Innovative educational activities using a model to improve cultural

competency among graduate students

Kathleen Bauera *, Yeon Baib

Introduction:

In the United States, heath care disparities plague health professionals.

Inequalities exist in regard to access to healthcare, delivery of quality
healthcare as well as health outcomes. Substantial health inequalities
exist based on age, gender, race, ethnicity, education, income,
disability, residence, and sexual orientation. In order to address this
concern, professional organizations, institutions of higher education,
and accrediting agencies involved in health care have focused on
individual and organizational cultural competency as one line of attack.
The Office of Minority Health (2014) defines cultural and linguistic
competence as “a set of congruent behaviors, attitudes, and policies
that come together in a system, agency, or among professionals that
enables effective work in cross-cultural situations. “ Substantial
population shifts also intensify the need for health care professionals to
acquire culturally respective health care practices. According to the US
Census Bureau (2014), beginning in the1970s the United States has
been moving toward a cultural plurality, where no single ethnic group
is a majority. By 2050, non-Hispanic whites will become less than 50
percent of the total population of the United States. This population
shift creates a myriad of health care challenges since each racial and
ethnic group has unique linguistic patterns, cultural traits, and health
profiles. In order to prepare future nutrition care professionals to work
effectively with diverse populations groups, the Campinha-Bacote
Model of Cultural Competence in the Delivery of Health Care Services
was used to design, implement, and evaluate a nutrition counseling
graduate class focusing on improving cultural competency.

Research Design

Purpose of the Study The premise of this pre- and post- comparison
study was that an interactive course exposing students to theoretical
and practical knowledge about cultural competence would be useful in
improving culturally sensitive skills. The objective was to determine the
effects of the course on the five constructs of the Campinha-Bacote
Model as well as perceived cultural competence.

2.2 Conceptual Model and Educational Design The Campinha-Bacote

Model of Cultural Competence in the Delivery of Health Care Services
(2014) looks at cultural competence as a process in which the
healthcare professional continually strives to work effectively within the
cultural context of a client (family, individual or community). “It is a
process of becoming culturally competent, not being culturally
competent.” Five interdependent constructs of this model include
cultural awareness, cultural knowledge, cultural skill, cultural
encounter, and cultural desire. Cultural competence is influenced by
working on any of these areas and strengthens the impact of the others
on the journey towards cultural competence. Research of this model
indicates that cultural encounters plays a pivotal role in the process
having the greatest influence on the other four constructs. The following
describes the constructs of this model and the specific learning
experiences focusing on each construct used in the graduate classes.
Although learning modules addressed one specific construct, one could
make the case that individual learning activities likely addressed
several constructs.

Cultural awareness is defined as “the deliberate self-examination and

in-depth exploration of our personal biases, stereotypes, prejudices and
assumptions that we hold about individuals who are different from us”
(CampinhaBacote, 2007). The goal of lessons and activities focusing on
this construct was to develop an awareness of the cultural beliefs and
values that influence conscious and unconscious thoughts and
understand that these attributes create a bias of acceptable behavior.
For one learning experience, students prepared and discussed collages
illustrating cultural factors influencing their perceptions of the world.
In order to challenge assumptions, students participated in Barnga, a
simple card game simulation in which players needed to negotiate
cultural clashes based on different perceptions and rules (Thiagarajan,
2006).

Cultural knowledge involves seeking and obtaining a sound educational

foundation of diverse cultural groups regarding cultural values, health-
related beliefs and practices and disease incidence and prevalence. As
can be seen in Table 1 a variety of assignments and activities addressed
this construct. In particular, the learning activities focused on cultural
terms, cultural competency models, ethnopharmacology (scientific
study of medicinal practices of cultural groups), cultural values, health
disparities, organizational cultural competence, and in depth
investigation of selected cultural groups focusing on ethnicity,
disabilities, and lifespan issues.

Cultural skill is the ability to use appropriate cross-cultural

communication skills to collect relevant cultural data and health
histories and provide an appropriate and sensitive nutrition
intervention. Students learned skills through, videos, readings,
lectures, in class technique practices, and working with volunteer
clients to practice cross-cultural interview techniques.

Cultural encounters with individuals from diverse cultural

backgrounds encourage practitioners to appreciate alternative
interpretations of reality and possibly question pre-existing beliefs
about a specific cultural group. Encounters create opportunities to
develop attitudes congruent with cultural competency, such as
appreciation and respect. Throughout the course students participated
in a variety of cross cultural encounters through readings, videos,
presentations, cross-cultural interviews, and individual field trips. One
component of the course was an eight-week book club. Students read
The Spirit Catches You and You Fall Down – A Hmong Child, Her
American Doctors and the Collision of Two Culture by Anne Fadiman
and winner of the 1997 National Book Critics Circle Award for
nonfiction. Students read assigned chapters, journaled answers to
assigned questions, and participated in class discussions regarding
their readings.

2.3 Sample Thirty-four students enrolled in two separate graduate

classes participated in the spring of 2010 and 2011. All students were
working on obtaining a Master of Science degree in Nutrition and Food
Science with a concentration in nutrition education. Combined data
indicated that 27 participants were 20-29 years old, 2 were 30-39 years
old, and 5 were 40 to 49 years old. Racial data indicated that 28 were
Caucasian, 5 were African American, and 1 was Asian. There were 3
male and 31 female participants.

2.4 Methods IRB approval was granted from Montclair State University.
All students were voluntary participants, and were notified of the
experimental evaluation of the course. Participants signed informed
consents. All data collection was done by research assistants and all
evaluation forms were coded. Coded evaluation forms were made
available to the instructor at the end of the course after students
received their grades. 3. Evaluation A pre and posttest using the
Inventory for Assessing the Process of Cultural Competence among
Healthcare Professionals – Revised (IAPCC-R), 2002, was used to
measure overall cultural competency as well as the five constructs of
the Campinha-Bacote Model. The IAPCC-R is a pencil/paper self-
assessment tool and has a Likerttype scale with 25 items. Response
options ranged from 1 (strongly disagree) to 4 (strongly agree). The total
scale ranges from 25 to 100. A score of 25 to 50 indicates cultural
incompetence, a score of 51 to 74 reflects cultural awareness, and a
score of 75 to 90 specifies cultural competence, and a score of 91 to 100
designates cultural proficiency. This tool has been used extensively
within the United States and has been tested for reliability and validity
for health care professionals. Reliability studies conducted in 12 states
have yielded an average reliability coefficient Cronbach alpha of .82
(Campinha-Bacote, 2007). A repeated measure ANOVA was used to
analyze the results. In addition students were queried for their
impressions of the effectiveness of the course on their overall cultural
competency. Also journal entries regarding reading assignments and
open –ended questions on the final evaluation provided qualitative
evaluation data. Thirty-four students enrolled in two separate graduate
classes participated in the spring of 2010 and 2011.

4. Results

4.1 Quantitative Evaluation of cultural competency constructs of the

Campinha-Bacote Model improved significantly after completion of the
course. The total competence score improved from “culturally aware”
(score of 68.7 at pre-) to “culturally competent” (score of 78.7 at post-).
The scores for each construct of the model also improved after
completion of the course. In addition, students perceived that a course
providing multiple interactive activities addressing constructs of this
model was very useful.

4.2 Qualitative Journals were submitted directly to the instructor and

designed to allow reflection of readings and course content. Students
used them to examine their own beliefs and biases. This qualitative
feedback allowed the instructor to observe trends or changes in student
opinions and reactions. The following are some excerpts from journal
entries:

 I was fascinated by what I have read so far about the Hmong and
their culture. Living in only one section of the world, I have fallen
victim to general prejudices that occur when we are introduced
to something completely foreign to what we are accustom to.

 This reading has reminded me that not everyone I counsel is

going to believe me when I tell them that changing their dietary
habits may help them get better.

 I did not cringe or squirm (as I thought I might) when I read about
the pig’s throat being slit because I began to understand the
practice as something very special and sacred to the Hmong. I
ask myself, “Who am I to judge the beliefs and practices of other
people?”

5. Conclusion

A number of government organizations emphasize the need to prepare

health practitioners to work effectively with diverse population groups.
As stated in the Health and Human Services Action Plan to Reduce
Racial and Ethnic Disparities: A Nation Free of Disparities in Health
and Health Care (2011): “The ability of the healthcare workforce to
address disparities will depend on its future cultural competence and
diversity.” In addition the principal standard of the National Standards
for Culturally and Linguistically Appropriate Services in Health and
Health Care (2013) states: “Provide effective, equitable, understandable,
and respectful quality care and services that are responsive to diverse
cultural health beliefs and practices, preferred languages, health
literacy, and other communication needs”.

Clearly educational institutions have the ability to be a conduit for

helping to meet these goals. The findings of this evaluation of two
graduate nutrition counseling classes indicated that learning modules
focusing on experiential learning activities and designed to address
constructs of the Campinha-Bacote Model can help develop levels of
cultural competence. These findings were in accord with empirical
findings from studies of cultural competence workshops (McDougle,
Ukockis, Adamshick , 2010), undergraduate and graduate courses
focusing on cultural competence (Brathwaite, 2012), and immersion in
a different culture (Wright & Lundy, 2014).
Health competence from a transcultural perspective. Knowing how to
approach transcultural care

Montserrat Pulido-Fuentesa* , & Luisa Abad Gonzálezb , &Maria de

Fátima da Silva Vieira Martinsc , & Juan Antonio Flores Martosd

Introduction

Intercultural health, including intercultural competence, is a field of

study which is generating a great deal of interest in the scientific
community. Cultural competence is now becoming a priority for
inclusion in the curriculum and training syllabuses of health
professionals. Current research and the concepts developed, in this
field, can be used to provide input for the content to be included in such
training programmes.

Concerns about studying intercultural health have been growing for a

long time. In Europe the migration of various population groups and
communities means the problem has become more visible and
widespread, nevertheless, it is important that intercultural health
concerns are not solely limited to these contexts and to minority and
indigenous groups (Knipper, 2010). Given its current relevance, it is
surprising, that it has not been paid more attention nor generated
greater and more forceful debate (unlike in Latin America), as there is
a clear need for intercultural dialogue across all areas of social, cultural
and political life, starting at an institutional level, but as Fernández
(2006, p. 317) says it is only ‘fashionable’ among certain programmes,
movements and collectives.

This is a delicate area of debate and the common perceptions in the

findings of studies addressing this issue – especially those conducted
among indigenous populations (Clifford et al, 2015) – all speak of the
difficulty and complexities in finding valid responses. Thus, work needs
to continue along these lines, in order to be able to put into practice the
recommendations of the great number of academic papers in this field.

As mentioned above, applying reductionism to the intercultural health

concept, by focussing solely on minorities, foreigners and ‘problematic’
groups, means that the socio-political and economic dynamics which
also come into play, get ignored or neglected. The term ‘intercultural’ is
complex and it also includes those population groups likely to be
subject to cultural competence care, while biomedical health culture
fails incorporate intercultural competence into its educational and
training programmes. While the terms “transcultural”, “intercultural”
or “interculturality”, are not new, it is impossible as Guilherme and
Dietz (2015) state “to establish fixed and stable lines between them, as
they form a complex web of meanings that to some extent may cross
each other”. According to Kleinman and Benson (2006), Kruse (2014),
the same thing happens with ‘cultural competence’ which is a new
ideological term, coined in response to the economic, political and
sociocultural rationale of the inter-cultural discourse, expressed in
different ways in different situations.

As mentioned above, applying reductionism to the intercultural health

concept, by focussing solely on minorities, foreigners and ‘problematic’
groups, means that the socio-political and economic dynamics which
also come into play, get ignored or neglected. The term ‘intercultural’ is
complex and it also includes those population groups likely to be
subject to cultural competence care, while biomedical health culture
fails incorporate intercultural competence into its educational and
training programmes. While the terms “transcultural”, “intercultural”
or “interculturality”, are not new, it is impossible as Guilherme and
Dietz (2015) state “to establish fixed and stable lines between them, as
they form a complex web of meanings that to some extent may cross
each other”. According to Kleinman and Benson (2006), Kruse (2014),
the same thing happens with ‘cultural competence’ which is a new
ideological term, coined in response to the economic, political and
sociocultural rationale of the inter-cultural discourse, expressed in
different ways in different situations.

The different tools which are being developed to assess cultural

competence, particularly those related to the sphere of health,
demonstrate the interest, concern and relevance that this issue holds
for health professionals, researchers and academics today. The design
of assessment tools to evaluate cultural competence training and the
development of guides on cultural competence for educating medical
students, nurses and other healthcare staff, plus the assessment and
analysis of this part of the curriculum is very striking in North
American. Under the slogan ‘Better communication for Better care’ the
American Medical Association (AAA, 2005) offered a series of tools
designed to help health organisations and institutions in general – but
more particularly Health workers – to respond to the needs of diverse
patient populations by enabling both health professionals and
organisations to offer improved communication and relationships.

Methodology

Our aim was to try and understand the intercultural –and transcultural
in the context of this study – nature of the social and cultural dynamics
at work around health processes which are critical to the acceptance,
implementation and integration of the premises put forward by cultural
competence programmes. Our approach was to analyse the different
models of intercultural competence and the different tools aimed at
guiding those health professionals who, like ourselves, question the
quality of the care we offer.
A qualitative methodology was selected with a strongly ethnographic
approach, given the particular characteristics of the study, in
accordance with Willis and Trondman (2000). The ethnographic
research design was based on data collection carried out during
fieldwork trips among the Achuar population (Ecuadorean Amazon)
which took place periodically over the years 2008 to 2010. These
inhabitants are recipients of a health promotion project, which is based
on the principles of western medicine and development cooperation.
One of the main objectives of this project is to improve the
epidemiological health indicators in the area by setting up and training
a network of health promoters together with the distribution of
community first aid kits – located where primary care takes place in the
community

The ethnographic approach adopted, included various information

gathering techniques, ie participant observation data collection,
qualitative interviews, fieldwork diaries, consideration from both emic
and etic perspectives. This combination was considered to offer the
most appropriate research methodology to explore more deeply and
illuminate an area which tends to remain hidden in the shadows and
which cannot be easily approached from more neutral attitudes and
perspectives. Various studies (Knipper, 2013; Willen 2013; Carpenter-
Song, & Whitley 2013; Hannah & Carpenter-Song, 2013) endorse
ethnography as the best approach for evaluating the social and cultural
dynamics explored in transcultural studies. In this case, all the above
ethnographic research tools were employed in order to provide the most
powerful set of data collection techniques possible.

The sample was made up of medical and nursing professionals, caring

for the health of the Achuar population. These professionals were either
of ecuadorian origin and thus dependent on their National Ministry of
Health, or health professionals from spanish development cooperation
organisations with specific health programmes and profiles – colonist
health personnel-, and finally local healthcare personnel of Achuar
origin. Two focus groups and 11 in-depth interviews were carried out
among 28 participants (this is part of a wider study), with systematic
and supervised participant observation in place. The gender
distribution of the sample was predominantly female – with just 2 male
physicians – this proportion being usual for studies among healthcare
professionals.

In the qualitative analysis and data interpretation, the search for

meaning and significance was given priority. A system of selective
coding was established, giving rise to categories, which were
systematically and constantly compared one to another. In addition to
the sources cited, further desk research was undertaken relating to the
field of Achuar medicine, relevant current legislation, and training
literature, such as that used by nurses who participated in the project.
Additional training materials developed for use by local health staff in
training sessions and courses were also studied. At the same time the
cultural practices of the Achuar people and their relationship with
political practice were researched and analysed. From an ethical
standpoint, the Helsinki Declaration was adhered to, and a paper has
already been published on this subject (Pulido, 2016).

Results:

The main findings reveal a ‘lack of continuity’ or a ‘discontinuity’ in

care, where the use of indigenous methods of diagnosis and therapeutic
resources coexist alongside the biomedical model. The latter being
incorporated via periodic interventions of colonist healthcare personnel,
attached to the Ecuadorian Health Ministry and/or international
organisations. Colonist personnel – with the exception of one Doctor
who had worked for more than 15 years among the Achuar people –
find the work difficult. Only very occasionally, and even then only for
short periods, has it been possible to get nurses and a doctor to work
at a health point, as they tend to leave in order to further their
professional career. Additionally, they can’t get used to the way of life,
they aren’t ready to work with ‘savages’ nor with people who have very
deeply rooted customs. Given the enormous difficulties in finding health
workers who want to work with the Achuar people, the Health Ministry
is attempting to find a way to reinforce the healthcare practitioners who
cover these posts (after having removed the economic incentive which
had been implemented for a while).

The lack of biomedical staff – attached to the Health Ministry – who

want to stay in these areas, leads to healthcare being carried out by the
health brigades – which carry out limited healthcare activities on a
sporadic and intermittent basis. In this way, these communities
occasionally receive at least some of the most basic necessities of
Primary Health Care, such as vaccination and delivery of medicines.
International organisations attempt to make good this situation, and
design projects to be carried out by development agents and health staff
– who are distant from the cultural context.

Nurses who participate in the health promotion projects are volunteers,

which suggest that a priori they are open to intercultural exchange, and
one might imagine that getting to know and learn about different
cultural realities could be sufficient to motivate for them. However, this
affective component does not always translate into a cultural awareness
of their own systems of values, biases, beliefs and professional
prejudices which they bring with them, and which inevitably come into
play, due to their inexperience in working in contexts far removed from
their own healthcare culture and because they have not received
cultural awareness training or information in this regard. They are
unaware of the significance of cultural dominance in the way they carry
out their work and this impedes cultural consonance, as there is a
tendency to impose their own cultural system of beliefs, values and
behaviour patterns: “They have to be vaccinated, so their children won’t
die, with this vaccine they won’t get sick” IN –Informant Nurse- 56.

Other more bureaucratic activities, such as attempts to formalise

health records or include clinical histories become an arduous task,
difficult to impose on a society without a written language where the
principles of writing have only recently been introduced. As a nurse
explained, complaining about the diversity of healthcare professionals
involved; the lack of systematic recording of care received or treatment
prescribed: “We tried to organise the vaccinations as it was bloody
chaos!” IN 6.

The institutions tend to generalise about the indigenous populations

and provide only very unspecific materials. There are further
difficulties, which make it even harder to carry out competent care. The
healthcare professionals knowledge of the Achuar people is minimal
while their training does not cover this subject; healthcare professionals
do not speak the local language and are ignorant of the Achuar people’s
approach and understanding of the process of being sick, their
therapeutic journeys, or belief systems relating to health or their
cultural values. In some of their assessments and reporting, the strong
need for Healthcare professionals to be able to understand the local
language via an interpreter was confirmed, which implies a lot more
than simply translating the symptoms, as the population plays back
terminology they believe appropriate in order to gain access to the
desired health services. As can be seen by the case of a male patient
who demanded an air ambulance for his ‘ovarian’ pain. The colonist
doctor faced with this demand, complained that: “The Achuar just want
a light aircraft to go and see their shaman. And, if that happens with
Fernando (a mestizo name) who I think speaks good Spanish and
understands me well, imagine what happens with all the others!” MI -
Medical Informant- 40.

The health professionals put their heart and soul into it, but they
experience a lot of anxiety and sometimes even a sense of failure, as a
doctor, who had been working there for 3 months, said: “I don’t provide
good care. Here things aren’t done well, they aren’t done as they should
be. Nor do they take their medication, nor can I make myself
understood. I don’t feel comfortable as a professional giving this type of
care. I feel rather ‘disabled’, I feel rather useless … (silence) ‘Frustrated’,
that’s the word. I can’t reach them and I don’t know how to, however
hard I try … I have never encountered their culture before, I respect it,
but they should respect mine too!” MI 40

Acquiring cultural knowledge of the beliefs and values relating to

health, implies attempting to understand the Achuar people’s world
vision, how they interpret illness and how this in turn guides their
thoughts and practices. The lack of rigorous data on the incidence and
prevalence of disease, among the Achuar people, according to
biomedical categories, is eclipsed by the categories of illnesses
recognised by this group but which are not included in any biomedical
statistics. To this end, local health staff are trained in the diagnosis and
application of treatment according to biomedical definitions, in order to
attempt to gather epidemiological information and achieve more
successful results, nevertheless bias and poorly defined medical
categories are still found. For the Achuar people, treatment efficacy not
only defines the disease category but it also brings into question the
capabilities of the healthcare staff. Health professionals continue to
dispense a worryingly high level of pharmaceutical drugs even though
they know that they will not be taken by the Achuar people. “Here a lot
more drugs are administered than outside, because you know that
outside they know about them, they know how to [take them]… Once I
told a patient that he didn’t need any treatment or vitamins, and he
asked if I was going to keep them for myself, because these drugs were
theirs, and that they had been sent for the Achuar people. Since then I
don’t confront anyone, I don’t oppose them, if they want them I give
them to them” MI 5.

It was noted that greater work experience and contact with other
cultural groups brought greater cultural sensitivity, knowledge and
competence, but even so, this was very far from the required minimum
standards.

Indigenous medicine has its own diagnostic methods and therapeutic

resources, the most notable being ritual ceremonies and the use of
medicinal plants. A third tier in Achuar medicine includes the
equipment, drugs, furniture, tools, remedies and language that western
medicine, with the best of intentions, has brought with it. Thus, the
indigenous medical landscape would be incomplete if we did not include
biomedicine. Indeed, not only would it be incomplete, but, as this is the
most visible and the least hidden element, it becomes very difficult to
exclude biomedicine from what purists may understand Achuar
medicine to be, even if we wanted to.

Discussion:

The inclusion of cultural competence as part of the syllabus in health

training courses is uneven throughout LatinAmerica, where although it
is quite often included in nursing studies, it rarely figures in medical
degrees. And, while there are many studies, which assess cultural
competence among students, there are far less among working
healthcare professionals. Nevertheless, studies (Plaza del Pino &
Soriano, 2009) indicate that the lack of cultural competence among
working professionals is extremely worrying because healthcare
professionals who do not acquire cultural competence in training, do
not acquire such tools in their later working lives. Thus paternalist care
patterns and attitudes from the developed world, persist, exacerbated
by the gender variables present in healthcare professions and often with
religious overtones (Pulido, 2013).

It is crucial to improve healthcare professionals training programmes

by including, in the syllabus, the appropriate sociological and
anthropological content to promote the understanding of illness from
the patient’s socio-cultural context (Seguín, 1964). This needs to be
implemented for all healthcare students across the board: starting from
the lower tiers, so specifically among nursing studies for the purposes
of this study, and also more broadly to include all university healthcare
science degrees.

Flores Martos (2011) points out that interculturality, and thus cultural
competence, has become a ‘magic’ word, used arbitrarily for anything
and everything, regardless of its original meaning. It is now a ‘politically
correct’ concept accepted widely, and almost mechanically, as
something positive. Under the umbrella of interculturalism or cultural
competence, there is the risk of implementing politically integrationist
and unifying policy strategies which would modify the existing health
models.

This language has been adopted by development cooperation agencies,

indicating that the agencies themselves play a dominant role in
validating and establishing the concept via their activities and funding
(Hita, 2011, p. 64). The importance of establishing political
relationships with other countries –based on development cooperation
agreements which have been redefined by the recession (Grasiot, 2015)–
and the consequences of the global movement of populations, present
new challenges for healthcare providers, not only in destination
countries but also when these migrants arrive at our own health centres
– irrespective of whether the healthcare professionals migrate or if they
receive migrating citizens from other countries.

The cultural competence demanded of healthcare professionals, is also

an essential requirement for development cooperation agency staff, as
it is the agencies which design, develop and execute biomedical health
projects in areas which are culturally different. In order to improve
communication between the people engaged in the process and so that
institutions’ activities can be appropriate and effective, it is necessary
to foment the complex integration of knowledge, awareness, attitude
and skills. (Pulido 2010, Abad 2005).

At the same time, quality control measures of intercultural competence

levels in healthcare, need to be put in place, using instruments and
tools which can clearly establish the minimum required criteria.
Conclusion:

Ethnography is the tool, par excellence, for the study of cultural

competence in complex health contexts, as it enables us to identify the
socio-cultural dynamics which contribute to the acquisition of
intercultural competence. It is recommended that the demarcation
between disciplines be set aside to allow anthropology to bring to
medical science a more holistic and integrated understanding of the
process of what being ill means to the local populations.

Health and educational institutions, development agencies and

healthcare professionals all need to acquire the appropriate cultural
skills in order to offer greater efficacy to the diverse users of established
health systems. They need to be able to take into account both the local
dimensions and the individual patient’s needs. On the one hand, this
implies educational and training programmes which includes
sensitization to, and awareness training in, cultural diversity, and, on
the other hand, the ability to measure levels of cultural competence by
using appropriate tools (which are currently being developed). There is
a clear need to reinforce relationships, communications, and exchanges
between countries, their governments and the cooperation agencies, in
order to collect all the relevant information about citizens’ health, as
well as citizens’ own perceptions of their health and healthcare.

The absence of cultural awareness in the educational programmes’

syllabus for healthcare staff, combined with the lack of coordination
between the different institutions, significantly reduces the degree of
patient compliance, the quality of health services provided and the
attainment of Primary Health Care objectives. Furthermore, the
communication competence demanded of patients themselves is an
indication of the asymmetrical relationship which continues to exist
between healthcare providers and their patients

For all the actors involved, interculturality including cultural

competence, implies moving away from the dual and divided
(dichotomic) thought model which persists in the humanitarian
landscape: donor vs receptor, expatriate vs local, NGO vs state, giver vs
receiver, biomedical vs traditional (Abramowitz et al, 2015). This applies
to the understanding of all healthcare processes (including illness and
perceptions of illness) and means developing common objectives born
of participant processes and new instruments for validating the
healthcare received by patients. A close relationship between the State
and all the institutions and organisations involved is necessary more
than ever.
 Structural Equation Modeling of Cultural Competence of Nurses
Caring for Foreign Patients

Jung-Won Ahn, PhD

Introduction:

The numbers of short-term and long-term foreign residents in Korea are

continuously increasing, reaching 1.89 million in 2015, equivalent to
3.7% of the Korean population. Since the Korean government
announced legal standards for the medical care of foreigners' in 2009,
the total number of foreign patients having received care in Korea has
increased to approximately 29 million.

To deliver effective medical services to the increasing number of foreign

patients, medical institutes and medical professionals must be
prepared. Hospitals are opening foreign patients' clinics within their
institutions, developing dietary menus for employing medical tour
coordinators and professional interpreters to accommodate the care of
foreign patients. Foreign patients reported satisfaction with the quality
of care and nursing services provided in Korea; however, dissatisfaction
with communication, patient education, culturally respectful services,
and discriminatory attitude toward patients from Asian ethnic groups
were also reported.

Developed countries entered into a multicultural society prior to Korean

efforts in the last few decades to develop the cultural competence of its
medical professionals [5]. Cultural competence is defined as the ability
to understand ones' beliefs, values, behaviors, and customs and to
effectively work within the cultural context of a client [6]; it is an
essential skill for medical professionals. Nurses are the biggest
workforce in the medical profession and are the first point of contact for
many patients. Nurses are required to understand the cultures and
behaviors of foreign patients and to provide appropriate services for
their needs

As Korean society has historically been homogeneous, levels of cultural

competence among Korean nurses and nursing students have been
reported to be lower than those in other developed countries [7,8].
Nurses have a somewhat neutral or negative perception towards
foreigners, and they have psychological and emotional difficulties when
caring for foreign patients

A variety of positive and negative individual and organizational factors

may affect the cultural competence of nurses. A study of nurses showed
that experience caring for foreign patients and having an interest in and
a desire to learn about cultural competence can positively affect nurses'
cultural competence [7,8]. Attending foreign language courses as well
as fluency in foreign languages and experience in working with people
from other cultural backgrounds have all shown a positive influence on
cultural competence. Nurses showed higher levels of cultural
competence when resources such as patient education materials and
guidelines for foreign patients were available within their institutions
[7]. On the other hand, ethnocentric attitude [10] and intercultural
anxiety [11] negatively impacted nurses' cultural competence.

Since the 1990s, several theories have been developed to explain the
cultural competence of nurses; however, most of these theories fail to
account for factors that may influence cultural competence. Ryan and
Twibell [12] proposed a model of transcultural nursing immersion
experience that conceptualized a link between situational
predetermining factors, modifying factors, transitional factors, and the
outcomes of nurses' clinical experience in other cultures. The model
describes the process by which adaptation during the immersive
experience of nursing overseas can affect both the personal and
professional growth of nurses [12]. Assuming that cultural competence
is the result of transcultural nursing experience, this model can be used
as a theoretical framework to explain the relationship between cultural
competence and its influencing factors. The antecedent conditions in
the model, such as personal attitude and previous experience, and
transitional factors, such as social support and coping response, can
be viewed as factors influencing cultural competence.

A conceptual model of nurses' cultural competence was constructed, as

seen in Figure 1. Personal/professional experience and personal
characteristics, representing the situational predetermining factor,
were conceptualized as multicultural experience and ethnocentric
attitude. Considering this was a crosssectional study, social support
was counted as a predetermined rather than a transitional factor and
conceptualized as organizational cultural competence support. The
modifying factor of personal response was divided into intercultural
anxiety and uncertainty, reflecting nurses' emotional and cognitive
responses when caring for foreign patients. The adaption strategies
comprising the transitional factor are referred to here as coping
strategies, and adjustments in communication were included as
cultural competencies as their development relates to skill in cultural
sensitivity. The outcomes of personal and professional growth are
conceptualized as nurses' cultural competence.

Method:

This study employed a cross-sectional design and used structured

equation modeling. A hypothetical model of nurses' cultural
competence and its influencing factors was developed by
conceptualizing a theoretical framework and reviewing relevant
literature. The hypothesis was tested by analyzing collected survey
data.

Participants were nurses sought from 20 tertiary hospitals located in

Seoul and Kyung-Gi Do, Korea. Participants had to fulfill the following
criteria: experience of nursing more than 10 foreign patients, at least 1
year of clinical experience, understanding of the study purpose, and
consent to participate. A sample of between 5 and 20 participants per
measurable variable, or at least 200 samples per model, is required for
structural equation modeling studies [15]. Over 350 questionnaires
were distributed, and 311 questionnaires were returned. Among the
returned questionnaires, 34 were excluded from the analysis due to
missing data.

Permission to use and translate measurement tools was obtained by

email from the respective authors. All measurement tools originally
written in English were translated into Korean by a bilingual researcher
who had studied and worked overseas for over 10 years. During the
translation process, the researcher contacted authors via email to
clarify and confirm the meaning of some ambiguous words. The
translated tools were evaluated by 11 experts using content validity
index. The expert panel included five professors of nursing and six PhD
students majoring in nursing. The results of the content validity index
were all above .8. Revised measurement tools were back translated to
English to confirm the accuracy of the Korean translation.

Data were collected using structured self-report questionnaires

between May 15th, 2014, and June 20th, 2014. The researcher
contacted nursing departments in 20 tertiary hospitals in the Seoul and
Kyung-Gi areas. The researcher explained the purpose of the current
study and its data collection methods to nursing managers and
requested their participation in the study. Eligible participants were
recruited as per the inclusion criteria. The participants were asked to
complete the informed consent form and fill in the survey. Prepaid
envelopes were sent to nursing departments for the collection of data.
Signed consent forms and competed surveys were collected 2 weeks
later by post.

Data were analyzed using SPSS statistics version 21.0 and AMOS
version 21.0 (Armonk, NY, USA: IBM Corp.). Descriptive statistics were
used to report participants' general characteristics and measured
variables. Hypotheses were examined using structural equation
modeling analysis. Missing values were estimated using the
expectation-maximization method in SPSS. Internal reliability of the
measurement tools was tested using Cronbach a. Construct validity
was examined using CFA, and all items with standardized estimates of
less than .50 were removed. The normality of the data was tested using
the skewness and kurtosis, and the result satisfied the normality
requirement; therefore, a maximum likelihood analysis was used for
estimation. Correlations between variables were analyzed using
Pearson's correlation coefficients. The tolerance and varianceinflation
factor (VIF) was calculated to ensure multicollinearity. Further, the
composite construct reliability and average variance extracted of the
tool were calculated to test convergent validity.

Results:

Of the 275 participants, the average age was 31.15 ± 6.09 years, and
174 (63.3%) were single. For the level of education, 60 (21.8%) were
diploma graduates, 187 (68.0%) were university graduates, and 28
(10.2%) held a postgraduate qualification. The average length of clinical
experience was 8.29 years ± 6.04 years, and the majority of participants
were staff nurses (77.8%). Participating nurses were currently working
in medical (40.7%), surgical (28.0%), VIP/international clinic (9.5%),
intensive care unit (3.6%), and other departments (18.2%).

The numbers of foreign patients looked after by nurses were 50e99

(29.1%), 20e49 (28.0%), 10e19 (26.2%), and 100 or more (16.7%). The
average duration of caring for foreign patients was 3.15 ± 3.91 years.
Of 275 participants, only 62 nurses (22.5%) had attended education
programs related to caring for foreign patients. Types of program
attended were in-service (14.9%), workshop (3.6%), nursing school
(2.9%), and conference (2.2%)

For the goodness of fit test, c2 /df, GFI, AGFI, CFI, SRMR, and RMSEA
were tested for the hypothetical model. The results were c2 ¼ 141.35 (p
.001), c2 /df ¼ 2.88, GFI ¼ .93, AGFI ¼ .87, CFI ¼ .92, SRMR ¼ .05,
and RMSEA ¼ .08, most of which satisfied the recommended criteria
for the fitness indices. The modification index between cultural
awareness and cultural skills was 20.17, which is greater than the
recommended cutoff of 5e10. The theoretical model was modified by
allowing covariance, adding a path between the errors of measurement
of two latent endogenous variables. The modification index decreased
to less than 9.6 after the modification, and the fitness indices for the
modified model improved to c2 ¼ 111.97 (p < .001), c2 /df ¼ 2.33, GFI
¼ .94, AGFI ¼ .89, CFI ¼ .94, SRMR ¼ .05, and RMSEA ¼ .

The path coefficient of the final model was evaluated. Among the 18
hypotheses in the hypothetical model, 12 (H1eH3, H5, H7e8, H11,
H13eH16, and H18) were confirmed to have statistically significant
direct, indirect, and total effects. H4 (impact of multicultural experience
on intercultural anxiety), H6 (impact of organizational cultural
competence support on intercultural anxiety), H9 (impact of
ethnocentric attitude on coping strategy), H10 (impact of organizational
cultural competence support on coping strategy), H12 (impact of
intercultural anxiety on coping strategy), and H17 (impact of
intercultural anxiety on cultural competence) failed to show any total
effects.

Direct, indirect, and total effects of variables and statistical significance

are shown in Table 5. Multicultural experience, ethnocentric attitude,
and organizational cultural competence support had direct effects on
intercultural uncertainty, explaining 18.3% of the variability in
intercultural uncertainty scores.

Ethnocentric attitude had direct, indirect, and total effects on

intercultural anxiety. Intercultural uncertainty had direct and total
effects on intercultural anxiety. Ethnocentric attitude and intercultural
uncertainty explained 8.6% of the variance in intercultural anxiety
scores.

Multicultural experience and intercultural uncertainty had direct,

indirect, and total effects on coping strategy, explaining 19.2% of the
variance in coping strategy scores.

All exogenous variables, except for intercultural anxiety, had

statistically significant effects on cultural competence. Multicultural
experience, ethnocentric attitude, organizational cultural competence
support, and intercultural uncertainty had direct, indirect, and total
effects on cultural competence. Coping strategy had direct and total
effects on cultural competence. These variables explained 59.1% of the
variance in cultural competence scores

Conclusion:

This study constructed and reviewed a theoretical model designed to

explain the cultural competence of nurses who have previous
experience of caring for foreign patients. The hypothetical model was
based on the transcultural nursing immersion experience model,
anxiety/uncertainty management theory, and the results of literature
review. The model was revised through CFA and conformance
verification, and the revised model was found to be adequate in
predicting nurses' cultural competence. Furthermore, the model
supported the direct paths proposed in 12 out of the 18 hypotheses
tested in the present study. Factors that have a direct and indirect
impact on nurses' cultural competence are multicultural experience,
ethnocentric attitude, organizational cultural competence support, and
intercultural uncertainty. Further, coping strategy had only a direct
impact on cultural competence. When combined, all of these variables
explained 59.1% of the variance in the cultural competence.

It is suggested that, to increase nurses' cultural competence, there

should be a standardized interventional program that would teach
cultural characteristics and nonverbal communication along with more
exchange programs with overseas nursing schools or hospitals to
provide nurses with more opportunities to experience various cultures
both directly and indirectly. If nurses paid greater attention to foreign
patients and acquire cultural experience and knowledge, they would be
less uncertain and would have positive attitude towards different
cultures. Consequently, nurses would be able to increase their cultural
competence and confidence in caring for foreign patients. As medical
agencies are in their infancy in developing cultural competence, both
organizational and individual efforts are required to improve cultural
competence. It is suggested that medical organizations recruit experts
and develop materials to support foreign patient care. By making such
efforts and increasing individual awareness of and attention to the
growing number of foreign patients, nurses will be able to make steady
improvements on the cultural competence required to care for foreign
patients.
 Attitudes of undergraduate nursing students to cultural diversity:
(Portuguese-Spanish) in a transboundary context.

E. Begoña García-Navarroab* & Emilia Martins Teixeira da Costac

Introduction

In the field of nursing, interpersonal relationships are part of everyday

life; in this interactive area the culture of care recipients and nurses
themselves is crucial in establishing an effective relationship and
achieving cultural competence of care. University teachers, responsible
for the training of future professionals, need to identify the students’
position on the phenomenon of diversity, and how it influences the care
that will be provided to future citizens. Although European common
competences for the Degree in Nursing are set (Burjales, 2005),
addressing responsibilities with regard to cultural care are different in
each nursing school.

Like much of society, nursing students have an attitude towards people

from other cultural backgrounds, determined by stereotypes and
prejudices generated largely by ignorance, which can hinder their
future professional work if we cannot plan a competent educational
intervention. Following the conclusions made by the authors of the
literature reviewed (Moran, Abramson & Moran, 2014; Sosa, Fernandez
& Zubieta, 2014; Sanchez & Rondon, 2013; Fernández, Gómez-
Fraguela, Romero & Villar, 2010; Souza & De Souza, 2014; Alonso,
Navarro & Lidon, 2014; Rúa, 2009; Gonçalves, 2012), it seems
appropriate in this study not only to explore and learn about the
attitudes of students in our school (taking into account the knowledge
they have regarding cultural care), but also to compare this with
another society, another environment with a different experience in the
inclusion process of immigrant citizens. An example of this is our
neighboring country, Portugal, in particular the Algarve region.

The Algarve has a history of migratory settlement very different from the
rest of the country, mirroring what happens in the tourist areas of our
country apropos elite immigration (Bäckström, 2012), characterized by
being from the European Community nations – British, German and
French - and over 60 years old; this community being 19.93% of the
over 65 population in the Algarvian region. Apart from elite
immigration, accepted by society for its great purchasing power, this
region also has economic migration from the PALOP countries, Brazil
and currently also receiving developing migratory flows from eastern
countries, in particular the Ukraine. This favors cross-border
comparison as to the attitudes of Portuguese natives with native
Spanish.
Methodology:

This is a descriptive observational quantitative design of populations by

means of surveys, as rated by Montero and León (2005). This design is
intended to describe how the attitudes of undergraduate nursing
students alter depending on other variables. The population subject to
study comprises of nursing students from the University of Huelva and
the University of the Algarve (Faro). When the two syllabi were analyzed,
we noticed that both have a commitment to cultural care, each of them
following a different approach: on the one hand, the curriculum of the
Escola Superior de Saúde do Algarve includes cultural diversity
explicitly, with the subject “Socio-Anthropology of Health”, which is
given in the second semester of the first year (having a total of four
credits); on the other hand, at the University of Huelva the nursing
department launched the subject “Nursing in the New Challenges in
Health” several years ago, (despite being a six credit subject, the topic
dedicated to this skill is only three hours’ duration, so it is insufficient
to culturally educate the students in this area).

A sample of 180 students had to meet two specific criteria to be included

in the research, the first of which was to belong to one of the two
selected universities and have studied the subject of cultural diversity.
The selection was a random sample size in both populations, the
sampling error was assumed ±3.5% (p = 0.5; confidence level = 95%).
We therefore had two groups: 95 Spanish students and 85 Portuguese
students; men and women, matched in both age (Spain: mean 22.5 and
standard deviation of 5.72; Portugal: mean 21.39 and standard
deviation of 4.77), academic course and place of residence (rural or
urban), the age range for both nationalities being from 18 to 59 years
and distributed proportionally.

To obtain the data a questionnaire previously developed and validated

was used (García-Navarro, 2006; GarcíaNavarro, 2015). The
questionnaire has four major categories with their correspondent
variables, which allow us to evaluates attitudes:

Knowledge about immigration etiology (causes of immigration,

immigrants’ health rights and obligations, administrative differences)

Knowledge about the most prevalent diseases in foreign and native

population (comparative ranking native/immigrant made by the
students) x Knowledge about most prevalent health issues in foreign
and native population (comparative ranking native/immigrant made by
the students)
Strategies developed by nursing students so as to conduct transcultural
care (access problems to the health system, professionals’ issues in the
nurse-patient relationship, nurses’ strategies in cultural care)

First, a descriptive analysis was performed and after these variables

were crossed with socio-demographic variables, student year,
nationality and the main variable. The standardized coefficient was
calculated to assess the degree of influence of the different variables on
the results achieved in each case.

For the development of research, an informed consent and student

information sheet was prepared, all the students agreeing to participate
in the research. The relevant ethical considerations and the principles
itemized in the Declaration of Helsinki were taken into account.

Results:

The results are presented in terms of the objectives set in the study. To
assess attitudes, four categories were generated by crossing each with
the independent variable Nationality (Luso-Spanish), besides this, they
were crossed with other independent variables: age, gender, grade, and
place of residence of the subjects.

Knowledge about immigration etiology

This category was identified to ascertain the attitude of the subjects to

foreign individuals, depending on the etiology of the migration process.
Analyzing this variable, we found significant differences between the
attitudes of Spanish students compared to those of the Portuguese, the
most important of which is the variable “health reasons”; 100% of
Spanish students interviewed thought that is an acceptable reason to
emigrate to other country, compared to 58.8% of the Portuguese
students.

Knowledge about most prevalent diseases in the foreign and native

population

This category was created to determine the differences in terms of

prevalent diseases of the foreign population. Since the objective of this
study was to analyze attitudes to cultural diversity, it was considered
important to analyze not only the opinion of the subjects regarding
common diseases in the immigrant population, but was also relevant to
understand how they compare with the common diseases of the native
population in each country. Thus, it was possible to deduce the attitude
towards some diseases in the “others” as a projection of what is not
desired for the native population. To calculate this variable, we asked
nursing students to rank each pathology on a scale of 0 - 10 in terms
of prevalence in both populations (immigrant and native). The most
significant differential in this category was infectious diseases: Spanish
students evaluated these pathologies as being three times more
prevalent in the foreign population, however, this was less obvious with
the Portuguese students (being 1.5 times more prevalent. The opposite
was found with cardiovascular disease, it was ranked higher in the local
population that in foreigners, whether Spanish or Portuguese. The most
important breakthrough became apparent in the analysis of nutritional
problems, where the Spanish clearly identified it as a foreign problem,
while in Portugal, they saw only 0.66 differential over its population.

Knowledge about the most prevalent health issues in foreign and native
population

In this category we found similar results to the previous one, the only
difference in this was that we analyzed those foreigners’ characteristics
that induce health problems such as drug addiction, HIV, hepatitis or
family planning, not common pathologies.

Strategies developed by nursing students so as to conduct transcultural

care

This category was created in order to ascertain the position of students

tending to the foreign population, and how the nurse should interact
with them. Predictably significant results were not only in the main
independent variable (Spanish/Portuguese nationality), but also the
variable “academic year studied”, the most mature students being more
inclusive and not just the ones who studied cultural diversity

Discussion:

From the results of this research we can confirm that the cultural
context that frames the academic curriculum of nursing degree
influences the attitudes of its students, despite being neighbors,
involving different cultural characteristics which affect perceptions,
attitudes and behaviors. Attitudes were measured across four
categories with corresponding variables; analyzing the category that
deals with student attitudes about the migration etiology shows that
96.9% of Spanish students thought that the main reason for emigrating
to Spain was economic, reflecting the current reality of Huelva province,
while the Portuguese students scored 12.3% lower, since Algarvian
immigration is different, elite migration being more prevalent than
economic immigration. However, even more remarkable is the attitude
shown by Spanish respondents to health tourism, because 100% of
respondents thought that is why foreigners choose our country as a
destination, whereas only 50% of the Portuguese share this perception,
despite the migration profile characterizing them as consistent with the
definition of health tourism.

Some studies (Navarro et al., 2014) show the opposite, indicating that
immigrants residing in Spain use fewer resources than the natives. The
Spanish population visits the doctor more frequently than immigrants:
the immigrants use the primary health care doctor less (12.7% versus
57.75%) and the consultant. The only anomaly is the immigrant
population use of emergency services (a 15.9% increase): they do not
know Spanish healthcare protocol, and hours/working conditions.

A further attitude evident from the results is that Spanish students

have about prevalent diseases, identifying infectious and contagious
ailments as the most frequent in the foreign population, and
cardiovascular diseases and mental health for the Spanish population.
This concept is reproduced in Spanish society, despite being
incompatible with the actual data (Belmonte, Czech & Arjona, 2012).
The main reasons why foreign people go to the doctor, as with the native
population, is due to skeletal and muscular diseases, respiratory
disorders, gastrointestinal problems or accidental injuries (frequently
linked to their social and labor situation).

Psychosomatic symptoms arising from migration process should be

added to work-related diseases. The data analyzed in this study is
contradictory, i.e. Spanish students consider mental health issues
more frequent in the native population. With the category “health
problems”, the trend is repeated, resulting in the mental health
problems like anxiety and depression being identified as “Spanish”
problems, however students from the neighboring country (Portugal)
did not agree; there was a statistically significant difference (p = 0.00)
as the Portuguese students perceived these problems as similar in both
populations (foreign/native), since the profile for immigration in the
Algarve is mostly from the European Community.

If we refer to previous research (Muñoz-de Bustillo & Anton, 2010), the

immigrant and native population use medical services for the same
reasons, dependent on their employment sector, which proves that they
are not a source of rare disease and danger to public health. So, once
again, the attitude to the “other” prevails over the evidenced data. The
results of this investigation underline this concept, considering that
Spanish students have identified tuberculosis and malnutrition as
prevalent health problems in the foreign population, and family
planning, childbirth and postpartum the main issues in the native
population (contradictory to the survey of Navarro et al.,2014 which
claims that immigrants have unimportant health problems, so rarely
visiting the consultant, only outnumbering Spaniards in visits to the
gynecologist and pediatrician). The reason is obvious: they are
responsible for the rising birth rates. With regard to the attitude to
maternal and pediatric problems, there is a great difference in the
attitude of the Portuguese students, as the profile of the foreign
population of the Algarvian region falls outside of the fertility range.

Finally, discussing the strategies that students use to care for

foreigners, we observed significant differences not only in terms of
nationality, Spanish students being more inclusive and culturally
competent (prioritizing actions and generating empathy 30% more than
the Portuguese students), but also the respondents’ academic year
indicates that strategies are more culturally competent later in the
academic course, although the topics related to the phenomenon are
offered in the first year; this happens in both countries, so it is perceived
that what really makes sensitive students is not only knowledge but
most of all maturity in the essential concepts of the nursing discipline.

Conclusion:

Given the results obtained in the study, it was found that the cultural
context is essential to the development of attitudes to immigration; data
showed that the cross-border area (Huelva/Algarve) has totally different
migration profiles, and elite migration is not considered a threat as
against economic or health immigration, that is perceived as such,
hence the attitudes of Portuguese students stand out as more equitable
and inclusive.

Considering that societal values and beliefs seem to have a bigger

impact on the development of the nursing students’ attitudes than the
information given during the first years of academic education, the
introduction of this content in the fourth year would thus be an
alternative to ensure cultural competency, in addition to regular
meetings with teaching staff to ensure cross-cultural competence is a
common thread throughout the degree.

It is important to remember that nursing care is, above all, a

communicative act and it is through care that meaningful and
respectful relationships with patients are developed. Students should
strive to increase awareness of their culture and incorporate that
knowledge into their nursing role, losing the fear of the unknown to
accept and understand the need to integrate Intercultural
Communicative Competence into their general competence, the right to
maintain a cultural identity without negating that of the “other”,
enriching each other with new knowledge.
 Predictors of cultural competence among nursing students in the
Philippines: A cross-sectional study

Jonas PreposiCruzPhD, MAN, BSN, RNaJoel C.EstacioMAN, BSN, RN,

RMbCristeta E.BagtangMPH, MAN, BSN, RNcPaolo C.ColetPhD, MAN,
BSN, RN, RMa

Introduction:

With the continued immigration of Filipino nurses and increasing

globalization, there is a need for globally competent nurses. Thus, the
development of cultural competence among nursing students is critical
in their preparation to assume their future responsibilities in the
profession.

This study investigated the predictors of cultural competence among

nursing students in the Philippines.

Design

This is a descriptive, cross-section study.

Participants and Setting

This study included 332 Bachelor of Science in nursing students in

three nursing schools situated in the northern Philippines.

Methods

The Cultural Capacity Scale was used to gather data from the
respondents. The demographic characteristics and cultural
background of the students were entered in a regression analysis to
predict their cultural competence.

Findings

From the 350 questionnaires distributed, 332 were sufficiently

responded to, and/or retrieved, giving a 94.9% response rate. A
majority of the respondents was female (78.9%), while the mean age
was 20.04 ± 3.19 years. Nearly half the respondents (44.6%) were in the
final year of the BSN program. In terms of cultural background, the
majority of the respondents had not received prior diversity training
(52.4%), had not experienced taking care of culturally diverse patients
in the past 12 months (63.3%), and did not live in an environment with
culturally diverse people (59.0%). However, more than half of them
(68.1%) had encountered patients belonging to the special population
group during their training in the past 12 months

From the 350 questionnaires distributed, 332 were sufficiently

responded to, and/or retrieved, giving a 94.9% response rate. A
majority of the respondents was female (78.9%), while the mean age
was 20.04 ± 3.19 years. Nearly half the respondents (44.6%) were in the
final year of the BSN program. In terms of cultural background, the
majority of the respondents had not received prior diversity training
(52.4%), had not experienced taking care of culturally diverse patients
in the past 12 months (63.3%), and did not live in an environment with
culturally diverse people (59.0%). However, more than half of them
(68.1%) had encountered patients belonging to the special population
group during their training in the past 12 months

Conclusion

Nursing education should devise strategies to ensure future culturally

competent Filipino nurses. Considering the fact that most of the Filipino
nurses will potentially work overseas, they should be well prepared to
provide competent care that is culturally sensitive.
 Cultural Diversity
Ethnicity: What is Ethnicity?
Ethnicity is based on a group (called an ethnic group) that is normally
based on similar traits, such as a common language, common heritage,
and cultural similarities within the group. Other variables that play a
role in ethnicity, though not in all cases, include a geographical
connection to a particular place, common foods and diets, and perhaps
a common faith. Race is a word with similar meaning though describing
more physical traits, as opposed to the cultural traits of ethnicity.
Race: What Does Race Mean?
Race is similar to ethnicity, but relates more to the appearance of a
person, especially the color of their skin. It is determined biologically,
and includes other inherited genetic traits such as hair and eye color
and bone and jaw structure, among other things.
Nationality: Which Nationality Are You?
Most of the time, nationality refers to the place where the person was
born and/or holds citizenship. However, often times nationality can be
determined by place of residence, ethnicity, or national identity. If a
person was born in Country A but immigrated to Country B while still
a toddler (yes, with their family), he or she might identify more with the
Country B nationality, having been raised there.
Another point regarding nationality is that there are some nations that
don’t have a state, or international recognition as such, yet people may
still point at it as the source of their nationality, such as the
Palestinians, the Kurds, and the Tamils.
Article 15 of the Universal Declaration of Human Rights states that
“Everyone has the right to a nationality,” and “No one shall be arbitrarily
deprived of his nationality nor denied the right to change his
nationality.” (They’re a bit late in switching to gender-neutral pronouns)
Now, let me throw a few more terms at you to add to the confusion:
Citizen
A citizen is typically either born in the country, born to citizens of the
country while abroad, married to a citizen of the country, or becomes
a citizen through the naturalization process. A citizen is a complete
member of the nation, able to vote and hold elected office.
National
A national is a person born in an area that is in the possession of a
country, but not part of its general administrative area. For example,
American Samoa is an unincorporated territory of the United States,
and its people are considered U.S. nationals; American Samoans may
not vote in U.S. presidential elections, or hold elected office in the U.S.,
but are entitled to free and unrestricted entry into the United States.
Heritage
Heritage can overlap on the ethnicity and nationality a bit at times, but
it generally refers to the ancestors of a person, and what they identified
with. For example, a child born to naturalized U.S. citizens hailing from
Venezuela could say they have a Venezuelan heritage, even if they don’t
share the ethnicity (perhaps they can’t speak Spanish), and they are
American as far as nationality.
Culture
Culture is similar to ethnicity, yet really more of a microcosm of it.
It may involve one trait or characteristic, sort of like a subset of the
various traits that make up an ethnicity. Perhaps a person may be
ethnically Jewish, or they could subject themselves to simply one or two
things of Jewish culture, such as wearing a kippah; this person may
not necessarily relate with the entire macro-ethnicity that is being
Jewish.
Identity
Identity is whatever a person identifies with more, whether it be a
particular country, ethnicity, religion, etc. I read this great article by
Zeba Khan on MuslimMatters.org: she was born in America, to a
Pakistani father and an American woman of Irish descent; she doesn’t
identify with either Pakistan or Ireland (too white for Pakistan, too dark
for Ireland), and not much with America (she wears the hijab and eats
halal). What she does identify with is her Muslim faith, which is similar
across boundaries throughout the world.
Race vs Ethnicity vs Heritage vs. Culture: Wrapping Up
When questions are asked in the wrong manner (where are you from?),
there usually is no offensive motive intended. These are colloquial terms
that have been accepted into common parlance.
Once you understand and recognize the differences between these
words, such as race vs ethnicity, it is important to remember to not get
offended when someone approaches you with their mis-worded
question. Just as we can better ourselves by learning the politically-
correct phrases to ask, we also need to understand others and look at
pure intent, rather than semantics.
 Understanding Transcultural Nursing

A PATIENT'S BEHAVIOR is influenced in part by his cultural

background. However, although certain attributes and attitudes are
associated with particular cultural groups as described in the following
pages, not all people from the same cultural background share the same
behaviors and views.
When caring for a patient from a culture different from your own, you
need to be aware of and respect his cultural preferences and beliefs;
otherwise, he may consider you insensitive and indifferent, possibly
even incompetent. But beware of assuming that all members of any one
culture act and behave in the same way; in other words, don't
stereotype people.
The best way to avoid stereotyping is to view each patient as an
individual and to find out his cultural preferences. Using a culture
assessment tool or questionnaire can help you discover these and
document them for other members of the health care team.
Keeping the caveat about stereotyping in mind, let's take a look at how
people from various cultural groups tend to perceive some common
behaviors and key health care issues.

Space and Distance

People tend to regard the space immediately around them as an

extension of themselves. The amount of space they prefer between
themselves and others to feel comfortable is a culturally determined
phenomenon.
Most people aren't conscious of their personal space requirements—it's
just a feeling about what's comfortable for them—and you may be
unaware of what people from another culture expect. For example, one
patient may perceive your sitting close to him as an expression of
warmth and caring; another may feel that you're invading his personal
space.
Research reveals that people from the United States, Canada, and Great
Britain require the most personal space between themselves and
others. Those from Latin America, Japan, and the Middle East need the
least amount of space and feel comfortable standing close to others.
Keep these general trends in mind if a patient tends to position himself
unusually close or far from you and be sensitive to his preference when
giving nursing care.

Eye Contact

Eye contact is also a culturally determined behavior. Although most

nurses are taught to maintain eye contact when speaking with patients,
people from some cultural backgrounds may prefer you don't. In fact,
your strong gaze may be interpreted as a sign of disrespect among
Asian, American Indian, Indo-Chinese, Arab, and Appalachian patients
who feel that direct eye contact is impolite or aggressive. These patients
may avert their eyes when talking with you and others they perceive as
authority figures.
An American Indian patient may stare at the floor during conversations.
That's a cultural behavior conveying respect, and it shows that he's
paying close attention to you. Likewise, a Hispanic patient may
maintain downcast eyes in deference to someone's age, sex, social
position, economic status, or position of authority. Being aware that
whether a person makes eye contact may reflect his cultural
background can help you avoid misunderstandings and make him feel
more comfortable with you.

Time and Punctuality

Attitudes about time vary widely among cultures and can be a barrier
to effective communication between nurses and patients. Concepts of
time and punctuality are culturally determined, as is the concept of
waiting.
In U.S. culture, we measure the passing and duration of time using
clocks and watches. For most health care providers in our culture, time
and promptness are extremely important. For example, we expect
patients to arrive at an exact time for an appointment—despite the fact
that they may have to wait for health care providers who are running
late.
For patients from some other cultures, however, time is a relative
phenomenon, and they may pay little attention to the exact hour or
minute. Some Hispanic people, for example, consider time in a wider
frame of reference and make the primary distinction between day and
night but not hours of the day. Time may also be marked according to
traditional times for meals, sleep, and other routine activities or events.
In some cultures, the “present” is of the greatest importance, and time
is viewed in broad ranges rather than in terms of a fixed hour. Being
flexible in regard to schedules is the best way to accommodate these
differences.
Value differences also may influence someone's sense of time and
priorities. For example, responding to a family matter may be more
important to a patient than meeting a scheduled health care
appointment. Allowing for these different values is essential in
maintaining effective nurse/patient relationships. Scolding or acting
annoyed when a patient is late would undermine his confidence in the
health care system and might result in more missed appointments or
indifference to patient teaching.

Touch
The meaning people associate with touching is culturally determined
to a great degree. In Hispanic and Arab cultures, male health care
providers may be prohibited from touching or examining certain parts
of the female body; similarly, females may be prohibited from caring
for males. Among many Asian Americans, touching a person's head
may be impolite because that's where they believe the spirit resides.
Before assessing an Asian American patient's head or evaluating a
head injury, you may need to clearly explain what you're doing and
why.

Always consider a patient's culturally defined sense of modesty when

giving nursing care. For example, some Jewish and Islamic women
believe that modesty requires covering their head, arms, and legs with
clothing. Respect their tradition and help them remain covered while
in your care.

Communication

In some aspects of care, the perspectives of health care providers,

patients, and families may be in conflict. One example is the issue of
informed consent and full disclosure. For example, you may feel that
each patient has the right to full disclosure about his disease and
prognosis and advocate that he be informed. But his family, coming
from another culture may believe they're responsible for protecting and
sparing him from knowledge about a serious illness. Similarly, patients
may not want to know about their condition, expecting their relatives
to “take the burden” of that knowledge and related decision making. If
so, you need to respect their beliefs; don't just decide that they're wrong
and inform the patient on your own.
You may face similar dilemmas when a patient refuses pain medication
or treatment because of cultural or religious beliefs about pain or his
belief in divine intervention or faith healing. You may not agree with his
choice, but competent adults have the legal right to refuse treatment,
regardless of the reason. Thinking about your beliefs and recognizing
your cultural bias and world view will help you understand differences
and resolve cultural and ethical conflicts you may face. But while caring
for this patient, promote open dialogue and work with him, his family,
and health care providers to reach a culturally appropriate solution. For
example, a patient who refuses a routine blood transfusion might
accept an autologous one.

Biologic Variation

Along with psychosocial adaptations, you also need to consider

culture's physiologic impact on how patients respond to treatment,
particularly medications. Data have been collected for many years
regarding different effects some medications have on persons of
diverse ethnic or cultural origins. For example, because of genetic
predisposition, patients may metabolize drugs in different ways or at
different rates. For one patient, a “normal dose” of a medication may
trigger an adverse reaction; for another, it might not work at all.
(Think of how antihypertensive drugs don't work as well for African
Americans as they do for white ones.) Culturally competent
medication administration requires you to consider ethnicity and
related factors—including values and beliefs about herbal
supplements, dietary intake, and genetic factors that can affect how
effective a treatment is and how well patients adhere to the treatment
plan.

Environmental Variation

Various cultural groups have wide-ranging beliefs about man's

relationship with the environment. A patient's attitude toward his
treatment and prognosis is influenced by whether he generally believes
that man has some control over events or whether he's more fatalistic
and believes that chance and luck determine what will happen. If your
patient holds the former view, you're likely to see good cooperation with
health care regimens; he'll see the benefit of developing behavior that
could improve his health. Some American Indians and Asian Americans
are likely to fall into this category.
In contrast, Hispanic and Appalachian patients tend to be more
fatalistic about nature, health, and death, feeling that they can't control
these things. Patients who believe that they can't do much to improve
their health through their actions may need more teaching and
reinforcement about how diet and medications can affect their health.
Provide information in a nonjudgmental way and respect their fatalistic
beliefs.

Cultural Competence
Cultural competence in healthcare refers to the ability for healthcare
professionals to demonstrate cultural competence toward patients with
diverse values, beliefs, and feelings. This process includes
consideration of the individual social, cultural, and feelings needs of
patients for effective cross-cultural communication with their health
care providers.[2] The goal of cultural competence in health care is to
reduce health disparities and to provide optimal care to patients
regardless of their race, gender, ethnic background, native languages
spoken, and religious or cultural beliefs. Cultural competency
training is important in health care fields where human interaction is
common, including medicine, nursing, allied health, mental health,
social work, pharmacy, oral health, and public health fields.
The term cultural competence was first used by Terry L. Cross and
colleagues in 1989,[1] but it was not until almost a decade later that
health care professionals began to be formally educated and trained in
cultural competence. In 2002, cultural competence in health care
emerged as a field[3] and has been increasingly embedded into medical
education curriculum since then.
Cultural competence is defined as a set of congruent
behaviors, attitudes, and policies that come together in a system,
agency, or among professionals and that enables them to work
effectively in cross-cultural situations.[1] Essential elements that enable
organizations to become culturally competent include valuing diversity,
having the capacity for cultural self-assessment, being conscious of the
dynamics inherent when cultures interact, having institutionalized
cultural knowledge, and having developed adaptations to service
delivery reflecting an understanding of cultural diversity.[1] By
definition, diversity includes differences in race, ethnicity, age, gender,
size, religion, sexual orientation, and physical and mental
ability.[5] Accordingly, organizations should include these
considerations in all aspects of policy making, administration, practice,
and service delivery.[6]
Cultural competence involves more than having sensitivity or
awareness of cultures. It necessitates an active process of learning and
developing skills to engage effectively in cross-cultural situations and
re-evaluating these skills over time.[7] Cultural competence is often used
interchangeably with the term cultural competency.
A healthcare system, sometimes referred to as health system, is the
organization of people, institutions, and resources that deliver
healthcare services to meet the health needs of target populations. A
culturally competent health system not only recognizes and accepts the
importance of cultural diversity at every level but also assesses the
cross-cultural relations, stays vigilant towards any changes and
developments resulting from cultural diversity, broadens cultural
knowledge, and adapts services to meet the needs that are culturally-
unique.[1]
As more and more immigrants are coming to America, healthcare
professionals with good cultural competence can use the knowledge
and sensitivity that they obtain in order to provide holistic care for
clients from other countries, who speak foreign languages.[8] The
challenges for American healthcare systems to meet the health needs
of the increasing number of diverse patients are becoming very obvious.
The challenges include but are not limited to the following:[1][9]

 Sociocultural barriers
 Poor cross-cultural communication
 Language barriers
 Attitudes toward healthcare
 Beliefs in diagnosis and treatment
 Lack of cultural competence in the design of the system
Leadership and workforce
In response to a rapid growth of minorities population in the United
States, healthcare organizations have responded by providing new
services and undergoing health reforms in terms of diversity in
leadership and workforce. Despite improvements and progress seen in
some areas, minorities are still underrepresented within both
healthcare leadership and workforce.[2] To improve the weak minorities
representation in leadership and workforce, an organization must
acknowledge the importance of cultures, be sensitive to cultural
differences, and establish strategic plans to incorporate cultural
diversity.
According to the national survey of the U.S. healthcare leaders
conducted by the search firm Witt/Kieffer, respondents viewed diverse
leadership as a valuable business builder. They associated it with
improved patient satisfaction, successful decision-making, improved
clinical outcomes, and stronger bottom line.[10]
To successfully recruit, mentor, and coach minority leaders in
healthcare, it is important to keep these social science principles and
cultural values in mind:[11]

 Branding - how health care leaders brand diversity in their

organizations? Without inclusion, branding would not be complete
 The concepts of self-categorization and "othering"
 Lack of leadership commitment - diversity and inclusion should be
an imperative of their organization
 The compelling national demographics of healthcare leadership and
workforce.
Clinical practice
To provide culturally sensitive patient-centered care, physicians should
treat each patient as an individual, recognizing and respecting his or
her beliefs, values and care seeking behaviors.[12] However, many
physicians lack the awareness of or training in cultural competence.
With the constantly changing demographics, their patients are
increasingly getting diverse as well. It is utterly important to educate
physicians to be culturally competent so that they can effectively treat
patients of different cultural and ethnic backgrounds.
In response to the increasingly diverse population, several states
(WA, CA, CT, NJ, NM) have passed legislation requiring or strongly
recommending cultural competency training for physicians.[13] In 2005,
New Jersey legislature enacted a law requiring all physicians to
complete at least 6 hours of training in cultural competency as a
condition for renewal of their New Jersey medical license, whether or
not they actively practice in New Jersey.[14] Physicians' responses to this
CME requirement varied, both positively and negatively. But the overall
feedback was positive towards the outcomes of participation in and
satisfaction with the programs.[15]
In order to provide culturally competent care for their diverse patients,
physicians should at the first step understand that patients' cultures
can influence profoundly how they define health and illness, how they
seek health care, and what constitutes appropriate treatment. They
should also realize that their clinical care process could also be
influenced by their own personal and professional experiences as well
as biomedical culture.[12] Dr. Like pointed out in one of his articles that
"in transforming systems, transcultural nurses, physicians, and other
health care professionals need to remember that cultural humility and
cultural competence must go hand in hand."[16]
Research
Cultural competence in research is the ability of researchers and
research staff to provide high quality research that takes into account
the culture and diversity of a population when developing research
ideas, design, and methodology. Cultural competence can be crucial for
ensuring that the sampling is representative of the population and
therefore application to a diverse number of people.[17] It is important
that a study's subject enrollment reflect as closely as possible the target
population of those affected by the health problem being studied.
In 1994, the National Institutes of Health established policy (Public Law
103-43) for the inclusion of women, children, and members of minority
groups and their subpopulations in biomedical and behavioral clinical
studies.[18] Overcoming challenges to cultural competence in research
also means that institutional review boardmembership should include
representatives of large communities and cultural groups as
representatives.
Medical education
The critical importance of training medical students to be future
culturally competent physicians has been recognized by accrediting
bodies such as the Accreditation Council on Graduate Medical
Education[19] (ACGME) and the Liaison Committee on Medical
Education (LCME) and other medical organizations such as American
Medical Association (AMA) and the Institute of Medicine (IOM).
Culture is definitely beyond ethnicity and race. Healthcare
professionals need to learn about the tolerance of other's beliefs.
Professional care is about meeting patients' needs even if they do not
align with the caretaker's personal beliefs. Discovering one's own beliefs
and their origin (from upbringing or modeling of parents, for example)
helps understand what is believed and moderates actions at times when
others are cared for with different beliefs. As a result, it is essential for
healthcare professionals to practice cultural competence and recognize
the differences as well as cultural sensitivities to provide holistic care
for the patients.
According to the LCME standard for cultural competence, "the faculty
and students must demonstrate an understanding of the manner in
which people of diverse culture and belief systems perceive health and
illness and respond to various symptoms, diseases, and
treatments."[20] In response to the mandates, medical schools in the
U.S. have incorporated teaching cultural competency in their curricula.
A search on cultural competency in the curriculum of a medical school
revealed that it was covered in 33 events in 13 courses in spring 2014.
A similar search was performed on health disparities yielding 16 events
in 10 courses covering the topic.
The cultural competence curriculum is intended to improve the
interaction between patients and physicians and to assure that
students will possess the knowledge, skills, and attitudes that enable
them to provide high quality and culturally competent care to patients
and their families as well as the general medical community.[21]
Patient education
Patient-Physician communication involves two sides. While physicians
and other healthcare providers are being encouraged or required to be
culturally competent in delivery of quality healthcare, it would be
reasonable to encourage patients as well to be culturally sensitive and
be aware that not all health care providers are equally competent in
cultures. When it comes to illness, cultural beliefs and values affect
greatly a patient's behavior in seeking healthcare. They should try their
best to communicate their concerns relating to their beliefs, values and
other cultural factors that might affect care and treatment to their
physicians and other healthcare providers. If effective communication
is unlikely achieved, then they should be provided with language
assistance and interpretation services. Recognizing that patients
receive the best care when they work in partnership with doctors,
the General Medical Council issued guidance for patients "What to
expect from your doctor: a guide for patients" in April 2013.[22][23]

Challenges to cultural competence

Language barriers
Linguistic competence involves communicating effectively with diverse
populations, including individuals with limited English
proficiency (LEP), low literacy skills or are not literate, disabilities, and
individuals with any degree of hearing loss.[24] According to the U.S.
Census in 2011, 25.3 million people are considered limited English
proficient, accounting for 9% of the U.S. population. Hospitals
frequently admit LEP patients for treatment. With cultural and
linguistic barriers, it is not surprising that it is hard to achieve effective
communication between the health care providers and the LEP
patients.
In order to improve communication and mutual understanding, health
care systems have used the professionally trained interpreters to
help health care providers to communicate with patients whose English
proficiency is limited. Studies have shown that trained professional
interpreters or bilingual health care professionals have a positive effect
on LEP patients' satisfaction, their quality of care, and outcomes.[25]
The National Culturally and Linguistically Appropriate Services (CLAS)
Standards in Health and Health Care developed by the Office of
Minority Health (OMH) are intended to advance health equity, improve
quality and help eliminate health care disparities.[26] The three themes
of the fifteen CLAS standards are Governance, Leadership, and
workforce; Communication and Language Assistance; and
Engagement, Continuous Improvement, and Accountability. The
standards clearly emphasized that the top levels of an organizational
leadership hold the responsibility for CLAS implementation, and that
language assistance should be provided when needed, and quality
improvement, community engagement, and evaluation are
importance.[27] that is a very good resource for healthcare systems and
organizations to follow to become culturally and linguistically
competent in the delivery of health care.
 Valenzuela City, Metro Manila

DOCTOR OF PHILOSOPHY IN NURSING

Major in Nursing Administration

CULTURAL DIVERSITY IN HEALTH AND ILLNESS

SUMMER – SY 2017 – 2018

Submitted to:
MA. VIRGINIA M. ALARILLA, Ph.D.

In Partial Fulfillment of the

requirements for the Degree in
DOCTOR OF PHILOSOPHY IN NURSING
Major in Nursing Administration

Submitted by:
MATT JOSEPH T. CABANTING, MAN, RN