Status of cultural competence in nursing education: A literature review

Journal of Multicultural Nursing & Health, Summer 2003 by Grant, LaVerne F, Letzring, Timothy D

This article reviews current literature related to the inclusion of cultural content in nursing curricula and the teaching strategies nurse educators use to help students develop a culturally competent practice of care. Since the American Nurses Association offered guidelines for strategies in 1986, many nursing programs have developed courses and units of study on cultural diversity. Some incorporate local clinical experiences, while others concentrate on international experiences. Few efforts have been made to determine the effectiveness of the teaching strategies. This review summarizes these educational endeavors as well as recent efforts in objective measurement of cultural competence.

KEY WORDS: Cultural Competence; Cultural Diversity; Nursing Education.

Non-European Americans make up approximately one-third of the United States (US) population. These groups sustained their identity, values, and belief systems and now want to be recognized in a bicultural, pluralistic, and multi-cultural manner (Bucher, 2000). Their numbers are growing and by 2080, non-whites will be the majority in the US (Andrews & Boyles, 1999). Early in the 21st century children of color will be near one-half of America's youth (Isaacs & Benjamin, 1991). Approximately one-fourth of America's elder population will be of non-white heritage by 2030 (Burke & Laramie, 2000). Better health care has contributed to these population shifts. Improved technology has increased the life expectancy of people, as well as decreased infant mortality and morbidity.

Shifting demographics have had a tremendous impact on health care and health care professionals. Health care professionals, especially nurses, need to be cognizant of the preferred health care practices of the people served. All clients may not be comfortable with Western medicine. Being colorblind, i.e. saying we are all alike, and ethnocentric, i.e., saying that the American way is the best, will not address the health care needs of America, nor will these attitudes enhance the health care needs of individuals in the US.

One place to begin learning the preferred health practices of diverse people is in the educational settings. Schools of nursing recognize the need to incorporate content about culture and cultural appropriate care, but there is no convincing evidence as to the best way to do it. The purpose of this paper is to review the recent educational endeavors of schools of nursing that incorporate cultural diversity in the curricula and summarize the current efforts being made to objectively measure cultural competence in nursing schools and practice.

THE NURSING ISSUE

How should schools of nursing introduce the concepts of culture and cultural appropriate care? One might think that teaching general knowledge about various cultures is the answer. However, cultural generalities are rarely applicable to all individuals within a culture (Dreher & MacNaughton, 2002; Eliason & Macy, 1992). General knowledge often leads to stereotyping. The consequence of stereotyping is inadequate or negligent client care. A client of a different culture may be labeled as "uncooperative, non-compliant or resistive" (Eliason & Macy, 1992, p. 14) to a health care regimen, when in reality, the care may be incongruent with the client's cultural beliefs and values (Leininger, 1989). Campinha-Bacote and Padgett (1995) wrote "non-compliance can be considered the failure of health care providers to provide culturally relevant care" (p. 31). When transcultural nursing knowledge is applied to a situation and cultural-specific interventions are implemented, the client's compliance to the medical regimen improves, health status improves, and use of health care services is initiated more frequently (DeSantis, 1991).

In 1986, the American Nurses Association (ANA) identified several approaches to integrate cultural diversity content into the curricula of nursing schools. The Association suggested content be approached by 1) integrating the concepts throughout the curriculum, 2) teaching aspects of nursing care in a specific unit, or 3) offering a required or elective course in cultural diversity. The latter course could be facilitated by faculty from several disciplines (nurses, anthropologists, medical sociologists).

Prior to the ANA publication, the literature is extremely limited, especially in the area of education. However since the late 1980s, the literature has proliferated with examples of how nursing schools incorporated cultural content, as well as methods of offering cultural clinical experiences. Some programs use local experiences and resources to promote culturally competent care. Others believe international experiences provide the most appropriate learning for culturally competent care. In addition, since the late 1990s, there have been several efforts made to define and measure cultural competence outcomes.

Teaching Strategies Using Local Experiences and Resources

The literature describes numerous examples of methods various nursing schools have used to make their students culturally competent. These methods range from standard courses, both required and elective, to projects conducted within a class with broader goals than just cultural competence. Table 1 summarizes this part of the literature.