Caring for Refugees: Measuring Cultural
Competence in Nursing
Andrea Addington RN, EdD
Objectives
Cultural competence in nursing education
I. Define Cultural competence
II. Describe rationale for cultural competence
III. Review of literature regarding teaching
techniques
IV. Analyze research on measuring cultural
competence
Culturally Congruent Care:
“ Culturally-based care knowledge, acts, and
decisions used in sensitive and knowledgeable ways
to appropriately and meaningfully fit the cultural
values, beliefs, and lifeways of clients for their health
and well-being, or to prevent illness, disabilities, or
death” (Leininger & McFarland, 2006, p. 15).
Cultural Competence:
• “ Is a multidimensional learning process that integrates
transcultural skills in all three dimensions (cognitive,
practical, and affective), involves transcultural self- efficacy
(confidence) as a major influencing factor, and aims to
achieve culturally congruent care” (Jeffries, 2007, p.29).
Rationale
The Institute of Medicine has reported that
“bias, prejudice, and stereotyping on the part
of healthcare providers may contribute to
differences in care” (Institute of Medicine
(IOM), 2002, p.1).
The US population is becoming
increasingly diverse, and
requires healthcare professionals
to be educated in culturally
competent care. (Davidhizar &
Giger, 2001).
Rationale
The National League for Nursing Accrediting
Commission (NLNAC, Inc. in 2008) has standards
that require cultural competency in practice as
well as standards for nursing schools to include
cultural diversity concepts in the curriculum.
Leininger Theory
Culture Care Diversity and Universality Theory
Cultural values beliefs and practices
Not ethnocentric
Individualistic vs. stereotypical
May cause conflict, stress, and racial bias
(incompetence)
Self reflection
Review of the literature
Canales and Bowers (2001)
described “a lack of progress in teaching
and evaluating cultural competence” (p.
102).
Few studies have used tools to measure
effects on student learning
Experiences to enhance CC
food, field trips, interviews, music (Hughes & Hood, 2007);
international immersion experiences (Caffrey, Neander, Markle, &
Stewart, 2005);
exchange programs within the United States to areas with different
cultures- immersion (Huttlinger & Keating, 1991);
experiences of ethnic activities such as pow-wows and cultural
festivals (Wendler & Struthers, 2002);
interviews (Flood, 2007);
caring for persons of a different culture in clinical settings (Lundberg,
Backstrom, & Widen, 2005, Addington, 2010).
Classroom-theory, journals, games, cultural content
Literature Review
Doutrich and Storey (2004)
13 nursing students
Partnered with public health nurses
for 16 weeks
Used Capina-Bacote’s Cultural
Competency Assessment tool
Significant increase in mean scores
Caffrey, Neander, Markle, and Stewart's
(2005)
Two groups of students compared: Both
groups showed an increase in cultural
competence
Classroom learning does have an effect
5-week international immersion provided
better learning experience, higher change in
mean scores
Griswald, et al. (2006)
• Evaluated medical students
• Two days of interactions with refugee clients in a clinic
• Demonstrated a gain in cultural competency
knowledge and communication skills
How do we teach CC?
Knowledge-books,
research, lecture
Experience-clinical
Theory of change
Barriers to change (beliefs)
Fearother cultureStems from family beliefs, political
beliefs, peers, religious beliefs
Fearcan cause anger, distrust
What is the fear of another culture?
Don’t understand, loss of control
Steps to Cultural competence
Get rid of fear-takes away barriers to change
In healthcare, this takes openness, willingness
Change beliefs
Meeting someone from another culture
Cultural assessment
Self assessment
Ability to communicate-translators
Being immersed in another culture
appears to develop changes in
ethnocentric thinking as well as provide
a basis for cultural knowledge that is
not attainable by classroom alone.
Research Questions
•
•
•
•
At the conclusion of a community health rotation, do nursing students who
worked with refugee clients, as compared to those students who did not
work with refugee clients, have an increased level of cultural competence
as measured by the Caffrey Cultural Assessment Tool?
Is there a significant difference in cultural competence in all students after
taking a Community Health course?
Is there a significant difference between nursing students’ self perceived
level of cultural competence after working with refugee clients than before
working with refugee clients?
What is the relationship between demographic factors and nursing
students' level of self perceived cultural competence?
Design
• This study was a two group pretest posttest quasiexperimental design to compare students in the
Community Health Refugee group (CHR) and
students in the Community Health group (CH).
Instrument
• The tool to assess the students cultural
competence was the Caffrey Cultural
Competence in Healthcare Scale
(CCCHS). It has 28 items using a 5 point
Likert scale.
Instrument
•
•
•
How comfortable are you in interacting socially with members
of a cultural group other than your own?
In general, how would you evaluate your comfort level in
caring for clients from a culture other than your own?
How knowledgeable are you about the healthcare beliefs of a
cultural group other than your own?
Sample
• Sampling was a random sample to divide students into
two groups: the students enrolled in the Community
Health clinical group assigned to refugee clients
(CHR), and the control group: students enrolled in the
Community Health course who did not take care of
refugee clients (CH).
Delimitations
• The study was done with a group of nursing students
from a small Midwestern Catholic Health Sciences
College. The results may not be generalized to all
colleges with nursing schools. The students were
enrolled in the BSN Community Health course.
Limitations
• Sample size- 20 students, refugee group only 6
• Assessment tool-perceptions of their cultural
competency skills and attitudes.
• The researcher is a faculty member
Significance of the Study
“Not only are nurses, physicians, other healthcare
providers, and institutions ethically and morally
obligated to provide the best culturally congruent care
possible, but they are also legally mandated to do so”
(Jeffries, 2006. p. xiv).
• Learning cultural competent skills may result in
decrease in health disparities
• Nurse educators understanding of student perceptions
• Curriculum implications
Population and setting
Private college
BSN nursing students taking the Community Health
course
Refugee Center
Two groups of students
CHR- working with refugee clients
CH-working with clients from the Visiting Nurse Services
Data Analysis
• The demographic data and the Caffrey Cultural
Competence in Healthcare Scale (CCCHS) was
analyzed using summary, descriptive, and inferential
statistics.
• Inferential included t-tests and ANOVA
Interventions
• In addition to students working with refugee clients to
increase cultural competence, the following were used
as teaching tools in the classroom and clinical setting:
• Heritage self assessment
• Client cultural assessment
• Journals
Chapter 4 Results: Demographic
•
•
•
•
•
•
•
•
Worked with refugee client
Status in nursing program
Gender
Age
Ethnic heritage
Religious background
English primary language
Previous time out of country
• Fluency in second
language
• Fluency
in second
• language
Contact with other
culturalwith
group
• Contact
other
• cultural
Work history
group as RN in
yearshistory as RN in
• Work
• years
Contact with clients from
anotherwith
culture
• Contact
clients from
• another
Contactculture
with health care
workerswith
from
another
• Contact
health
care
culture from another
workers
culture
Contact with clients from another
culture
• . Only 10% (n=2) of the students had a moderate or
great amount of contact with clients from another
culture, with 90% (n=18) categorized as only ‘little’ or
‘some’ contact.
Contact with healthcare workers
from another culture
• . Most students (70%, n=16) had minimal amount of
contact with health care workers from another culture.
Four students (20%) had a moderate to great deal of
contact.
Descriptive statistics for CCCHS
Cultural competence: level of comfort, knowledge,
and awareness in providing care to persons from
cultures other than their own
Pretest scores 56-108
Posttest 64- 116
Highest gain 32 points
Lowest gain loss of 14 points
14 students showed a gain
Question scores
• Question 10 “How comfortable are you / would you be
in working with a translator in a healthcare setting?”
(82 total points)
• Question 16 “How knowledgeable are you about
another culture’s beliefs and practices related to organ
donation?” (44)
High scores >70,
average 3.5/5 per student
• Question 19
• Question 20
• Question 21
• Question 23
• Question 25
Awareness of own limitations providing
culturally competent care.
Comfort in advocating for clients of
another culture with other healthcare
providers.
General evaluation of comfort level in
caring for clients from another culture.
Comfort in working with another
member of healthcare team from
another culture.
Interest in working with culturally
diverse staff.
Scores 2.5 average per student
(out of 5) Lower scores
•
•
How knowledgeable are you about the healthcare
beliefs of a cultural group other than your own?
How knowledgeable are you about the health care
practices of a cultural group other than your own?
Inferential statistics
• Hypothesis one was “students working with refugee
clients will have an increased level of self perceived
attitudes, skills’ and knowledge of cultural competence
after they worked with refugee clients than students
who did not work with refugee clients.”
ANOVA
•
•
•
•
•
•
CHR pretest mean 2.79, posttest 3.13
CH pretest mean 2.77, postest 2.99
CHR Difference .33
CH Difference .22
Posttest ANOVA (F [1,18] = .236, p= .632)
Null accepted-not statistically significant
T-test refugee status
• (t = .486, df = 18, p= .633)
• Null accepted
• So between the 2 groups of students, did not see
statistically significant differences in scores
• I believe that with a larger sample size, it would have
shown significant differences
Outcomes t-test
Change is possible!
We have more in common as humans than difference,
but none of us is more human than another”
Maya Angelou
“Working with refugees
stretched me to reach
beyond my comfort zone.
Coming from a small town,
I had never had contact
with another culture. I am
so glad I had this
experience I may otherwise
never have had.” Nursing student