the impact that educators can play in role-modeling desired behaviors and found this was an effective method of instruction. Montenery et al. (2013) explored how faculty transfer their CC knowledge to the educational setting so that nursing students can learn positive behaviors and relate them to patient care. It is essential that they possess an awareness of the examples they provide to students in providing culturally competent care and skills (Morton-Miller, 2013). While research has supported the role of faculty in developing student nurse CC, limited studies explore the purposeful understanding of how faculty members convey this knowledge. Some studies even show that faculty members are not adequately prepared in CC (Kardong-Edgren, 2007; Kardong-Edgren et al., 2005; Sealey et al., 2006). 2.3. Purnell's Model of Cultural Competence The PMCC was originally designed as an organizing framework to teach undergraduate students about CC. The realization that the model is a grand theory and has applications outside of nursing education extended its use to frame culture and CC for all involved in the care of persons from diverse backgrounds. The wholistic nature of the PMCC (Purnell, 2005) is appropriate for professionals in all disciplines to address ethnocentric behaviors, a lack of cultural awareness, and cultural insensitivity. The PMCC has at its core a dark circle representing what is still unknown about culture and CC. Framing the dark circle are 12 domains comprising culture. Four outer circles represent from inside to out, person, family, community, and global society. The 12 cultural domains of the PMCC are: overview/heritage, communication, family roles and organization, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy, death rituals, spirituality, health-care practices, and healthcare practitioners. Along the bottom of the circular model is a lightning bolt showing the transition from unconsciously incompetent, consciously incompetent, consciously competent, and unconsciously competent as practitioners dynamically interact with the characteristics of culture (Purnell, 2005). The PMCC provides a framework for health care providers as they explore culture didactically and practically while caring for individual patients, families, groups, or communities. The model frames circumstances and factors that shape worldview and provide an insight into culture. This serves to highlight what is necessary within the context of culture for a particular patient so that appropriate care can be planned to improve the health of all clients within the context of their culture (Purnell, 2005). The PMCC can also be used to assess CC and plan for revisions in curriculum as pedagogical decisions are made. The model can be used as an assessment to understand CC in students (Hayward and Charrette, 2012) and faculty, and it is an effective resource for faculty in organizing curricula so that students are taught the fundamental aspects of culture (Hudiburg et al., 2015). Faculty professional development sessions in CC are well suited to follow the PMCC framework.
3.2. Sample and Participant Selection A convenience sample of 89 faculty in Texas was recruited through the Texas Organization of Baccalaureate and Graduate Nursing Education (TOBGNE) and the Texas Organization for Associate Degree Nursing (TOADN) Listservs, which, together, comprise a listing of all nursing program deans and directors in Texas. Inclusion criteria were: fulltime faculty; employed by a university or college in Texas; and teaching nursing students. Full time faculty teaching in both an undergraduate and graduate programs were included. A subset of 10 participants was recruited for the qualitative interviews. 3.3. Setting The quantitative surveys were administered online through a link in the email sent to the listservs. The survey was open for a two-week period. Interviews were conducted by telephone. 3.4. Assessment and Measures CC is conceptually defined as acting in a manner that acknowledges the cultural background of another individual and tailoring the attitudes and behaviors of the individual providing care towards the culturally diverse individual (Marzilli, 2014). A decision was made to use define CC operationally with the Nurses' Cultural Competence Scale [NCCS]. This instrument was selected due to its ease of use and budgetary constraints, and it can be applied to the PMCC. The NCCS is a 41-item survey with four subscales (cultural awareness - 10 items, cultural knowledge 9 items, cultural sensitivity - 8 items, and cultural skills - 14 items) (Perng et al., 2007). Each subscale uses a five-point Likert scale to measure the participant's response: 1 = totally disagree, 2 = 25% agree, 3 = 50% agree, 4 = 75% agree, and 5 = 100% agree. Total scores range from 41 to 205 with higher scores indicative of a higher level of CC. The NCCS was originally written in traditional Chinese and evaluated by four experts; it has been translated into English. Several studies support the reliability and validity, with a reported Cronbach's α between 0.78 and 0.96 and a reliability between 0.79 and 0.89 of the Chinese version (Lin, 2013; Perng et al., 2007; Perng and Watson, 2012). The English version has shown to be promising as it has been piloted in English, and results are pending for the validity and reliability associated with the English version. The NCCS assesses the PMCC. The subscales of awareness and sensitivity relate to the four outer rings of the PMCC; global society, community, family, and person. The subscales of knowledge and skills assess and inform the 12 inner domains of the PMCC; health care practitioners, overview, communication, family, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy, death, spirituality, and health care practices. Along the bottom of the model is the lightning bolt representing the continuum through which cultural competency occurs, and this is represented in the change of the NCCS score depending on when the nurse completes the assessment. This was also reflected in certain qualitative discussions. Qualitative data were obtained through semi-structured interviews based on open-ended questions. These questions were intended to solicit information from the participants regarding their cultural encounters, existing knowledge, and feelings associated with CC. The qualitative interview also examined their desire related to CC. 3.5. Procedures
3. Methods 3.1. Design A convergent parallel mixed-methods design was used to examine CC in faculty. A quantitative strand measured CC. A qualitative strand explored faculty perceptions of CC.
Through the TOBGNE listserv, nursing deans and directors received an email asking them to forward the information to their faculty members. The email contained an IRB statement and a link to the online survey. Participation was entirely voluntary with no benefit, reward, or coercion, and anonymity was in place for all participants completing the quantitative strand. Following the quantitative questions, faculty
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members were taken to a separate survey and asked if they would be interested in participating in the qualitative strand of the study. Those opting into the qualitative strand were asked to provide their name and contact information for participation in an interview. These participants were contacted, and an interview was arranged and completed following submission of a signed informed consent. 3.6. Data Analysis and Strategy Quantitative data were imported into SPSS version 20 (IBM, Inc., Armonk, NY, USA). The first part of the research question which determined the level of CC of participants, was analyzed using descriptive statistics. Means and standard deviations were calculated for each of the four CC subscales and the overall level of CC. Descriptive statistics were also used to evaluate the level of CC in each faculty member. The second portion of the research question examined the perceptions of CC in the faculty member and was evaluated using the constant comparative method. Trustworthiness was maintained by having a second researcher review, code, and analyze the data for comparison with the PI's coded data. Theoretical constructs were independently conducted and mutually agreed upon. Additionally, triangulation, member checking, and keeping a field journal were used to ensure trustworthiness. Inspired by the work of Corbin and Strauss (2008) qualitative analysis procedures, themes were identified. Constructs and examples of the constructs were used to support each theme. The themes were related back to the PMCC. The subscales of awareness and sensitivity relate to the four outer rings and the subscales of knowledge and skills assess and inform the 12 inner domains. 4. Data/Results 4.1. Sample Characteristics 89 participants comprised the final sample. The sample was primarily female, white, educated at the MSN level, with a mean age of 55. Most spoke English as a first language, and the majority had experience traveling abroad. 4.2. NCCS Score Descriptive statistics were used to analyze the level of CC and the four NCCS subscales. Total NCCS scores ranged from 81 to 197. The NCCS total and subscale scores follow: NCCS Total (162.3 ± 21.7), Awareness Subscale (41.5 ± 7.2), Knowledge Subscale (33.8 ± 6.5), Sensitivity Subscale (32.8 ± 5.3), and Skill Subscale (54.3 ± 9.2). The mean, standard deviation, percent, minimum score, and maximum score for each subscale and the total NCCS instrument is presented in Table 1. Participants' CC scores as measured with the NCCS were moderate. Texas faculty scored lower on the skills and knowledge subscale but scored slightly higher in the awareness and sensitivity subscales. This finding is consistent with the literature (Mahabeer, 2009; Molewyk Doornbos et al., 2014). Considering the application to the PMCC, this supports that faculty members may be more aware of CC and sensitive to the needs of the culturally diverse in terms of the components of the PMCC known as global society, community, family, and person as
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this area of the NCCS is scored higher. The important thing to note is that while awareness and sensitivity are higher, the skills and knowledge subskills are lower, corresponding to the inner domains of the PMCC. This points to a weakness in faculty members' ability to know what to do and the tools in which to address the needs of the culturally diverse patient as they journey through the CC continuum moving from unconsciously incompetent, consciously incompetent, consciously competent, and unconsciously competent. 4.3. Qualitative Findings Key experiences related to distinct cultural differences were vividly embedded in the thoughts shared by participants. Faculty members recalled experiences with a particular patient or situation that highlighted the knowledge needed to provide care. Findings from the interview process were framed within the domains of the PMCC as a means to link the qualitative findings to the theoretical framework and to the quantitative data collected through the NCCS as referenced in terms of the PMCC. The qualitative data was related more closely to the 12 domains of the PMCC that is seen in the NCCS as representative of the subscales of knowledge and skills, an area that scored lower in the quantitative data. The domain of communication includes the major components of language as well as contextual use, volume and tone, spatial distancing, and non-verbal communication. One participant described needing social space when conversing with a Hispanic individual. She felt that her personal space was being encroached upon so she proceeded to step back, and each time she stepped back, the other person would step forward. The participant told that she had learned previously about the issue of personal space with the Hispanic culture, but that knowledge did not guide her actions until she had the actual experience. The domain of family roles and organization provides knowledge for health care providers as they seek to understand gender roles, attitudes towards the elderly, social status, extended family, and alternative lifestyles. A participant shared the story of caring for a Roma patient and being surprised by the family structure. “Gypsies really do not recognize immediate family members as we do or as other cultures do… the entire family is the tribe.” The participant described the experience as interesting and challenging, and associated the experience with providing culturally competent care. Workforce issues include acculturation, autonomy, and language barriers. A participant told of interactions with faculty colleagues when selecting a course textbook. The participant noted the importance of having pictures of minorities and diverse people in a textbook but found this was not a selling point to anyone else. A colleague remarked with shock, “Does that matter?” The participant noted “It really struck me that people's world views are different. They can look right at you but they see through you, especially people of color, and if you cannot see people, you are not really culturally competent.” This was not an example of caring for a patient from a different cultural background, but it illustrated how differences can occur between two culturally diverse people. The domain of biocultural ecology includes medically necessary things like how drugs are metabolized based on biological variation, genetics, and heredity. A participant remarked, “… Our students work in [a large, metropolitan area] when they graduate so that is very
Table 1 NCCS and subscales mean and percent.
Awareness subscale Knowledge subscale Sensitivity subscale Skill subscale NCCS total with outlier
Minimum score
Maximum score
Mean (S.D.)
Mean as a % of total possible
10 9 8 14 41
50 45 40 70 205
41.5 (7.2) 33.8 (6.5) 32.8 (5.3) 54.3 (9.2) 162.3 (21.7)
83% 75% 82% 78% 79%
As shown in Table 1, the NCCS and subscales with minimum, maximum, mean, and mean as a percent of total possible points.
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multicultural as far as the work staff and patient population because [the city] itself is very diverse.” This participant expressed that the experience caring for this diverse population provided students with the skills to be culturally competent and understand the biological difference in patients. The domain of high-risk behaviors includes tobacco, alcohol, recreation drugs, physical activity, and safety. A participant noted that caring for homosexual men was challenging because it was unclear how to address their sexual behaviors in conducting a history. The participant feltill prepared to address these without being perceived as judgmental. Nutrition is a domain that includes how food is perceived, rituals, deficiencies, limitations, and health promotion all related to food. A participant recalled caring for a patient and being offered a beverage. The participant had learned about providing culturally competent care to Hispanic patients and the importance of social exchange before initiating care. Pregnancy includes fertility practices, pregnancy beliefs, birthing practices, and care during the post-partum period. A participant recalled caring for a pregnant, Hispanic female patient with a hemoglobin level that was “not compatible with life.” The patient needed her husband's approval for transfusion because it was related to her pregnancy. The domain of death rituals also includes bereavement. A participant was providing post-mortem care. The participant could not recall the patient's exact culture but was struck by the differences in the death practices between the patient's and her own and described the experience as “different or conflicted with what I might have done.” Spirituality includes religious practices, prayer, understanding the meaning of life, and spirituality and health. A participant told of the challenge of caring for a Hmong patient. She did not understand exactly what the patient needed from a religious standpoint, and described the process was noted as “confusing and scary” because it was very out of the ordinary. The participant felt they should be doing something to address the patient's spiritual needs, but did not know what interventions should be taken. The domain of health care practices also includes traditional practices, transplantation beliefs, self-medication, mental health barriers, and magico-religious beliefs. A participant shared the experience of providing care to an Arab woman in a battered women's shelter. The participant remembered having to research the best way of providing culturally competent care to better craft an appropriate plan of care. This was something the participant did not know how to address, and the time spent researching appropriate health care practices, specifically related to the idea of mental health. To address the health care needs, the nurse was able to locate another Arab woman that had experienced similar circumstances to help the patient cope. The domain of health care practitioners includes perceptions of practitioners, folk practitioners, and gender and health care. One participant remarked, “Back in the 80s there was some mention of cultural differences, but it was not the emphasis or focus.” 5. Discussion The data from this study support that faculty participants were moderately culturally competent. Faculty members serve as role models for students (Klunklin et al., 2011; Reju et al., 2014), and they need a comprehensive understanding of culture, CC, and their own perceptions of the skills, knowledge, awareness, and sensitivity involved in caring for culturally diverse patients. This is coupled with research that supports that the actions of the faculty shape the students (Strouse and Nickerson, 2016). If nursing, as the most trusted discipline in the U.S. (Jones, 2015; Saad, 2015), is to truly address the care culturally diverse patients' need, nurses must not only be sensitive and aware of cultural needs, but have the skills and knowledge to correctly address those needs so that patient-centered care is provided to all patients (Kohlbry, 2016). When faculty are able to model culturally competent behaviors, students receive the best didactic and practical instruction in culturally competent nursing (Ume-Nwagbo, 2012). The moderate
CC quantitative findings related to the outer rings of the PMCC, global society, community, family, and person supports the qualitative findings that faculty members are aware and sensitive to the domains related to CC in the PMCC but do not identify a high level of knowledge or skills necessary to provide culturally competent care. This supports specific professional development sessions for faculty members to better support and prepare students. The qualitative findings suggest that the faculty have an awareness of eleven of the twelve domains in the PMCC within the context of the patient, family, community, and global society. The qualitative findings showed that the participants focused on specific memories caring for patients from diverse backgrounds. They referenced their own memories for their experience in caring for a patient of a particular cultural background which is consistent with the literature that supports experience with various aspects of culture as an important aspect of providing culturally competent care. The domain of Overview/Heritage was not present in the participant interviews because this represents a demographic aspect of culture that faculty members do not consider to be essential to the discussion of culture. Based on this level of understanding expressed in the qualitative findings, it does not support that faculty have a mastery level of understanding of the domains in the PMCC or CC. From these findings, it is noted that the deficit in specific knowledge and skills can be addressed through professional development sessions for faculty. By structuring professional development education around the 12 domains, faculty can further develop their knowledge and skills related to nursing care. It should be noted that the interview process did not obtain any discussion of CC professional development since nursing school and is an opportunity to develop sessions specifically for faculty. The concept of CC is more than just a set of behaviors that the faculty member will complete. CC is an important tool that nurses can use to help reduce health disparities (Cupelli, 2016; Roberts et al., 2014; Starr et al., 2011). It is important to consider that teaching styles largely vary, and delivering culturally competent care in the health care setting does not necessarily mean the faculty member will effectively teach the concepts. However, the role of faculty members as a role model cannot be underestimated as an important tool for teaching students CC skills (Klunklin et al., 2011; Reju et al., 2014; Strouse and Nickerson, 2016). The strength of the study is in the mixed-methods design and qualitative and quantitative data strands that support the other. However, this study relies on interviews and self-reported assessment of the instrument. Self-reported data has the potential to show bias as the participants strive to select that which may be more enticing to the researcher. It is also important to consider that the sample cannot be representative of all Texas pre-licensure faculty (Cicolini et al., 2015). 6. Conclusion Professional development offerings should be made available to faculty to provide specific education on knowledge and skills essential to CC. The PMCC is the theoretical framework utilized in this study, and based on the data results, framing the professional development sessions in line with the 12 domains of the PMCC may be an effective tool to help develop the sessions about CC skills for faculty members as they model these skills to students. This curriculum may be offered to faculty in any number of settings and formats, including workshops, seminars, conferences, and infographics for busy nurse educators. CC training should focus on each of the 12 domains with specific attention to the domain of Overview/Heritage. Future studies should evaluate how students perceive the effectiveness of CC education from their faculty members. Acknowledgements The author was a participant in the 2015 NLN Scholarly Writing Retreat, sponsored by the NLN Chamberlain College of Nursing Center for the Advancement of the Science of Nursing Education.
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Assessment of cultural competence in Texas nursing faculty Collen Marzilli, PhD, DNP, MBA, RN-BC, CCM, APHN-BC, CNE, Assistant Professor The University of Texas at Tyler, Braithwaite Building 2170, 3900 University Blvd., Tyler, TX 75799, United States
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Article history: Received 27 April 2016 Received in revised form 2 August 2016 Accepted 16 August 2016 Keywords: Purnell model of cultural competence Nursing Health Culture Values Nursing education Nurses' cultural competence scale
a b s t r a c t Background: Cultural competence [CC] is an essential component of nursing education and nursing practice yet there is a gap in the research evaluating CC in faculty and how to practically develop this skillset for faculty members. Objectives: To explore CC in faculty as evaluated with the Nurses' Cultural Competence Scale [NCCS] and apply the findings to the Purnell Model of Cultural Competence [PMCC] to guide professional development opportunities for faculty members. Design: This was a concurrent mixed-methods study. Setting: Faculty members teaching in Texas nursing programs were recruited for the study. Quantitative data was collected using an online survey tool and qualitative data was collected over the phone. Participants: 89 Texas faculty members completed the quantitative strand and a subset of 10 faculty members completed the qualitative strand. Methods: Descriptive statistics were used to examine the quantitative data and Strauss and Corbin's methodology guided the evaluation of the qualitative data. These two strands were used to support the results. Results: Faculty in Texas are moderately culturally competent. The qualitative findings support the application of the PMCC to the areas identified by the NCCS. Conclusion: The PMCC may be applied to the application of culture and values in nursing professional education as supported by the NCCS. Recommendations are to include the PMCC as a structure for the creation of professional development opportunities for faculty. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction Cultural competence [CC], which is acting in a manner that acknowledges the cultural background of another individual and tailoring the attitudes and behaviors of the individual providing care towards the culturally diverse individual (Marzilli, 2014), is of paramount importance to address health disparities in the United States (U.S.). As U.S. CC education needs to be integrated into the nursing curriculum, it is important to understand the level of CC in faculty members as they are responsible for teaching this important skill. Applying this understanding to Purnell's Model of Cultural Competence [PMCC] provides opportunities for faculty development to better prepare nurse educators to advance their own cultural competency and model this behavior for students. By framing faculty understanding of culture and faculty development sessions in the PMCC, pedagogically faculty members may be better prepared to understand and address this for students. Faculty members' perceptions of CC are not well-documented. Therefore, the purpose of this mixed-methods study was to determine the level of CC in pre-licensure faculty in Texas and explore faculty perceptions of what it means to be culturally competent while
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http://dx.doi.org/10.1016/j.nedt.2016.08.021 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
applying these findings to the PMCC. The research question was: In pre-licensure faculty members, what is their level of CC and their perceptions of CC? Ultimately, faculty are paramount in teaching necessary skills. Considering the challenges related to fear in the general public (Cook, 2015), faculty members should understand their own level of cultural competency, seek opportunities to improve this, and actively model and teach these skills to students. 2. Background/Literature 2.1. CC in Nursing Education CC in nursing education has been studied through qualitative methodologies like interviews. Studies have identified many resources for the development of CC, such as experiential learning (Harris et al., 2013; Harrowing et al., 2012; Gillund et al., 2013; Kratzke and Bertolo, 2013; Michael et al., 2012). These studies, while essential to the body of knowledge regarding CC in students do not provide quantitative data to evaluate or identify means to improve CC in nursing students. Campinha-Bacote (2006) found that nursing students who expressed a desire to be culturally competent achieved a higher level of CC than their peers who did not express such a desire (Fitzgerald et al., 2009).
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Quantitative studies found that knowledge gained in an immersion environment or a classroom setting was essential to increasing CC (Michajlyszyn et al., 2012. Wilson et al. (2010) found that providing knowledge through a CC workshop had lasting benefits. 2.2. CC in Faculty Faculty members are role models for pre-licensure nursing students (Felstead, 2013). Warner and Esposito (2009) studied the impact that educators can play in role-modeling desired behaviors and found this was an effective method of instruction. Montenery et al. (2013) explored how faculty transfer their CC knowledge to the educational setting so that nursing students can learn positive behaviors and relate them to patient care. It is essential that they possess an awareness of the examples they provide to students in providing culturally competent care and skills (Morton-Miller, 2013). While research has supported the role of faculty in developing student nurse CC, limited studies explore the purposeful understanding of how faculty members convey this knowledge. Some studies even show that faculty members are not adequately prepared in CC (Kardong-Edgren, 2007; Kardong-Edgren et al., 2005; Sealey et al., 2006). 2.3. Purnell's Model of Cultural Competence The PMCC was originally designed as an organizing framework to teach undergraduate students about CC. The realization that the model is a grand theory and has applications outside of nursing education extended its use to frame culture and CC for all involved in the care of persons from diverse backgrounds. The wholistic nature of the PMCC (Purnell, 2005) is appropriate for professionals in all disciplines to address ethnocentric behaviors, a lack of cultural awareness, and cultural insensitivity. The PMCC has at its core a dark circle representing what is still unknown about culture and CC. Framing the dark circle are 12 domains comprising culture. Four outer circles represent from inside to out, person, family, community, and global society. The 12 cultural domains of the PMCC are: overview/heritage, communication, family roles and organization, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy, death rituals, spirituality, health-care practices, and healthcare practitioners. Along the bottom of the circular model is a lightning bolt showing the transition from unconsciously incompetent, consciously incompetent, consciously competent, and unconsciously competent as practitioners dynamically interact with the characteristics of culture (Purnell, 2005). The PMCC provides a framework for health care providers as they explore culture didactically and practically while caring for individual patients, families, groups, or communities. The model frames circumstances and factors that shape worldview and provide an insight into culture. This serves to highlight what is necessary within the context of culture for a particular patient so that appropriate care can be planned to improve the health of all clients within the context of their culture (Purnell, 2005). The PMCC can also be used to assess CC and plan for revisions in curriculum as pedagogical decisions are made. The model can be used as an assessment to understand CC in students (Hayward and Charrette, 2012) and faculty, and it is an effective resource for faculty in organizing curricula so that students are taught the fundamental aspects of culture (Hudiburg et al., 2015). Faculty professional development sessions in CC are well suited to follow the PMCC framework.
3.2. Sample and Participant Selection A convenience sample of 89 faculty in Texas was recruited through the Texas Organization of Baccalaureate and Graduate Nursing Education (TOBGNE) and the Texas Organization for Associate Degree Nursing (TOADN) Listservs, which, together, comprise a listing of all nursing program deans and directors in Texas. Inclusion criteria were: fulltime faculty; employed by a university or college in Texas; and teaching nursing students. Full time faculty teaching in both an undergraduate and graduate programs were included. A subset of 10 participants was recruited for the qualitative interviews. 3.3. Setting The quantitative surveys were administered online through a link in the email sent to the listservs. The survey was open for a two-week period. Interviews were conducted by telephone. 3.4. Assessment and Measures CC is conceptually defined as acting in a manner that acknowledges the cultural background of another individual and tailoring the attitudes and behaviors of the individual providing care towards the culturally diverse individual (Marzilli, 2014). A decision was made to use define CC operationally with the Nurses' Cultural Competence Scale [NCCS]. This instrument was selected due to its ease of use and budgetary constraints, and it can be applied to the PMCC. The NCCS is a 41-item survey with four subscales (cultural awareness - 10 items, cultural knowledge 9 items, cultural sensitivity - 8 items, and cultural skills - 14 items) (Perng et al., 2007). Each subscale uses a five-point Likert scale to measure the participant's response: 1 = totally disagree, 2 = 25% agree, 3 = 50% agree, 4 = 75% agree, and 5 = 100% agree. Total scores range from 41 to 205 with higher scores indicative of a higher level of CC. The NCCS was originally written in traditional Chinese and evaluated by four experts; it has been translated into English. Several studies support the reliability and validity, with a reported Cronbach's α between 0.78 and 0.96 and a reliability between 0.79 and 0.89 of the Chinese version (Lin, 2013; Perng et al., 2007; Perng and Watson, 2012). The English version has shown to be promising as it has been piloted in English, and results are pending for the validity and reliability associated with the English version. The NCCS assesses the PMCC. The subscales of awareness and sensitivity relate to the four outer rings of the PMCC; global society, community, family, and person. The subscales of knowledge and skills assess and inform the 12 inner domains of the PMCC; health care practitioners, overview, communication, family, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy, death, spirituality, and health care practices. Along the bottom of the model is the lightning bolt representing the continuum through which cultural competency occurs, and this is represented in the change of the NCCS score depending on when the nurse completes the assessment. This was also reflected in certain qualitative discussions. Qualitative data were obtained through semi-structured interviews based on open-ended questions. These questions were intended to solicit information from the participants regarding their cultural encounters, existing knowledge, and feelings associated with CC. The qualitative interview also examined their desire related to CC. 3.5. Procedures
3. Methods 3.1. Design A convergent parallel mixed-methods design was used to examine CC in faculty. A quantitative strand measured CC. A qualitative strand explored faculty perceptions of CC.
Through the TOBGNE listserv, nursing deans and directors received an email asking them to forward the information to their faculty members. The email contained an IRB statement and a link to the online survey. Participation was entirely voluntary with no benefit, reward, or coercion, and anonymity was in place for all participants completing the quantitative strand. Following the quantitative questions, faculty
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members were taken to a separate survey and asked if they would be interested in participating in the qualitative strand of the study. Those opting into the qualitative strand were asked to provide their name and contact information for participation in an interview. These participants were contacted, and an interview was arranged and completed following submission of a signed informed consent. 3.6. Data Analysis and Strategy Quantitative data were imported into SPSS version 20 (IBM, Inc., Armonk, NY, USA). The first part of the research question which determined the level of CC of participants, was analyzed using descriptive statistics. Means and standard deviations were calculated for each of the four CC subscales and the overall level of CC. Descriptive statistics were also used to evaluate the level of CC in each faculty member. The second portion of the research question examined the perceptions of CC in the faculty member and was evaluated using the constant comparative method. Trustworthiness was maintained by having a second researcher review, code, and analyze the data for comparison with the PI's coded data. Theoretical constructs were independently conducted and mutually agreed upon. Additionally, triangulation, member checking, and keeping a field journal were used to ensure trustworthiness. Inspired by the work of Corbin and Strauss (2008) qualitative analysis procedures, themes were identified. Constructs and examples of the constructs were used to support each theme. The themes were related back to the PMCC. The subscales of awareness and sensitivity relate to the four outer rings and the subscales of knowledge and skills assess and inform the 12 inner domains. 4. Data/Results 4.1. Sample Characteristics 89 participants comprised the final sample. The sample was primarily female, white, educated at the MSN level, with a mean age of 55. Most spoke English as a first language, and the majority had experience traveling abroad. 4.2. NCCS Score Descriptive statistics were used to analyze the level of CC and the four NCCS subscales. Total NCCS scores ranged from 81 to 197. The NCCS total and subscale scores follow: NCCS Total (162.3 ± 21.7), Awareness Subscale (41.5 ± 7.2), Knowledge Subscale (33.8 ± 6.5), Sensitivity Subscale (32.8 ± 5.3), and Skill Subscale (54.3 ± 9.2). The mean, standard deviation, percent, minimum score, and maximum score for each subscale and the total NCCS instrument is presented in Table 1. Participants' CC scores as measured with the NCCS were moderate. Texas faculty scored lower on the skills and knowledge subscale but scored slightly higher in the awareness and sensitivity subscales. This finding is consistent with the literature (Mahabeer, 2009; Molewyk Doornbos et al., 2014). Considering the application to the PMCC, this supports that faculty members may be more aware of CC and sensitive to the needs of the culturally diverse in terms of the components of the PMCC known as global society, community, family, and person as
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this area of the NCCS is scored higher. The important thing to note is that while awareness and sensitivity are higher, the skills and knowledge subskills are lower, corresponding to the inner domains of the PMCC. This points to a weakness in faculty members' ability to know what to do and the tools in which to address the needs of the culturally diverse patient as they journey through the CC continuum moving from unconsciously incompetent, consciously incompetent, consciously competent, and unconsciously competent. 4.3. Qualitative Findings Key experiences related to distinct cultural differences were vividly embedded in the thoughts shared by participants. Faculty members recalled experiences with a particular patient or situation that highlighted the knowledge needed to provide care. Findings from the interview process were framed within the domains of the PMCC as a means to link the qualitative findings to the theoretical framework and to the quantitative data collected through the NCCS as referenced in terms of the PMCC. The qualitative data was related more closely to the 12 domains of the PMCC that is seen in the NCCS as representative of the subscales of knowledge and skills, an area that scored lower in the quantitative data. The domain of communication includes the major components of language as well as contextual use, volume and tone, spatial distancing, and non-verbal communication. One participant described needing social space when conversing with a Hispanic individual. She felt that her personal space was being encroached upon so she proceeded to step back, and each time she stepped back, the other person would step forward. The participant told that she had learned previously about the issue of personal space with the Hispanic culture, but that knowledge did not guide her actions until she had the actual experience. The domain of family roles and organization provides knowledge for health care providers as they seek to understand gender roles, attitudes towards the elderly, social status, extended family, and alternative lifestyles. A participant shared the story of caring for a Roma patient and being surprised by the family structure. “Gypsies really do not recognize immediate family members as we do or as other cultures do… the entire family is the tribe.” The participant described the experience as interesting and challenging, and associated the experience with providing culturally competent care. Workforce issues include acculturation, autonomy, and language barriers. A participant told of interactions with faculty colleagues when selecting a course textbook. The participant noted the importance of having pictures of minorities and diverse people in a textbook but found this was not a selling point to anyone else. A colleague remarked with shock, “Does that matter?” The participant noted “It really struck me that people's world views are different. They can look right at you but they see through you, especially people of color, and if you cannot see people, you are not really culturally competent.” This was not an example of caring for a patient from a different cultural background, but it illustrated how differences can occur between two culturally diverse people. The domain of biocultural ecology includes medically necessary things like how drugs are metabolized based on biological variation, genetics, and heredity. A participant remarked, “… Our students work in [a large, metropolitan area] when they graduate so that is very
Table 1 NCCS and subscales mean and percent.
Awareness subscale Knowledge subscale Sensitivity subscale Skill subscale NCCS total with outlier
Minimum score
Maximum score
Mean (S.D.)
Mean as a % of total possible
10 9 8 14 41
50 45 40 70 205
41.5 (7.2) 33.8 (6.5) 32.8 (5.3) 54.3 (9.2) 162.3 (21.7)
83% 75% 82% 78% 79%
As shown in Table 1, the NCCS and subscales with minimum, maximum, mean, and mean as a percent of total possible points.
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multicultural as far as the work staff and patient population because [the city] itself is very diverse.” This participant expressed that the experience caring for this diverse population provided students with the skills to be culturally competent and understand the biological difference in patients. The domain of high-risk behaviors includes tobacco, alcohol, recreation drugs, physical activity, and safety. A participant noted that caring for homosexual men was challenging because it was unclear how to address their sexual behaviors in conducting a history. The participant feltill prepared to address these without being perceived as judgmental. Nutrition is a domain that includes how food is perceived, rituals, deficiencies, limitations, and health promotion all related to food. A participant recalled caring for a patient and being offered a beverage. The participant had learned about providing culturally competent care to Hispanic patients and the importance of social exchange before initiating care. Pregnancy includes fertility practices, pregnancy beliefs, birthing practices, and care during the post-partum period. A participant recalled caring for a pregnant, Hispanic female patient with a hemoglobin level that was “not compatible with life.” The patient needed her husband's approval for transfusion because it was related to her pregnancy. The domain of death rituals also includes bereavement. A participant was providing post-mortem care. The participant could not recall the patient's exact culture but was struck by the differences in the death practices between the patient's and her own and described the experience as “different or conflicted with what I might have done.” Spirituality includes religious practices, prayer, understanding the meaning of life, and spirituality and health. A participant told of the challenge of caring for a Hmong patient. She did not understand exactly what the patient needed from a religious standpoint, and described the process was noted as “confusing and scary” because it was very out of the ordinary. The participant felt they should be doing something to address the patient's spiritual needs, but did not know what interventions should be taken. The domain of health care practices also includes traditional practices, transplantation beliefs, self-medication, mental health barriers, and magico-religious beliefs. A participant shared the experience of providing care to an Arab woman in a battered women's shelter. The participant remembered having to research the best way of providing culturally competent care to better craft an appropriate plan of care. This was something the participant did not know how to address, and the time spent researching appropriate health care practices, specifically related to the idea of mental health. To address the health care needs, the nurse was able to locate another Arab woman that had experienced similar circumstances to help the patient cope. The domain of health care practitioners includes perceptions of practitioners, folk practitioners, and gender and health care. One participant remarked, “Back in the 80s there was some mention of cultural differences, but it was not the emphasis or focus.” 5. Discussion The data from this study support that faculty participants were moderately culturally competent. Faculty members serve as role models for students (Klunklin et al., 2011; Reju et al., 2014), and they need a comprehensive understanding of culture, CC, and their own perceptions of the skills, knowledge, awareness, and sensitivity involved in caring for culturally diverse patients. This is coupled with research that supports that the actions of the faculty shape the students (Strouse and Nickerson, 2016). If nursing, as the most trusted discipline in the U.S. (Jones, 2015; Saad, 2015), is to truly address the care culturally diverse patients' need, nurses must not only be sensitive and aware of cultural needs, but have the skills and knowledge to correctly address those needs so that patient-centered care is provided to all patients (Kohlbry, 2016). When faculty are able to model culturally competent behaviors, students receive the best didactic and practical instruction in culturally competent nursing (Ume-Nwagbo, 2012). The moderate
CC quantitative findings related to the outer rings of the PMCC, global society, community, family, and person supports the qualitative findings that faculty members are aware and sensitive to the domains related to CC in the PMCC but do not identify a high level of knowledge or skills necessary to provide culturally competent care. This supports specific professional development sessions for faculty members to better support and prepare students. The qualitative findings suggest that the faculty have an awareness of eleven of the twelve domains in the PMCC within the context of the patient, family, community, and global society. The qualitative findings showed that the participants focused on specific memories caring for patients from diverse backgrounds. They referenced their own memories for their experience in caring for a patient of a particular cultural background which is consistent with the literature that supports experience with various aspects of culture as an important aspect of providing culturally competent care. The domain of Overview/Heritage was not present in the participant interviews because this represents a demographic aspect of culture that faculty members do not consider to be essential to the discussion of culture. Based on this level of understanding expressed in the qualitative findings, it does not support that faculty have a mastery level of understanding of the domains in the PMCC or CC. From these findings, it is noted that the deficit in specific knowledge and skills can be addressed through professional development sessions for faculty. By structuring professional development education around the 12 domains, faculty can further develop their knowledge and skills related to nursing care. It should be noted that the interview process did not obtain any discussion of CC professional development since nursing school and is an opportunity to develop sessions specifically for faculty. The concept of CC is more than just a set of behaviors that the faculty member will complete. CC is an important tool that nurses can use to help reduce health disparities (Cupelli, 2016; Roberts et al., 2014; Starr et al., 2011). It is important to consider that teaching styles largely vary, and delivering culturally competent care in the health care setting does not necessarily mean the faculty member will effectively teach the concepts. However, the role of faculty members as a role model cannot be underestimated as an important tool for teaching students CC skills (Klunklin et al., 2011; Reju et al., 2014; Strouse and Nickerson, 2016). The strength of the study is in the mixed-methods design and qualitative and quantitative data strands that support the other. However, this study relies on interviews and self-reported assessment of the instrument. Self-reported data has the potential to show bias as the participants strive to select that which may be more enticing to the researcher. It is also important to consider that the sample cannot be representative of all Texas pre-licensure faculty (Cicolini et al., 2015). 6. Conclusion Professional development offerings should be made available to faculty to provide specific education on knowledge and skills essential to CC. The PMCC is the theoretical framework utilized in this study, and based on the data results, framing the professional development sessions in line with the 12 domains of the PMCC may be an effective tool to help develop the sessions about CC skills for faculty members as they model these skills to students. This curriculum may be offered to faculty in any number of settings and formats, including workshops, seminars, conferences, and infographics for busy nurse educators. CC training should focus on each of the 12 domains with specific attention to the domain of Overview/Heritage. Future studies should evaluate how students perceive the effectiveness of CC education from their faculty members. Acknowledgements The author was a participant in the 2015 NLN Scholarly Writing Retreat, sponsored by the NLN Chamberlain College of Nursing Center for the Advancement of the Science of Nursing Education.
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