cultural competency of fresno state nursing students

ABSTRACT CULTURAL COMPETENCY OF FRESNO STATE NURSING STUDENTS The purpose of this research was to determine if there were significant differences in levels of cultural awareness in students from different racial and ethnic immigrant backgrounds, in a program that integrates cultural content into its curriculum with respect to race/ethnicity background, current program status, and participation in opportunities provided by the program. This study utilized primary data, collected by using the Cultural Awareness Survey with a total of 182 student participants from Fresno State and a 41.3% response rate. One-way analysis of variance was used to test for significance among the variables of race/ethnicity, program status, and participation. The study found that there were no statistical differences in cultural competence between students of different class standings in the nursing program as well as for the variable of participation. The study did not find statistically significant differences in cultural competence among students from different racial/ethnic and immigrant backgrounds. These results suggest that there may be no differences in cultural competency among nursing students because of their racial/ethnic backgrounds. However, several limitations must be taken into consideration prior to making generalizations regarding this study. Bessie Yang December 2015

CULTURAL COMPETENCY OF FRESNO STATE NURSING STUDENTS

by Bessie Yang

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Public Health in the College of Health and Human Services California State University, Fresno December 2015

APPROVED For the Department of Public Health: We, the undersigned, certify that the thesis of the following student meets the required standards of scholarship, format, and style of the university and the student's graduate degree program for the awarding of the master's degree.

Bessie Yang Thesis Author

Vickie Krenz (Chair)

Public Health

John Capitman

Public Health

Janice Mathurin

West Fresno Family Resource Center

For the University Graduate Committee:

Dean, Division of Graduate Studies

AUTHORIZATION FOR REPRODUCTION OF MASTER’S THESIS

X

I grant permission for the reproduction of this thesis in part or in its entirety without further authorization from me, on the condition that the person or agency requesting reproduction absorbs the cost and provides proper acknowledgment of authorship.

Permission to reproduce this thesis in part or in its entirety must be obtained from me.

Signature of thesis author:

ACKNOWLEDGMENTS I would like to express my gratitude to my advisor, Dr. Vickie Krenz and my committee members: Dr. John Capitman and Janice Mathurin for their guidance, insightful comments and encouragement. I would also like to thank Dr. Ndidi Griffin-Myers, Chair of Fresno State’s School of Nursing for supporting my research. Lastly, I would like to dedicate my thesis to my family: my parents, my brothers and sisters. Thank you all for supporting me throughout writing this thesis and for your unwavering love.

TABLE OF CONTENTS Page

LIST OF TABLES ................................................................................................. vii CHAPTER 1: INTRODUCTION ............................................................................ 1 Background ....................................................................................................... 4 Problem Statement ............................................................................................ 8 Purpose ............................................................................................................ 10 Theoretical Rationale ...................................................................................... 10 Hypotheses ...................................................................................................... 16 Assumptions .................................................................................................... 16 Limitations ...................................................................................................... 17 Delimitations ................................................................................................... 17 Definition of Terms ......................................................................................... 18 Summary ......................................................................................................... 19 CHAPTER 2: LITERATURE REVIEW ............................................................... 21 Introduction ..................................................................................................... 21 Cultural Competence Overview ...................................................................... 21 Importance of Diversity in Nursing Schools................................................... 25 Cultural Competency in the Nursing Curriculum ........................................... 29 Summary ......................................................................................................... 37 CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY .......................... 40 Setting and Population .................................................................................... 40 Study Design ................................................................................................... 41 Instrument ....................................................................................................... 41 Data Collection................................................................................................ 43

vi Page Data Analysis .................................................................................................. 44 Summary ......................................................................................................... 44 CHAPTER 4: RESULTS ....................................................................................... 45 Demographics ................................................................................................. 45 Analysis of Hypotheses ................................................................................... 49 CHAPTER 5: DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS ............................................................................ 60 Sample ............................................................................................................. 60 Sampling Bias ................................................................................................. 62 Discussion of Hypotheses ............................................................................... 64 Implications for Public Health ........................................................................ 69 Conclusions and Recommendations ............................................................... 70 Summary ......................................................................................................... 72 REFERENCES ....................................................................................................... 74 APPENDIX: THE CULTURAL AWARENESS STUDENT SURVEY .............. 89

LIST OF TABLES Page

Table 1 Demographic Composition of Sample...................................................... 46 Table 2 Participants’ Birthplace, Language, and Admission Status .................... 47 Table 3 Distribution of Participants with Cultural Competence Program Involvement .............................................................................................. 48 Table 4 Participants’ CAS Mean Scores and Standard Deviation by Subscale ... 48 Table 5 One Way ANOVA Summary Table for the Independent Variable Class Standing ................................................................................................... 49 Table 6 Means and Standard Deviations for CAS Subscales, by Nursing Program ................................................................................................... 50 Table 7 One Way ANOVA Summary Table for the Independent Variable Graduation Year ...................................................................................... 50 Table 8 Means and Standard Deviations for CAS Subscales, by Graduation Year .......................................................................................................... 51 Table 9 One Way ANOVA Summary Table for the Independent Variable Race-Ethnicity .......................................................................................... 52 Table 10 Means and Standard Deviations for CAS Subscales, by Race/Ethnicity .......................................................................................... 53 Table 11 One Way ANOVA Summary Table for the Independent Variable Immigrant Status ...................................................................................... 53 Table 12 Means and Standard Deviations for CAS Subscales, by Immigrant Status ........................................................................................................ 54 Table 13 One Way ANOVA Summary Table for the Independent Variable Student Status ........................................................................................... 54 Table 14 Means and Standard Deviations for CAS Subscales, by Student Status ........................................................................................................ 55 Table 15 One Way ANOVA Summary Table for the Independent Variable Language .................................................................................................. 55 Table 16 Means and Standard Deviations for CAS Subscales, by Language ....... 56 Table 17 One Way ANOVA Summary Table for the Independent Variable Opportunity .............................................................................................. 57 Table 18 Means and Standard Deviations for CAS Subscales, by Opportunity ... 58

viii Page Table 19 One Way ANOVA Summary Table for the Independent Variable Course ...................................................................................................... 58 Table 20 Means and Standard Deviations for CAS Subscales, by Curriculum .... 59 Table 21 Race/ Ethnicity of Fresno State Nursing Students and of Study Sample ...................................................................................................... 61 Table 22 Participants’ CAS Mean Scores by Subscale for Rew et al., 2003 Study ......................................................................................................... 64

CHAPTER 1: INTRODUCTION Caring for racially and ethnically diverse populations requires the need for cultural competence training and educational programs (Loftin, Hartin, Branson, & Reyes, 2013). The rising cultural diversity in the country suggests a need for greater cultural competence in the provision of healthcare. The American College Health Association (ACHA, 2011) has defined cultural competency as “the capacity of an individual, an organization, or an institution to respond to the unique needs of populations whose cultures are different from that which might be referred to as ‘dominant’” (para. 1). This study addressed the need for college nursing programs to prepare their students to enter the nursing profession as culturally competent healthcare practitioners. The purpose of this research was to identify differences in levels of cultural competency in students from different racial and ethnic immigrant backgrounds, in a program that integrates cultural content into its curriculum. The ability of the healthcare profession to achieve cultural competency depends on actions taken by various healthcare sectors, each with different motivations, approaches, and leverage points for advancing in this field (Betancourt, Green, Carrillo, & Park, 2005). One discipline of the healthcare profession in which cultural competency is particularly important is in nursing. The immediate contact with patients and the wide variety of services provided will require a strong skill set. The content and effectiveness of cultural competency training in nursing education programs have direct impact on the foundation a student needs to develop and manage through their professional career. Determining the degree to which students in training programs exhibit cultural competence awareness will shed light on the success of the profession and indicate directions for improvement.

2 The decreasing size of the physician workforce will be the catalyst to the growing population of nurses. As nurses become the front line of care for patients, it is important that college nursing programs adequately prepare future nurses to provide care in a cross cultural setting. The following section will explain the need for research to be done for how programs develop student nurses. This study examined the cultural competence awareness of students in a nursing preparation program at Fresno State. This study sought to identify differences between students’ level of cultural competence and the impact of the nursing program’s incorporation of cultural competence in course work. Research is lacking regarding how nursing programs implement cultural competency training into courses; thus identifying the deficits of students in this area is difficult. Little is known about what nursing students learn about the complexities of cultural competency (Vandenberg & Kalischuk, 2014). The important first step is developing a sense of awareness. The present study included an assessment of the student’s knowledge, beliefs and skills pertaining to cultural competency. Levels of competency may vary due to multiple factors such as racial/ethnic backgrounds and participation in components of the nursing curriculum. Healthcare professionals are integral parts of the healthcare delivery system and are keys to the improvement of health for patients (Moxley, Mahendra, & Vega-Barachowitz, 2004). This study focused on the training that nursing students must go through in order to provide culturally competent care. Nurses must keep current with major developments in the healthcare system, especially developments that directly impact interactions with patients. Changing demographics have brought major changes to the provision of healthcare services. In an attempt to provide guidance for training healthcare professionals to meet the challenges of the changing demographics, the California Endowment issued

3 Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals (Gilbert, 2003). The document identified that as of its publication in 2003 “no criteria by which to plan or assess courses of study in cultural competence” had been developed (p. v). This means that there is no universal or widely accepted way to ensure that healthcare professionals are being adequately trained in cultural competence. This finding still holds significance to the present study. Acknowledgement for the need to prepare nurses in cultural competence training has long been discussed, but literature in how and what was implemented in the curriculum to create an outcome is scarce. Recent literature, for nursing programs agree that there are no universal criteria (Calvillo et al., 2009; Clark et al., 2011; Holland, 2015; Mareno & Hart, 2014; Riley, Smyer & York, 2012; Waite & Calamaro, 2010). All suggested adding new pedagogies that need to be standardized in order to create professional and personal development of the students. This is why it is important to place responsibility in nursing schools to create awareness, knowledge and attitudes that will grow with the student as they progress into professional care. Nursing programs can create, unlike hospitals and clinics, a structured learning environment and regiment for retaining information. Cultural competency training early on will develop a strong foundation for a skill set that will be incredibly valuable in cross cultural care. The need for this study is to examine through the students’ awareness if they feel they are adequately being trained. A unified conceptual training framework is needed to ensure that the education healthcare providers receive is appropriate and effective (Betancourt et al., 2005). It is important that nurses are self-aware, knowledgeable about their patients, and continually striving to improve patient satisfaction. Nursing organizations (e.g., American Nurses Association, American Academy of Nurse

4 Practitioners, American Association of Colleges of Nursing, and National Council of State Boards of Nursing), are aware of the importance of cultural competence, and the concern for a culturally sensitive and culturally competent nursing workforce is growing rapidly with the ever changing demographics. Background Cultural competence plays an important role in how nurses interact with their patients. The U.S. population is estimated to be 313,933,954 on July 4, 2012 (U.S. Census Bureau, n.d.), cultural competence in conducting routine patient care cannot be an afterthought. In 2010, White alone accounted for a majority of the population (72%), followed by Hispanics (16%), Black or African American (13%), Asian (5%), and American Indian and Alaska Native (0.9%). With a diverse population; members of racial and ethnic minorities often experience barriers to access and quality care. With lower educational rates, limited English proficiency and health insurance covered this group has poorer health statuses than people in other groups. The changing demographics and economics of this multicultural world combined with long standing health disparities between ethnic groups make cultural competency an increasingly important priority for providers and health organizations (Barrow, 2010). Culturally competent nurses are one factor needed to reduce the health disparities that plague minority groups in the United States and bring about greater health equity. Health Disparities and Cultural Competency The National Institutes of Health (NIH, 2013) has recognized the essential relationship between health disparities and cultural competency:

5 Cultural competency is critical to reducing health disparities and improving access to high-quality health care, health care that is respectful of and responsive to the needs of diverse patients. When developed and implemented as a framework, cultural competence enables systems, agencies, and groups of professionals to function effectively to understand the needs of groups accessing health information and health care—or participating in research—in an inclusive partnership where the provider and the user of the information meet on common ground. (“Why Is Cultural Competency Important?” para. 2) As the NIH statement illustrates, cultural competency is extremely important as the United States progresses towards greater diversity. Cultural competency is a requirement of quality practice and an issue that needs to take precedence among those working in the healthcare industry and preparing others for work in the field. The large increase in minority and ethnic populations has created a platform for growing disparities in health status (Overman, 2009). The size and growth of the gaps in health status and healthcare between many minority groups and the general population are alarming. The Centers for Disease Control and Prevention has reported that members of racial and ethnic minorities in the United States experience poorer health outcomes and lower access to healthcare (Schneider, 2011). Health disparities exist for several reasons, the failure to prepare nurses for expertise in having a cultural competency skill set has exacerbated the level of care patients receive (Alexander, 2008). Health disparities have several root causes, including personal behaviors, provider knowledge and attitudes, and societal and cultural values (National Institute on Minority Health and Health Disparities, n.d.; Thomas, Fine, &

6 Ibrahim, 2004). One of the reasons ethnic and minority groups have disproportionately lower access to care may be that most have lower socioeconomic status and less education. Nurses work in a variety of health care settings that allows them to be integral parts in a patient’s care routine, it is imperative that nurses feel confident when working with members of a different ethnic group (Benkert, Templin, Schim, Doorenbos, & Bell, 2011). As being an individual of providing care, nurses need to be aware of personal biases that may conflict with the treatment of the patient. Reducing racially or culturally based inequities in medical care is a moral imperative. The first steps, at both the individual and the societal levels, are honest self-examination and the acknowledgement of need (Geiger, 2001). By 2020 ethnic minorities will make up 35% of the American population (Barrow, 2010). With the implementation of the Patient Protection and Affordable Care Act by the Obama administration, millions in minority populations who did not have healthcare will gain access to healthcare. Although the guarantee that they will actually have health coverage remains a matter of debate, the promise undeniably marks a new era for many (Kirsch, 2013). The initial implementation period will be very difficult and will test the competency of the nation’s nurses. The relevance of this study was to examine how the nursing discipline is preparing students for entering into the workforce. Curricula should provide culturally competent training opportunities in framing attitudes and skills. This present study put an emphasis on assessing the students’ awareness on cultural competency and how being from different racial/ethnic backgrounds may influence different levels of awareness.

7 Cultural competency is vital to success for nurses and other healthcare professionals. It demands willingness on the part of health organizations and nurses to improve self-awareness and act upon that awareness. Cultural Competency Training A number of different agencies and organizations (e.g., American Nurses Association, American Academy of Nurse Practitioners, American Association of Colleges of Nursing, and National Council of State Boards of Nursing) have made multiple attempts to make cultural competency training a priority. They have developed tools and assessments in hopes of reducing the chronic lack of cultural sensitivity in healthcare practice. Building cultural competence entails acquiring knowledge of pasts, values, belief systems, and behaviors of diverse groups (Abbey, 2006). The problem is not whether or not nursing organizations believe cultural competence training is important because it is. The problem is how nurses are being trained to retain conscientious methods while working in a setting with culturally diverse groups. Interest in how undergraduate and graduate training for cultural competence has grown and resources are continually being developed to increase competence in interacting with people of diverse ethnic and cultural backgrounds (Brennan & Cotter, 2008; Geiger, 2001). The literature revealed that there are discrepancies in how nursing schools teach cultural competency and which method produces a better outcome. An agreed starting point for training is allowing students to perform a self- assessment. This will bring awareness to personal biases in learning and determine what obstacles the school may have to overcome in regards to deficits in cultural competency training.

8 Recent literature has explained the benefits of self-assessment for nurses. Learning environments should be able to cultivate the skill of self-assessment in order to be more productive. Healthcare providers are held accountable under the principle of self-regulation for their competence in the delivery of quality healthcare; to remain effective they must be lifelong learners in their profession (Ward, Gruppen, & Regehr, 2002). Cultural competence is a tool they should utilize; it can be synced with the provider’s professional persona. Cultural competence is critical to the delivery of quality patient care, especially in geographic areas that are demographically diverse. The opportunity that exists for nursing schools to impact the future workforce in this area is huge. Nurses must acquire the necessary knowledge and skills in cultural competency and the foundation must be created in school. Improvements must be made to address the lack of cultural competency training. Problem Statement Cultural competence is a set of skills healthcare providers need in order to provide quality patient-centered care (Campinha-Bacote, 2011). Healthcare services that are respectful and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients can help bring about positive health outcomes (U.S. Department of Health and Human Services, Office of Minority Health, 2013). To determine whether organizations or individual practitioners are culturally competent to deliver quality care, the organizations or individual providers need to perform regular self-assessments. Assessments are important for understanding and measuring the factors that affect cultural competence and for determining what training needs are present. The National Center for Cultural Competence (n.d.) observed that “assessing attitudes,

9 practices, structures and policies of programs and their personnel is a necessary, effective and systematic way to plan for and incorporate cultural and linguistic competency within organizations” (para. 1). This study will allow students to assess not only their own awareness in cultural competency, but the general experience they have in the classes and program will also be assessed to outline any factors that inhibit training. Nurses and other healthcare providers should be aware of their skill levels and regulate their performance and knowledge acquisition so they keep up with advances and changes in the field that affect patient care. Nurses need to meet the expectations of the public by maintaining their ability, which requires assessment of their knowledge, skills, and performance (Gordon, 1992). Only when they regularly assess themselves can they improve upon their abilities. Self-assessment is important because it allows for individuals to reflect on their beliefs and actions. Self-assessment can be enhanced by assessments from the patients indicating how culturally competent the patient perceives the nurse-patient interaction to be. Self-assessment is especially important for nurses and nurse practitioners. Nurses are often the first medical personnel a patient encounters, and their manner and provision of care can be defining factors in whether a patient develops trust with the staff. Research has demonstrated that nurse practitioners with low or high self-efficacy levels may be at risk for delivering culturally incongruent and incompetent care (Olaivar, 2014). Nurses should habitually self-assess skills, attitudes, and beliefs to provide unbiased care. This routine of assessing and developing skills can be taught early on in a nursing program. Assessment of cultural competency is lacking not only not only among healthcare practitioners, but also among students preparing to enter the nursing profession. However, the literature identifying and describing instruments that

10 measure cultural competence in nursing students and nursing professionals is inadequate (Loftin et al., 2013). The lack of objective measurement means that college programs cannot evaluate their effectiveness in training nurses in cultural competency. This study addresses the need for college nursing programs to prepare their students to enter the nursing profession as culturally competent healthcare practitioners. Purpose The purpose of this study was to assess the cultural competence of nursing students at one university and the cultural competency training portion of the school’s program. This study investigated the students’ self-awareness regarding cultural competency and how their racial/ethnic background shapes their attitudes, skills and beliefs. Three constructs of cultural competence were examined: skill, knowledge, and awareness. These constructs were derived from CampinhaBacote’s (2002) cultural competence theory. This study used the Cultural Awareness Scale (CAS) developed by Rew, Becker, Cookston, Khosropour, & Martinez (2003), from the students enrolled in nursing courses to find differences between students from different racial/ethnic and immigrant backgrounds. Theoretical Rationale The theoretical framework for this study is Campinha-Bacote’s (2002) The Process of Cultural Competence in the Delivery of Healthcare Services. This model views cultural competence in healthcare as an ongoing process in which the nurse continually strives to achieve the ability to effectively work within the cultural context of the client, whether that client is an individual, a family, or a community. What this means is that nurses in a diverse ethnic community do not have to acculturate to the beliefs of anyone in that community, but over the

11 lifespan of their practice in that community they become knowledgeable about and skilled in addressing the various cultures through interactions with family, peers, and larger social contexts (Unger & Schwartz, 2012). This model requires that nurses view themselves as becoming culturally competent rather than as already being competent (Campinha-Bacote, 2002). Campinha-Bacote’s theory contains five constructs: cultural awareness, cultural knowledge, cultural desire, cultural skill, and cultural encounters. Campinha-Bacote integrated different factors used as constructs of the theory of cultural competency into a collective framework of guidance. Although the present study used only three of the five constructs, all five are described here to give the reader a full understanding of see how they are interwoven in the healthcare delivery model. Cultural awareness is the self-examination and in-depth exploration of one’s own cultural and professional background (Campinha-Bacote, 2002). This process involves the providers’ acknowledgment of their own assumptions and biases about individuals from different backgrounds. This acknowledgment is important because if providers are not aware of their own biases, they can unknowingly participate in cultural imposition. Cultural knowledge is obtained by developing a foundation of information about diverse cultural and ethnic groups. Campinha-Bacote (2002) cited the following by Lavizzo-Mourey to explain cultural knowledge: “[T]he integration of three specific issues makes up this construct: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy” (p. 182). Doctors still lack continuous development for dealing with patients of different ethnic backgrounds and often fail to ask specific questions that would indicate multicultural awareness (American Heart Association, 2010).

12 Cultural knowledge is essential to the provider understanding the client’s point of view. Cultural knowledge includes awareness of barriers to health access that ethnic minorities may experience. Providers must comprehend different dimensions of knowledge (i.e., understanding the meaning of culture and its importance to healthcare delivery), attitudes (i.e., having respect for variations in cultural norms), and skills (i.e., eliciting patients’ explanatory models of illness). The purpose of acquiring knowledge about diverse backgrounds is to ensure patient-centered care and personalization (Saha, Beach, & Cooper, 2008). Cultural skill is the ability to collect data relevant to the cultural aspects of the client’s problem. Cultural skill includes the ability to properly perform a cultural assessment with the client and apply information gained from that assessment while performing a physical assessment. For example, body structure, skin color, and laboratory variances may be cultural aspects of a physical assessment. Cultural encounter denotes the ability of the health provider to directly engage in cross-cultural interactions. Cultural encounters refine the health provider’s beliefs about a specific cultural group. The final construct in the model, cultural desire, encompasses all four of the above constructs; it is the motivation of the provider to grow in each area of cultural competence. There is a dearth in the literature about how Campinha-Bacote’s (2002) framework has been applied to research studies. This correlates to the existing problem of the lack of literature of how nursing programs’ implement cultural competency training into the curricula. However, Campinha-Bacote has been a pioneer in the field of nursing in cultural competency and her model has been used in literature to explain areas where nurses should gain more experience.

13 Through personal communication (as cited in Lipson & Desantis, 2007), Campinha-Bacote stated that from 2005 to 2006, about 20 schools of nursing used Health Resources and Service Administration grants to implement her model. The California schools are Loma Linda and San Jose State Universities. Researchers have advocated the use of her model for nursing schools to frame curriculum around (Adam, 2008; Adams, 2010; Buscemi, 2011; Halloran, 2009; Ingram, 2012; Leuning, Swiggum, Wiegert, & Mccullough-Zander, 2002; Maier-Lorentz, 2008; Reeves, 2001; Zoucha & Broome, 2008). Her model has also been used to construct opportunities for schools to increase cultural competency training. Promotion for continuing education programs on cultural competence for nurse educators is imperative in order to improve knowledge and confidence disseminating information to students. In a study by Sealey, Burnett, & Johnson, (2006), cultural competence was examined among faculty of baccalaureate nursing programs in Louisiana. Faculty assessed their level of agreement with statements addressing cultural competence on a 5-point Likert scale. The instrument used was the Cultural Diversity Questionnaire for Nurse Educators. This study used Campinha-Bacote’s (2002) model. A total of 313 nursing faculty participated in the study and mean score results were for the 5 subscales; cultural awareness (4.14), desire (3.67) knowledge (3.65), skills (3.65), and encounters (3.56). Overall cultural competence was rated as 3.73. Sealey et al. interpreted that the results indicated that the levels of cultural competency fell short of expectations for those that have the most accountability for preparing the future nursing workforce. In another study, a prospective, cross-sectional, descriptive study design conducted by Mareno and Hart (2014), with 365 nurses examined the difference in levels of awareness, knowledge, skills, and comfort of nurses with undergraduate

14 and graduate degrees when working with diverse patient populations. The conceptual model used was the Campinha-Bacote (2002) Process of Cultural Competence in Delivery of Healthcare Services. The Clinical Cultural Competency Questionnaire (CCCQ), developed by Like (2001) and revised by Krajic, Strassmayr, Karl-Trummer, Novak-Zezula, and Pelikan (2005), is a 5-point likert scale with scores ranging from 0 (not at all) to 4 (very). Results revealed that undergraduate-degree nurses scored lower than graduate-degree nurses on cultural knowledge. And both groups of nurses reported little cultural diversity training was implemented in the educational and workplace setting. Findings concluded that undergraduate and graduate nursing programs should integrate cultural competency in different stages, first by starting with awareness and knowledge then providing core training in skills and gaining comfort in cultural encounters. A structured nursing curriculum with cultural content can increase cultural competence in students and staff of a nursing program, as demonstrated by Sargent, Sedlak, and Martsolf (2005) using the Inventory for Assessing the Process of Cultural Competence (IAPCC). The purpose of this study was to assess cultural competency of nursing students and faculty. Participants were 88 first year and 121 fourth year nursing students and 51 nursing faculty members. This study used Capinha-Bacote’s (2002) model to explain how curriculum should reflect cultural competence at all levels of the program. The researchers found a positive correlation between IAPCC scores and several demographic variables of the students of the nursing college. The IAPCC is an instrument developed by Campinha-Bacote in 2002 that measures cultural competency for health professionals. The IAPCC has been found to be a reliable instrument in several assessments of health providers (Bowen, Haras, & Holman, 2006; Giles, 2008; Kardong-Edgren, 2007; Kattner, 2006; Noble, 2007; Wilbur, 2008).

15 Instructors and program administrators have difficulty finding the most effective process for preparing nursing students to care for diverse populations (Larsen & Reif, 2011). Instructors and program administrators can use the IAPCC only to identify gaps in students’ understanding; once they identify the deficits, they are responsible to make changes that support the students’ acquisition of cultural competence. Campinha-Bacote’s (2002) model can serve as a reference for programs implementing cultural content into the curriculum. Encouraging student participation in cultural activities will help students enhance their competency and grow in areas that need expertise in dealing with culturally sensitive situations in the health field. These studies and researchers have reiterated that fact that cultural competence makes a significant difference in patient health outcomes and practitioners’ ability to self-assess their overall competence. The use of the process of cultural competence in the delivery of healthcare services model in the study of cultural competence as a framework for the present study is expected to provide the following outcomes according to the five constructs of the model: 1. In the area of cultural awareness, participants should be able to recognize how their own belief systems affect their decision making and how the ways they reach decisions can be misinterpreted by individuals from cultures different from theirs. 2. In the area of cultural knowledge, participants should be better able to understand their client’s explanations of the problem or need for which they are seeking treatment. Additionally, the research should provide the school’s nursing department with data that can be used to modify or revise the training program to better meet the needs of students.

16 3. In the area of cultural skills, participants should be better able to conduct cultural assessments without the use of stereotypical judgments and assumptions. This means identifying preferred languages, identifying support services for nonEnglish speaking people, and assessing clients’ health literacy in order to provide information in appropriate formats. To achieve this outcome, the university’s nursing department may need to expand and diversify the areas in which students experience cross-cultural medicine. 4. In the area of increasing cultural encounters, administrators of the nursing program should encourage nursing students to engage directly in crosscultural interactions with clients from diverse backgrounds. 5. In the area of increasing cultural desire, the nursing program should give motivate students to engage in the process of building cultural competence through the coursework offered. Hypotheses To assess the cultural competence of nursing students in a nursing education program the researcher tested the following hypotheses: 1. There is no significant difference in cultural competence between students of different class standings in the nursing program. 2. There is no significant difference in cultural competence between students of different racial/ethnic and immigrant backgrounds. 3. There is no significant difference in cultural competence between students of different levels of participation in the nursing program’s integration of cultural competence. Assumptions In conducting the study, the researcher made the following assumptions:

17 1. The variables of immigrant status, enrollment status, language, participation are reliable measures of the cultural competence of nurses. 2. The research can be conducted while maintaining confidentiality about nurse-patient consultations. 3. The students who participated in the research provided truthful responses on the survey instrument. Limitations The study is limited by the following factors: 1. Data collected will consist of students’ self-reported assessments. 2. Students’ assessments will be based on their individual perceptions of cultural competence. 3. The accuracy of the data depends on students giving honest responses. 4. Because participation will be voluntary, the researcher cannot guarantee a sample size adequate for generalization of results to the Fresno State student nursing population. Delimitations The researcher agreed to the following delimitations: 1. Participation will be limited to baccalaureate and master’s nursing students. 2. Students will be allowed only one opportunity to complete the instrument. 3. The study relies upon the cooperation of the nursing department staff. 4. The research is limited to one time period: the spring 2015 semester.

18 Definition of Terms Some of the terms used in this study are defined below. Concept of culture is the understanding that culture plays a controlling role in shaping how people perceive reality, acquire a sense of self, think, feel, behave, and understand the behaviors of others (Gilbert, 2003). Cross-cultural refers to an interaction between two or more cultures or having knowledge when comparing the two (Gilbert, 2003). Cultural competence “encompasses a set of integrated attitudes, knowledge, and skills that enable a healthcare professional or organization to care effectively for patients from diverse cultures, groups, and communities” (Gilbert, 2003, p. 11). Cultural effectiveness is “the ability to achieve desired results for patients through mutually satisfactory relationships between providers and patients” (Gilbert, 2003, p. 11). Cultural proficiency is the acknowledgment by providers and healthcare systems of the positive influence that culture has on an individual’s health (National Alliance for Hispanic Health, 2001). Cultural responsiveness is the ability to accurately and skillfully meet the needs of individuals belonging to a specific culture or cultures (Gilbert, 2003). Cultural sensitivity is an awareness of one’s own beliefs and culture and the beliefs and cultures of others (Gilbert, 2003). Culture is defined as follows: “An integrated pattern of learned core values, beliefs, norms, behaviors, and customs that are shared and transmitted by a specific group of people. Some aspects of culture, such as food, clothing, modes of production, and behaviors, are

19 visible. Major aspects of culture, such as values, gender role definitions, health beliefs, and worldview, are not visible.” (Gilbert, 2003, p. 11) Healthcare professionals are “individuals educated to provide specialized care in the area of health” (Gilbert, 2003, p. 12). Multicultural means a mixture of two or more cultures (Gilbert, 2013). A stereotype occurs when cues in the environment make negative images associated with an individual’s group status prominent; this triggers a physiological and psychological process that has detrimental consequences for behavior (Burgess, Warren, Phelan, Dovidio, & van Ryn, 2010). Self-assessment is an evaluation of oneself. Self-assessment acts as a mechanism for identifying one’s weaknesses and one’s strengths (Eva & Regehr, 2005, para.3). Self-regulation/self-acting requires individuals to participate in behaviors that move them toward a goal (Terry & Leary, 2011, p.354). Summary This research examined the levels of cultural competence of Fresno State University nursing students and explored the contribution of the nursing program curriculum to those levels. Campinha-Bacote’s (2002) theory was used as the framework for the study with the emphasis on three constructs: skill, knowledge, and awareness. The specific variables chosen to be a part of the assessment were race/ethnicity, graduation date, second language spoken, immigrant status, student enrollment status, because they were significant components to the students’ background. Background literature revealed that cultural competence in the delivery of healthcare is a worldwide concern. Healthcare practitioners must recognize how

20 devastating ignorance about cultural competence can be on patients. The importance of this topic was affirmed by statements issued by major health groups such as the NIH, APHA, AAMC, and CDC. These groups have supported studies of cultural competence as a dimension of the healthcare system. The present study examined the cultural competence of nursing students at Fresno State and the role of participation of cultural competence programming and individual features in shaping attitudes and skills.

CHAPTER 2: LITERATURE REVIEW Introduction Cultural competence is an essential skill that nursing students need to develop. Personal biases can cause negative health outcomes for the patient if not properly assessed. Nursing programs and literature have acknowledged the importance of implementing training that is culturally compatible with the population. The following chapter reviews cultural competency, discusses the importance of a diverse nursing population, and nursing curriculum. Cultural Competence Overview The best delivery of health services and the most positive health outcomes occur when there is cultural congruence between the patient and the healthcare provider (Stein, 2010). Researchers have identified the development of cultural competence as an essential strategy in effective healthcare delivery. This strategy enables professionals to deal appropriately with cultural differences in healthcare (Bloch, 2012; Cowan & Norman, 2006; Institute of Medicine Committee on Quality of Health Care in America , 2001; Smedley, Stith, & Nelson, 2002; Whittemore, 2007). The purpose of this research was to identify differences in levels of cultural competence in students from different racial and ethnic immigrant backgrounds, focusing on skills, attitudes, and knowledge (constructs of Campinha-Bacote’s theory, 2002) among nursing students in a program that integrates cultural content into its curriculum. A nursing education program should prepare students to enter a workforce that will interact with a diverse population of patients. Identifying levels of cultural competence of students will indicate how well the program prepares its students to deliver healthcare to an ethnically and culturally diverse

22 patient population. Nurses’ cultural competence affects patient care satisfaction. Clinicians that recognize the all-encompassing role that culture has on an individual’s health know how closely their cultural competence is linked to their clinician competence (Comas-Diaz, 2011). There is no universal guideline for implementing cultural competency in a clinician’s learning or practice, but healthcare professionals agree that a nurse’s cultural competency impacts patient health outcomes (Stein, 2010). The literature reviewed in this chapter provides a picture of the impact of cultural competency and the development of implementing it into nursing programs. Culture and Cultural Competence Culture is composed of several variables that have lasting effects on an individual’s experience. Cultural processes regularly fluctuate within the same ethnic or social group because of differences in socioeconomic status, religion, ethnicity, age, and political status. Because of these processes, culture is a “very elusive and nebulous concept, like art” (Epner & Baile, 2012). Cultural awareness means appreciating and accepting these differences. Insensitivity to someone’s cultural background implies there is no acknowledgment of something important and valuable to that person. Healthcare professionals cannot see and treat patients as diseases and body parts; there must be a refocused concentration on viewing patients as people (Lifshitz, 2006). Culture is a multi-faceted construct that can be viewed through several different lenses. The fact that 80% of people in the United States claim ethnic ancestry from one of over 105 ethnicities indicates that culture is increasingly multi-ethnic and complex (U.S. Census Bureau, 2012). A generally accepted view of culture is that it is represented by a certain set of values, beliefs, and practices

23 and is subject to change (Mich & Keillor, 2011). Jimenez (2010) defined culture as “an embodiment of an individual’s ethnic background,” noting that ethnic culture “remains identifiably tethered to a particular ancestry, ideological, institution” (p. 1756). This also includes “symbols and practices around which ethnicity coalesces and that epitomize group belonging” (p. 1756). Nationally, healthcare programs and organizations are dealing with the challenges associated with patient populations that are increasingly racially, ethnologically, linguistically, and culturally diverse (Ahmann, 2002). It has been well researched that minority groups experience more negative health outcomes than majority groups (Angood, 2013; Horevitz, Lawson, & Chow, 2013). One of the reasons for health disparities is that immigrants face tremendous challenges in finding, trusting, and receiving care (Cortese-Peske, 2013). For example, when immigrants seek medical attention, providers are not always knowledgeable of the endemic conditions with which the immigrants are dealing and they do not know how to reassure the patient; the absence of reassurance can discourage minority patients. As presented in Smedley et al. (2000), the Institute of Medicine released a comprehensive study dealing with healthcare disparities titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The researchers found that biases, prejudices, stereotyping, and clinical uncertainty in healthcare providers contributed to differences in care rendered by those providers. Patients’ experiences with discrimination negatively affected the trust they might have placed in healthcare providers, lowered their expectations of the providers, and led to noncompliance with treatment and lower rates of satisfaction. Care of patients should demonstrate sensitivity to their beliefs and be respectful of their family’s

24 decisions. Subtle behaviors such as eye contact or lack thereof can have adverse effects on how the consultation progresses. The absence of cultural competence in the health care system poses a number of problems. Over the past 20 years, advances in the understanding of the value of cultural competence in healthcare delivery have pointed out the need for quality enhancement, language access, and refugee health services as well as the damage of systemic racism (Aggarwal & Desilva, 2013). The lack of cultural sensitivity training for providers of healthcare can lead to discriminatory practices (Majumdar, Browne, Roberts, & Carpio, 2004). On the other hand, cultural sensitivity in healthcare delivery leads to nondiscriminatory practices with satisfactory results. The NIH (2013) stated that cultural competence in healthcare professionals benefits consumers, stakeholders, and communities and supports positive health outcomes. The NIH warned that medical programs that do not include cultural competence as a component yields poor results. And this has also been true for other professions in the health field, such as nursing. Accrediting bodies such as the Commission on Collegiate Nursing Education and the Accreditation Commission for Education in Nursing (ACEN) mandate that academic nursing programs demonstrate that graduates are able to deliver culturally competent nursing services at the basic and advanced practice levels (ACEN, 2013; American Association of Colleges of Nursing, 2008). Nursing programs should lead the way in incorporating cultural awareness into the curricula because the nursing workforce will soon be challenged with dealing with more patients, many of whom are from ethnic backgrounds different from the majority of nurses.

25 Importance of Diversity in Nursing Schools The American Nurses Association (2015) has endorsed the value of increasing diversity in the nursing discipline. There is need for a culturally representative nursing workforce as the United States population continues to diversify. The quality of care can improve with a larger percentage of nurses from different cultures (Gilchrist & Rector, 2007). A diverse nursing population can overcome barriers such as language and provide stronger patient centered care. Ethnic minority students have an invaluable comprehension of the community they come from (Duerksen, 2013). A pioneer in the field of nursing, CampinhaBacote (1998) has long expressed the importance of retaining students from different racial and ethnic background as a challenge to the nursing profession. The difference in cultural attributes the students contribute will positively add to the discipline of nursing. The following sections will illustrate the important relationship that nurses from different ethnic backgrounds can have with patients through performing culturally competent care. Current Status of Healthcare Workforce One of the major issues facing the future of the nursing profession is to increase the ethnic diversity of the nursing workforce (Institute of Medicine, 2010). To recognize the importance of nurses today, an overview of the current workforce is provided. The Association of American Medical Colleges (AAMC, 2010) estimated that the overall physician shortage will reach over 130,000 by the year 2020.The predicted shortage in the near future means that nurses will be the front line of care for many patients. The National Sample Survey of Registered Nurses reported 2,824,641 registered nurses (RNs) and 690,038 licensed practical nurses (LPNs) in the United States in 2008 (U.S. Department of Health and

26 Human Services, Health Resources and Services Administration, 2010). The duties of these nurses, according to the American Nurses Association (2015), include but are not limited to: health screenings and administering medication and personalized counseling under the supervision of a practicing medical doctor. Nurses must have the ability to collect relevant data about patients’ health such as physicality, biological, and physiological variances. One skill required for collecting these data is the ability to generate, receive, and understand nonverbal and verbal cues (Campinha-Bacote, 2011). The current workforce can benefit from increasing the percent of minority nurses who can be valuable assets in providing patient centered care. The potential for nurses to realize the importance of cultural competency is only increased by the amount of diverse encounters, and schools can create a sense of empowerment during training by ensuring that these opportunities arise (Graham & Norman, 2008). Ethnicity The need for the demographic composition of the nursing workforce needs to change to more closely reflect the demographics of patients. Eventually, the increasing diversity in the nursing workforce will make cross-cultural conflicts inevitable, and will require the need to be able to recognize such conflicts and resolve them without putting their patients at risk (Plotnikoff & Barnes, 2000). The increasing diversity in the nursing workforce also means that a more diverse group of patients from rural communities will seek care and cultural backgrounds play a large role in their knowledge and practice of health behaviors (Chuang et al, 2012). The same underrepresentation applies to nurses, both RNs and LPNs. Registered nurses are nurses who have graduated from a university or college and

27 passed the national licensing exam to obtain a nursing license. An LPN provides basic and routine care under the supervision of an RN or a physician. Approximately 9.9% of RNs are Black or African American (non-Hispanic); 8.3% are Asian; 4.8% are Hispanic or Latino; 0.4% are American Indian or Alaskan Native; and 1.3% categorize themselves as of two or more races (U.S. Department of Health and Human Services, 2010). These nursing statistics show the devastating fact of low minority representation in a country that will need first-hand attendees who understand the importance of culturally sensitive medicine. The nursing pipeline, measured by the number of individuals who pass licensing exams, has been bolstered significantly since the year 2000. The number of RN test passers has grown 108% and the number of LPN passers has risen 80%. However, although trends indicate that the field will diversify, the proportion of non-White RNs increased only 20% in the last decade (U.S. Department of Health and Human Services, 2010). Sociologists project that by 2043 the United States will be a majorityminority nation for the first time in its history; this means that no single ethnicity will constitute a majority (Hempel, 2013). Immigration has historically played an integral role in the changing demographics of the United States. Current health trends such as the rise in obesity and the aging of the population suggest that the health of the United States is not getting better. Schools preparing nurses recognize the importance of implementing cultural competency training, but somewhere along the way in the system students miss opportunities to gain more knowledge, skills, and awareness of cultural competency. In addition to training of future nurses, programs can benefit from a diverse population of students that can enrich patient care if the student is from similar ethnic backgrounds.

28 Fresno State is somewhat unusual because of its large proportion of firstgeneration students (FGS), neither of whose parents earned a bachelor’s degree. FGS make up two thirds of the undergraduate student population, and the university’s Office of Institutional Research, Assessment, and Planning (Rudd & Leimer, 2009) has stated that this population is continuing to grow. FGS are most likely to be Hispanic (85% of the Hispanic student population at the school are FGS), Asian (74%), African American (69%) or American Indian (70%). It is important to keep in mind that the backgrounds of these individuals, particularly their ancestry, can enhance their value in the workforce, especially in the health field. Patients want to be able to connect with their service providers through linguistic affinity or, more importantly, by feeling the providers understand their culture and beliefs. Linguistics The increasing need for cross-cultural care means that nurses who possess a second language are in high demand. The ability to communicate clearly with patients in their own language improves both diagnosis and recovery. Linguistic barriers reduce the likelihood of optimal care. A linguistic barrier is any clinical situation between a provider and a patient where communication is obstructed because a mutual language is not shared (Coomer, 2011). Bilingualism has value in the labor market. Hospitals and other healthcare facilities often give incentives for bilinguals to enter their employ. To meet government requirements and limit legal liability, bilinguals may receive a wage premium. On average, RNs who are bilingual earn 11% more than monolinguals (Coomer, 2011). Recent immigration has changed the composition of the labor force and administrators of healthcare

29 facilities are realizing the importance of having health professionals who possess skills in more than one language (Hudelson, 2005; Kalist, 2005). Empirical evidence demonstrates that linguistic barriers can perpetuate inequity and compromise nursing care (Carnevale, Vissandjée, Nyland, & VinetBonin, 2009). Accommodations for linguistic barriers, such as nurses requesting the help of interpreters, can cause substantial stress, especially if the patient or family feels the interpreter is incompetent in translating. Some evidence suggests that linguistic barriers are more problematic for nurses than for physicians because nurses are the first line of help for patients seeking care. In the initial encounter between patient and nurse, before the patient meets the doctor, information about the patient needs to be gathered in a thorough manner; therefore, clear communication between patient and nurse is critical. In addition, clear and compassionate communication with the patient at the first encounter can bring comfort and reassurance to the patient. Culture and ethnicity are barriers in creating effective and efficient patientcentered care and satisfaction (Jhutti-Johal, 2013; Schouten & Meeuwesen, 2006). A difficulty in communication, which is affected by both culture and ethnicity, has also been a barrier as communication is a main component of patient care. Individual behaviors influence patient health outcomes and create a ripple effect on satisfaction, compliance, and patient adherence to treatment (Ong, de Haes, Hoos, & Lammes, 1995). With a diverse nursing student population, the future of the workforce will be increasingly able to work with underserved minorities. Cultural Competency in the Nursing Curriculum Nursing leaders have long understood the importance of preparing nurses for practicing in diverse and comprehensive settings, often as collaborators to

30 doctors. As early as 1972, the American Nurses Association supported numerous efforts to increase cultural awareness and decrease practices that are discriminatory towards patients (Hoffman, Messmer, Hill-Rodriguez, & Vazquez, 2005). As previously mentioned, accrediting bodies require baccalaureate nursing curriculum and academic experience be linked to understanding of and exposure to individuals’ ethnic origins, sex, and race in order to promote a stronger, culturally competent professional. In accordance with accrediting standards, nursing faculty and curriculum should reflect approaches to teaching cultural competency (Long, 2012).The American Association of Colleges of Nursing has suggested various actions for developing cultural competency curricula (Giger et al., 2007). As discussed earlier, health profession literature has supported the role of cultural competence training for nurses. Inconsistencies exist in the availability and quality of cultural curricular content that should be implemented (CampinhaBacote, 2006). Two formidable attempts have been made to have a standardized curriculum. As mentioned in Gilbert (2003), the California Endowment and the American Association of Colleges of Nursing (2008) have provided frameworks to create a sustainable initiative for nursing schools to start implementation. Nurses should be educationally prepared to provide culturally congruent care for patients. The knowledge and skills to provide this level of ability should be nurtured in school programs (Douglas et al., 2014). Institutions must evaluate and adjust their curricula to meet the needs of increasingly diverse patient populations. Implementation Problems As cultural content began to be integrated into nursing curricula, a main concern emerged. The early teaching approach emphasized stereotypes and differences among cultures and groups rather than understanding (Hughes &

31 Hood, 2007). In response, nurse educators expanded the approach, embracing cultural content within the context of holistic nursing practice. The depth of integration in programs range from guiding the whole curriculum to selected courses infused with content. Another problem with implementing the teaching of cultural competence in the nursing curriculum was difficulty understanding cultural aspects of care. Faculty as well as nursing students and practicing nurses had little fundamental knowledge of diverse cultures. Faculty must be adequately prepared to identify issues with teaching nursing education in relation to culture and human nature (Bednarz, Schim, & Doorenbos, 2010). Therefore, with no real grasp of cultural differences in beliefs and attitudes toward healthcare; the impact of culture on healthcare expectations and practices is not fully appreciated. Faculty will play an integral role in training students to meet the demands of the health care setting. Preparation of faculty is a key issue in incorporating cultural competence content in nursing education (Lipson & Desantis, 2007). Cultural focus is often reduced to sociodemographic characteristic outcomes rather than including an in depth analyses of the effects of cultural value, beliefs and practices affect health outcomes of behavior. Educators are responsible for grooming cultural competence in students, yet there is no a predetermined plan for updates, training, or educational requirements; it is left to the discretion of individual faculty members (Marcinkiw, 2003; Montenery, Jones, Perry, Ross, & Zoucha, 2013). Institutions must adequately prepare and train nurse educators to foster an environment where students feel comfortable in engaging in cultural discussions and training. In a study conducted by Kardong-Edgren et al. (2005), 94 nursing faculty from two conferences, were asked to describe faculty attitudes toward and

32 perceived level of confidence in cultural knowledge of four ethnic groups; Hispanics, African Americans, Southeast Asians, and Anglos. Participants completed the Cultural Attitudes Scale, the Cultural Self-efficacy Scale, and a demographic survey and wrote a response to an open-ended question. Results indicated that nurse faculty had the highest level of confidence with Anglos and lowest cultural knowledge of Asians. 81% of the respondents were Anglos, this explains why the highest level was associated with Anglo culture. This study supports that not only does there need to be diversity in students, but faculty from different backgrounds are also important to the enrichment of programs incorporating cultural competence training. Campinha-Bacote, Yahle and Langenkamp (1996) had expressed that the professional challenge nurse educators will face in upcoming years was teaching cultural awareness. Nurse educators from the underrepresented ethnic groups: African American, Hispanic American, Asian American and Native American only make up 7% of the 32,000 population (McNeal, 2012). Other researchers (Halstead, 2012; Pepper, Beck, Mooney, Clark, & Keefe, 2010; Robinson, 2005; Taylor & Alfred, 2010) support the importance of a diverse nurse educator population as well as how the nursing faculty shortage will only exacerbate problems with recruiting educators from minority backgrounds. This reinforces the action to retain nursing students from different cultural backgrounds that will grow to be the leaders of the next generation. Implementation Strategies Cuellar, Brennan, Vito, and de Leon Siantz (2008) developed a framework for teaching cultural competency in the undergraduate nursing curriculum: Blueprint for Integration of Cultural Competence in the Curriculum (BICCC).

33 Each undergraduate year, lessons focus on a specific component of cultural competency followed by learning objectives. The freshman-year focus is on developing a foundation of knowledge regarding culture and diversity. In their sophomore year, students concentrate on health disparities and application of knowledge from the freshman year. Junior year learning consists of analysis and implications of health and illness of individuals. The senior-year curriculum integrates all the above, enabling students to analyze and synthesize cognitive, affective, and psychomotor skills related to cultural issues, essentially enabling them to practice as culturally competent nurses. The BICCC has been used in other studies (Brenna & Cotter, 2008; Tulman & Watts, 2008), where teaching strategies and examples that helped incorporate cultural diversity in clinical practice, such as role-play simulations of hypothetical situations were used. The BICCC is a useful tool for institutions that need direction and strength in the curriculum. In an attempt to refocus curriculum on cultural competence, a School of Nursing in large Midwestern University received a grant from the U.S. Department of Health and Human Resources, Health Resources and Services Administration. Community leaders and health workers were invited to deliberate with faculty and students to make recommendations about a graduate nursing curriculum by Axtell, Avery, & Westra, (2010). The committees were composed of community members representing 19 different community-based, 11 faculty members from the school of nursing and two nursing students. There were five areas of competencies that the community felt graduate students should possess: self-awareness, basic knowledge of culture and identity, attitudes that promote cross-cultural communication, cross-cultural clinical skills, and advocacy skills. It was strongly advised that these areas be incorporated throughout the entire

34 curriculum rather than presented in a single course. This process also strengthened the relationship the school had with the community. This collaborative process to incorporate cultural content with the community was a unique way to reflect the intentions of the school to better work with the patient population they serve. There is a dearth of literature that explains how cultural content is implemented into nursing curriculum. The literature reviewed revealed several important reasons as to why cultural competence training has been an elusive area in curriculum development. But what is a start in the right direction is the assessment for students and faculty to bring about an awareness of where the program stands in terms of providing culturally appropriate training. Cultural competence begins with one’s self-awareness (Martin, 2008). Nurses must be able to do self-evaluations on the importance of their life experiences, family, and ultimately their own cultural beliefs and how they can affect another person. Obtaining an awareness of patients’ beliefs, attitudes, biases, and behaviors is the first step nurses can take to improve access and quality of care (Markova & Broome, 2007). Assessments can help students and programs find deficiencies in the curriculum and allow reason for modification. In a study conducted at a nursing college, Hughes and Hood (2007) demonstrated that trans-cultural teaching strategies impacted students and allowed them to reflect deeply on attitudes and behaviors associated with cultural diversity. The researchers used a cross-cultural evaluation tool pre- and post-implementation of new teaching strategies. The tool consisted of 20 items assessing behavior and attitude on a five-point Likert-type scale ranging from “always” exhibited to “never” demonstrate. Significant Cronbach’s alpha increases in student scores were measured after students engaged in the learning activities to promote cultural sensitivity.

35 In a study of 236 students in the New York University College of Nursing, Krainovich-Miller et al. (2008) used the Cultural Awareness Scale (Rew et al., 2003) to measure cultural awareness. Results indicated more cognitive behavior for students in their last year of school compared to beginning nursing students. This finding suggested that as nursing students progress in educational programs they gain in cultural competence. Healthcare professionals have become increasingly aware of connections between spirituality and culture and the significance of spirituality to healthcare (Narayanasamy, 2006). In a study of 126 nurses who play critical roles in healthcare, participants completed questionnaires regarding cultural care. Most respondents reported believing that patients’ cultural needs should be given consideration in treatment. A significant number of respondents reported they would like to have continual education on cultural care to better meet the needs of their patients. In a related study, Grossman, Mager, Opheim, and Torbjornsen (2011) used the Transcultural Self-Efficacy tool to measure students’ perceptions of selfefficacy in using cognitive, practical, and affective transcultural nursing skills. The tool was an 83-item instrument that used a 10-point Likert-like scale with responses ranging from not confident (0) to totally confident (10). All students reported believing that being committed to developing one’s own personal cultural assessment skills during the simulation improved their ability to perform a cultural assessment. Passing the national certification licensing examination for registered nurses requires cultural knowledge. This requirement places responsibility on nursing institutions to address cultural issues in their curricula and there by graduate beginning nurses who are culturally competent (Purnell & Paulanka,

36 2008). As previously stated, the changing demographics of the nursing workforce will be a catalyst for more productive and culturally sensitive patient-centered care that will eventually create a stronger healthcare system (de Leon Siantz & Meleis, 2007). Nursing programs should cultivate an environment for lifelong learners that are eager to elevate the level of care of the current workforce. Nursing programs should promote self-awareness and periodical assessments can allow for an opportunity to find areas of need in training. Several more studies support the use of assessments (Aponte, 2009; Grilo, Santos, Rita, & Gomes, 2014; Lima, Newall, Kinney, Jordan, & Hamilton, 2014; Shattell et al., 2013) as tools to modify curriculum. The reviewed literature demonstrated that awareness of one’s biases can reduce discrimination and prejudice when working with patients from different cultural backgrounds. There are several areas that need to be addressed for changing a curriculum and one component that has proven to show positive increase in competency is service learning. Service Learning and Nursing Student Cultural Competence Service learning experiences emphasize the importance of focusing on the strengths of a culture that can contribute to health promotion (MkandawireValhmu & Doehring, 2012). International service learning is an option acquiring some degree of cultural competency. It enables nursing students to put themselves into a different culture and environment. Research has shown that students who travel abroad increase their self-confidence through exposures they would not have experienced in their native country (Foronda, 2010; Larson, Ott, & Miles, 2010; Wiegerink-Roe & Rucker-Shannon, 2008). Long (2014) conducted a qualitative and quantitative study of the influence of a 2-week service-learning medical experience on a nursing student group that

37 traveled to Belize, Central America. Of the 34 nursing students in the study, 17 stayed in their community as a control group and 17 went to Belize. Qualitative data were collected from self-reflection journals and quantitative data were collected from pre/posttests. Results with a p-value less than .05 indicated that the group that traveled improved in self-efficacy in knowledge and confidence. The control group did not express feelings of growth or gratitude while working with different ethnicities at local facilities whereas the intervention group expressed gratitude for the country they came from and greater self-awareness. Nursing programs can benefit greatly by allowing students to participate in service learning. Several researchers have supported the incorporation of service learning to provide another outlet for students to experience cross cultural health (Amerson, 2010; Caffrey, Neander, Markle & Stewart, 2005; Fitzpatrick, 2007; Jarrell et al., 2014; Jeffers & Ferry, 2014; Wehling, 2008). This component of the curriculum can enhance achieving goals in developing culturally competent students that are comfortable working in their community. The purpose of this present study was to examine the differences in cultural competency of nursing students from different racial/ethnic backgrounds in a program that consists of cultural content in the curriculum. The reviewed literature demonstrated that there was less consistency in the content, method, and outcomes assessment of cultural competence in nursing curricula (Pacquiao, 2007). Summary The literature demonstrated that cultural competence is important in providing satisfactory patient-centered care. Culturally competent nurses should be skilled in consultations with patients, acquire knowledge of diverse cultures, and are aware of their own culture and the behaviors and attitudes of people of

38 other cultures. The importance of these traits has been supported by the literature reviewed in this chapter. Patients’ perspectives regarding how the nurse should perform may be different from those of the patients, often because of past experiences with healthcare practitioners. These differences in expectations should surface during the initial patient-nurse consultation. Nurses should be able to pick up on cues about expectations and other issues and resolve the patient’s concerns. It is essential that cultural competence be viewed not as a tool, but as a part of the health provider’s evolving conscious and life. Well known health associations and advocacy groups have urged the inclusion of cultural competency training in the ongoing professional development of nurses. The literature also shows a need for improvement in this area so that nurses and researchers alike can continue successful education in cultural competence. Major health groups such as the APHA, AAMC, and CDC support the movement for cultural competency training because they recognize the positive impact on health outcomes of a culturally competent healthcare workforce. Implementing effective training in cultural competence for nurses requires reliable measures of the training program’s success. The many studies that have been conducted using the constructs of Campinha-Bacote’s (2002) model suggest that these constructs are useful in research that evaluates nursing education in cultural competence. Thus the constructs of cultural skill, cultural knowledge, and cultural awareness are used in the present study. Nursing students are in an advantageous position to receive adequate support and training in cultural competency. Opportunities should be made available in programs to expand courses and activities that explore the multifaceted issue. The present study

39 examined the cultural competence of nursing students at Fresno State and the role of participation of cultural competence programming and individual features in shaping knowledge, attitudes and skills.

CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY The purpose of this research was to examine the cultural competence of nursing students at Fresno State and how cultural competency training portion of the school’s program shaped the students’ skills, knowledge, and awareness regarding cultural issues. This chapter presents the methods that were used to investigate the hypotheses that were previously defined. The type of data, the methods used to collect the data, and how the data were analyzed are described. This descriptive study sought to identify different perceptions of cultural competency in the nursing program with respect to the age, gender, race/ethnicity, and immigrant background of students. Setting and Population The study was conducted on the Fresno State campus in order to examine a college nursing student population. Fresno State was chosen as the setting for this study because no study had been done at this school to assess the cultural competency of nursing students and explore the differences cultural and ethnic backgrounds of students can have on cultural competency. Both undergraduate and graduate nursing students participated in the study. Study Setting This research was conducted at Fresno State. The school as well as the area in which it is situated is ethnically and culturally diverse. The emphasis on cultural competence acknowledges strengths in all cultures and sub-cultures. Incorporating cultural competence into service improvement in the nursing profession focuses on members of four target minority groups: African American, Asian American, Hispanic American, and Native American (Laws & Chilton, 2013). The research

41 setting provided opportunities for participants to experience cultural encounters with all four groups. The study site is located in the Central Valley of California. California’s population in 2012 was estimated at 38,041,430. From the American Community Survey, the distribution of the major ethnic groups is as follows: 32.2% were White, 50.8% were Hispanic or Latino, 9.4% were Asian and 0.5% were American Indian or Alaska Native (U.S. Census Bureau, 2013a). Study Design The study conducted was a cross sectional, observational study. Three constructs of Campinha-Bacote’s (2002) cultural competence theory: skill, knowledge, and awareness were emphasized. Participants performed selfassessments with the use of the Cultural Awareness Student Survey (CAS), located in the Appendix. Students reported their perceptions of their status on cultural competency. The two other constructs of the model will be examined only briefly. The construct of cultural encounters is not a great concern for this particular study because the study population, by virtue of its demographics and geographic setting, experiences a variety of cultural encounters with patients. Cultural desire is not examined in detail because it is a construct that rests on personal motivation. Instrument The instrument that measured the variables associated with cultural competence was the CAS. The instrument enabled the study to identify differences between the students’ cultural competence and racial/ethnic background, class standing and participation in a program where the curriculum incorporated cultural competency. The instrument was the CAS designed by Rew et al. (2003). The

42 researchers established the reliability and content validity of the instrument. A Cronbach’s alpha reliability coefficient of .91 was obtained from a sample of 72 student nurses. In the second phase, the items were presented to a panel of experts in nursing and culture to determine content validity. A content validity index of .88 was calculated. Cronbach’s alpha coefficients for the five categories ranged from .66 (Awareness of Attitudes) to .88 (Research), .81 (Classroom and Clinical Instruction), .83 (General Educational Experiences) and .88 (Clinical Practice). In the present study, a reliability test was conducted and Cronbach’s Alpha reliability coefficient was .847. Cronbach’s alpha coefficients for the five categories ranged from .82 (Awareness of Attitudes) to .81 (Research), .82 (Classroom and Clinical Instruction), .79 (General Educational Experiences) and .82 (Clinical Practice). Preceding the CAS, 14 demographic items were included: gender, age, race/ethnicity, graduation date, parents’ origin of birth, second language spoken at home (if yes, students were asked to specify what language), identified as a first, second or third generation student, which program currently enrolled in BSN or MSN, and current location of practicum site. Two questions pertaining to the nursing curriculum were: whether the curriculum’s cultural competency course work increased the students’ cultural competency by: completing a course that emphasized cultural competency and if the student engaged in opportunities presented by the program to enhance learning of cultural competency (if yes, students were asked to specify). The CAS consisted of five subscales: General Educational Experience (14 items) pertained to general educational experiences related to cultural awareness, Cognitive Awareness (7 items) addressed personal beliefs of the student, Research Issues (4 items) how the student perceives if research done is relevant to cultural

43 issues , Behaviors/Comfort with Interactions (6 items) referred to the student’s behavior and comfort with people from different cultural backgrounds, and Care/Clinical Issues (5 items) related to the knowledge and of working with patients from different cultural backgrounds . In the original study done by Rew et al. (2003), the Likert scale was from a one to six. For the present study, the scale was modified into zero to six. Naturally, the results of means from this study will be smaller. Responses to each item are indicated on a Likert-type scale ranging from 0 to 6, with 0 being “strongly disagree” and 6 being “strongly agree.” A total of six items are reversed coded—that is, the direction of the scale is reversed—in order to reduce response bias. Data Collection This study used primary data collected through the service of Google Docs. With the cooperation of the Nursing Department, the survey was e-mailed to participants. Student participants were asked not to share their names and the electronic survey did not provide an opportunity for students to disclose any information other than responses to the survey items. A total of 491 students were emailed the survey link that took them to the Google forms application that hosted the instrument. Students were informed that the survey would take approximately 15 minutes to complete. Data collected were saved on a password-protected account through Google Documents. Data collection started February 3, 2015, and continued with weekly reminders for students to participate. The study concluded data collection on February 26, 2015.The researcher assumed students were truthful in their answers and the data were therefore accurate. Surveys were disseminated to participants in four waves: February 3 (34 responses), February 9 (90 responses), February 17 (36 responses), and February

44 23 (43 responses). The 21 Doctor of Nursing Practice students were omitted from the study because of their heavily research-oriented coursework. The total number of completed surveys was 182. The response rate was 41.3% Data Analysis The Statistical Package for the Social Sciences (SPSS) was used to perform statistical tests on the collected data. Before conducting analysis, the reverse phrased items (8, 9, 12, 13, 16, and 22) were reversed scored. To reflect this analytical adjustment, their scores fell into the range of 0= strongly agree to 6=strongly disagree. One-way Analysis of Variance (ANOVA) was used to analyze the independent variable of race/ethnicity, which had several categorical groups. Each subscale of the CAS was scored to yield means; this was done for by adding the total points in the subscale divided by the number of items in the subscale. A total composition score of the five subscales was calculated to reflect a student’s overall CAS score; this was done by adding the individual subscale scores together and dividing by five. This score was represented in the tables as “CULCOMP”. Missing data were not used in the computations for descriptive statistics and for ANOVA. The CAS score was then used in ANOVA to test against the three hypotheses. Summary The purpose of this research was to evaluate the cultural competency of students from different racial/ethnic and immigrant backgrounds and components of the nursing program in providing course work that enhanced cultural competence in areas of skill, knowledge, and awareness. This was accomplished by administering the CAS to undergraduate and master students in the nursing programs at Fresno State.

CHAPTER 4: RESULTS This study examined the cultural competence of nursing students at Fresno State and how the cultural competency training portion of the program shapes the students’ skills, knowledge, and awareness regarding cultural issues. The descriptive study utilized the CAS to survey 182 Fresno State student participants during the spring 2015 semester. Included in this chapter are the demographics of the students that participated in the study, characteristics of students such as language, immigration status, and admission status. The means of the current and original study are presented. Means and standard deviations by variables are presented in tables and are arranged accordingly to their ANOVA tests. This chapter provides the descriptive statistics that were derived from the study. Demographics Study participants were currently enrolled nursing students at Fresno State. The CAS was distributed by e-mail to all BSN and MSN nursing students during the spring 2015 semester. Tables 1 and 2 present the demographic characteristics of the participants. The mean age of participants was 26.92 years. The most common race/ethnicities were non-Hispanic White and Hispanic-Latino. A total of 77% of the students were born in the United States, 55.5% of the students responded that both parents were not born in the United States. A total of 48.4% of students spoke another language other than English at home. The majority of students (54.4%), enrolled in the program identified as being first generation students. Students with parents not born in the United States represented the majority of the population with 55.5%. The distribution of students who took a course in cultural competence in the nursing program and of those who engaged in opportunities to enhance the learning of multicultural health is shown in Table 3.

46 Table 1 Demographic Composition of Sample Demographic Variable Gender Male Female Missing Age 20-24 25-29 30-34 35-39 40+ Missing Race/ethnicity Non-Hispanic White Asian/Asian American Hispanic/Latino African American/Black Hawaiian/Pacific Islander American Indian/Alaskan Native Multi-Racial Other Missing Nursing Program BSN MSN Missing Graduation Year 2015 2016 2017 Total

n

%

24 153 5

13.2 84.1 2.7

112 26 16 12 16 0

61.5 14.3 8.8 6.6 8.8 0.0

69 51 42 2 3 1 3 11 0

37.9 28.0 23.1 1.1 1.6 0.5 1.6 6.0 0.0

148 34 0

81.3 18.7 0.0

56 58 68

30.8 31.9 37.4

182

100.0

47

Table 2 Participants’ Birthplace, Language, and Admission Status Characteristic

n

%

Born in the United States Yes No Missing

141 41 0

77.5 22.5 0.0

Both parents born in the United States Yes No Missing

81 101 0

44.5 55.5 0.0

Language spoken other than English Yes No Missing

88 92 2

48.4 50.5 1.1

Admission status First-generation student Second-generation student Third-generation student

99 60 23

54.4 33.0 12.6

Total

182

100.0

48 Table 3 Distribution of Participants with Cultural Competence Program Involvement Cultural competence in curriculum

n

%

Taken a course that emphasized cultural competence Yes No Missing Total

139 39 4 182

76.4 21.4 2.2 100.0

Engaged in program opportunities to enhance learning of multicultural health Yes No Missing Total

93 86 3 180

51.1 47.3 1.6 100.0

The mean scores and standard deviation by subscales are presented in Table 4. Students scored the highest on the Cognitive Awareness subscale and scored the lowest on the Behaviors/Comfort with Interactions subscale. Table 4 Participants’ CAS Mean Scores and Standard Deviation by Subscale Std. D

Section General Educational Experience Cognitive Awareness Research Issues Behaviors/Comfort with Interactions Patient Care/Clinical Issues

3.88 3.98 3.78 1.91 4.80

1.01 1.22 1.29 .840 1.15

Total

3.67

.807

49 Analysis of Hypotheses The three hypotheses designed for this study were analyzed and the results are presented below. Accommodating the ANOVA tables are the corresponding descriptive statistic tables organized by the study’s variables. Hypothesis 1 Hypothesis 1 stated: There is no significant difference in cultural competence between students of different class standings in the nursing program. As displayed in Table 5, One-way ANOVA showed the following differences between BSN and MSN students: F (1, 158) = 1.01, p = .32, M = 3.66, SD = .807. Because the p-value is greater than 0.05, there is no statistically significant difference and the null hypothesis is accepted. Table 5 One Way ANOVA Summary Table for the Independent Variable Class Standing Source

Df

SS

MS

F

p

Between groups

1

0.66

0.66

1.01

0.32

Within groups

158

102.89

0.65

Total

159

103.55

As displayed in Table 6, students in the MSN program scored higher on the CAS than BSN students. Both groups scored the lowest on the Behaviors/comfort with interactions subscale. Both groups scored the highest on the Care/clinical issues subscale. Graduation dates, also used for testing this hypothesis, the One was ANOVA is presented in Table 7. The test produced an F (1, 158) = .244, p=.80, M = 3.66, SD = .807, further accepting the null hypothesis.

50

Table 6 Means and Standard Deviations for CAS Subscales, by Nursing Program CAS Subscales

BSN n

M

MSN SD

n

M

Total SD

n

M

SD

General education experience

140 3.86 1.04

31

4.00 0.84 171 3.88 1.00

Cognitive awareness

146 3.92 1.20

33

4.26 1.14 179 3.98 1.19

Research Issues

139 3.71 1.29

34

4.03 1.29 173 3.78 1.30

Behaviors/comfort with interactions

145 1.92 0.80

34

1.85 1.09 179 1.91 0.86

142 4.82 1.17

32

4.76 1.09 174 4.81 1.15

131 3.63 0.79

29

3.79 0.88 160 3.66 0.81

Care/clinical issues Cultural competence

Table 7 One Way ANOVA Summary Table for the Independent Variable Graduation Year Source

df

SS

MS

F

p

Between groups

2

0.29

0.15

0.22

0.80

Within groups

157

103.25

0.66

Total

159

103.55

51 As displayed in Table 8, the newest cohort of students, class of 2017 scored the highest on the CAS. All groups scored the lowest on the Behaviors/comfort with interactions subscale. All groups scored the highest on the Care/clinical issues subscale. Table 8 Means and Standard Deviations for CAS Subscales, by Graduation Year CAS Subscales

2015 n

M

General education experience

52

3.73

Cognitive awareness

55

Research Issues

2016 SD

2017

n

M

SD

n

M

1.01

54

4.02

0.77

65

3.89

4.07

1.17

56

4.08

0.82

68

52

3.69

1.37

56

3.85

1.10

Behaviors/comfort with interactions

55

1.91

0.90

57

2.04

Care/clinical issues

45

4.85

1.10

55

Cultural competence

48

3.63

0.82

51

Total SD

n

M

SD

1.17

171

3.88

1.00

3.83

1.44

179

3.98

1.19

65

3.80

1.40

173

3.78

1.30

0.88

67

1.81

0.81

179

1.91

0.86

4.75

1.00

66

4.82

1.31

174

4.80

1.15

3.72

0.66

61

3.63

0.91

160

3.66

0.81

Hypothesis 2 Hypothesis 2 stated: There is no significant difference in cultural competence between students of different racial/ethnic and immigrant backgrounds. As displayed in Table 9, one-way ANOVA revealed the following: For race/ethnicity, F(2,140) = 1.07, p = .345, M = 3.66, SD = 0.796. The p-value was greater than 0.05, this indicated there was not a statistically significant difference and the null hypothesis is accepted.

52 Table 9 One Way ANOVA Summary Table for the Independent Variable Race-Ethnicity Source df SS MS F p Between groups Within groups Total

2 140 142

1.36 88.71 90.07

0.67 0.63

1.07

0.35

Data from Table 10 indicate that the race/ethnicity with the highest CAS score was Hispanic/Latino, followed by Non-Hispanic White and Asian. Originally, race was broken out into at least eight categories, but descriptive statistics showed very few people in five of these groups (e.g., two African Americans). This was not a valid test as presented and a four level variable (NonHispanic White, Hispanic/Latino, Asian and Other) was not interpretable because there is a problem here with the “other” group, about 20 people or 11% of total and are very diverse therefore, ANOVA was run with just three race/ethnicity groups. The totals represented are for just the three groups. All groups scored the lowest on the Behaviors/comfort with interactions subscale. All groups scored the highest on the Care/clinical issues subscale. The only subscale where NonHispanic White students scored the highest was in General education experience. For students born in the United States, F (1, 3) = 5.33, p = .63, M = 1.95, SD = 0 .328. The p-value greater than 0.05 indicated there was not a statistically significant difference between being born in the United States and not being born in the United States (Table 11). In Table 12, students born outside the U.S. had a higher CAS score of 3.75. Both groups scored the highest on the Care/clinical issues subscales. Students born in the U.S. scored the lowest (1.86) on the General education experience subscale. Students born outside the U.S. scored the lowest on the Behaviors/comfort with interactions subscale (1.82).

53

Table 10 Means and Standard Deviations for CAS Subscales, by Race/Ethnicity CAS Subscales

Non Hisp. White n

M

SD

Hispanic/Latino n

M

SD

Asian n

M

Total SD

n

M SD

General education experience

66

3.97 0.98

47

3.90 1.03

41

3.82 0.97

154

3.91 0.99

Cognitive awareness

68

3.73 1.17

50

4.33 1.16

41

3.99 1.09

159

3.98 1.17

Research Issues

65

3.80 1.33

49

3.92 1.38

39

3.60 1.27

153

3.79 1.33

Behaviors/comfort with interactions

66

1.89 0.88

51

2.05 0.95

42

1.75 0.70

159

1.91 0.87

Care/clinical issues

65

4.77 1.33

48

4.91 0.98

41

4.84 0.93

154

4.80 1.11

Cultural competence

60

3.63 0.87

46

3.81 0.77

37

3.57 0.69

143

3.67 0.80

Table 11 One Way ANOVA Summary Table for the Independent Variable Immigrant Status Source

df

SS

MS

F

p

Between groups

2

0.62

0.31

0.47

0.63

Within groups

157

102.94

0.66

Total

159

103.55

54 Table 12 Means and Standard Deviations for CAS Subscales, by Immigrant Status CAS Subscales Born in the U.S. Born Outside U.S. Total n M SD n M SD n M SD General education 136 1.86 1.01 34 3.98 1.01 170 3.88 1.00 experience Cognitive 138 3.91 1.17 40 4.21 1.17 178 3.99 1.19 awareness Research 134 3.70 1.25 38 4.01 1.31 172 3.78 1.29 Issues Behaviors/comfort 139 1.94 1.01 39 1.82 0.82 178 1.91 0.86 with interactions Care/clinical 137 4.82 1.16 36 4.72 1.15 173 4.81 1.15 issues Cultural 129 3.63 0.80 30 3.75 0.81 160 3.66 0.81 competence Table 13 displays the One-way ANOVA results for the variable student status. There were no significant differences between first-, second-, and thirdgeneration students; F (2, 157) = 1.406, M = 3.66, SD = 0.807. The p-value of .248 for this variable is greater than 0.05; therefore, the null hypothesis is accepted. Table 13 One Way ANOVA Summary Table for the Independent Variable Student Status Source

Df

SS

MS

F

p

Between groups

2

1.82

0.91

1.406

0.25

Within groups

157

101.73

0.65

Total

159

103.55

As displayed in Table 14, third generation students scored the highest on the CAS. All groups scored the lowest on the Behaviors/comfort with interactions subscale. All groups scored the highest on the Care/clinical issues subscale.

55 Table 14 Means and Standard Deviations for CAS Subscales, by Student Status CAS Subscales

First Generation n

M

SD

Second Generation

Third Generation

n

M

SD

n

M

Total

SD

n

M

SD

General education experience

93

3.89 1.05

59

3.78

1.04

19

4.20 0.97

171

3.88 1.00

Cognitive awareness

97

3.96 1.19

60

3.94

1.28

22

4.24 0.97

179

3.98 1.19

Research Issues

95

3.69 1.35

56

3.74

1.21

22

4.28 1.21

173

3.78 1.30

Behaviors/comfort with interactions

99

1.77 0.78

58

1.99

0.89

22

2.33 0.99

179

1.91 0.87

Care/clinical issues

94

4.80 1.25

58

4.77

1.04

22

4.95 1.01

174

4.80 1.15

Cultural competence

88

3.59 0.87

53

3.68

0.72

19

3.93 0.74

160

3.66 0.81

There was no statistical significance between participants’ language spoken (language other than English) and cultural competence, this is represented in Table 15. The One-way ANOVA revealed, F (2, 157) = 0.469, p = .26, M = 3.66, SD = 0.807; there is no statistically significant difference for this variable and the null hypothesis is accepted. Table 15 One Way ANOVA Summary Table for the Independent Variable Language Source

df

SS

MS

F

p

Between groups

1

0.83

0.83

1.29

0.26

Within groups

156

99.95

0.64

Total

157

100.77

56 Multilingual students scored higher (3.74) on the CAS than their monolingual counterparts (3.60) as displayed in Table 16. Both groups scored the lowest on the Behaviors/comfort with interactions subscale. Both groups scored the highest on the Care/clinical issues subscale. Table 16 Means and Standard Deviations for CAS Subscales, by Language CAS Subscales

Monolingual

Multilingual

n

n

M

M

SD

SD

Total n

M

SD

General education experience

88

3.90 1.03

81

3.89 0.96 169 3.89 0.99

Cognitive awareness

91

3.71 1.23

86

4.30 1.07 177 3.99 1.19

Research Issues

87

3.79 1.31

84

3.80 1.30 171 3.78 1.29

Behaviors/comfort with interactions

90

1.93 0.90

87

1.90 0.84 177 1.91 0.87

Care/clinical issues

89

4.78 1.28

83

4.85 1.01 172 4.81 1.15

Cultural competence

83

3.60 0.90

75

3.74 0.70 158 3.66 0.80

Hypothesis 3 Hypothesis 3 stated: There is no significant difference in cultural competence between students of different levels of participation in the nursing program’s integration of cultural competence. For the variable of students who engaged in opportunities to enhance the learning of multicultural health is shown in Table 17. One-way ANOVA revealed the following: For students that have engaged in opportunities the program has established (for those that did not) and

57 cultural competency, F (1, 156) = .320, p = .572, M = 3.64, SD = .804. The pvalue was greater than 0.05 and the null hypothesis was accepted. Table 17 One Way ANOVA Summary Table for the Independent Variable Opportunity Source

df

SS

MS

F

p

Between groups

1

0.21

0.21

0.32

0.57

Within groups

156

101.30

0.65

Total

157

101.51

Students that were engaged in extracurricular opportunities the program had established to enhance learning of multicultural health scored higher than students that did not engage in opportunities. Table 18 shows that both groups scored the lowest on the Behaviors/comfort with interactions subscale. Both groups scored the highest on the Care/clinical issues subscale. The One-way ANOVA results of students who took a course in cultural competence in the nursing program is displayed in Table 19. Between students who took a course that emphasized cultural competence (for those that did not) and cultural competency, F (1, 154) = .489, p = .486, M = 3.67, SD = 0.806. The p-value greater than 0.05 means there was no statistically significant difference and the null hypothesis was accepted. As reported in Table 20, the students that reported taking a course that emphasized cultural competence had a higher CAS than students who did not take the course. Both groups scored the lowest on the Behaviors/comfort with interactions subscale. Both groups scored the highest on the Care/clinical issues subscale.

58

Table 18 Means and Standard Deviations for CAS Subscales, by Opportunity CAS Subscales

Extra Curricular n

M

No Extra Curricular

SD

n

M

Total

SD

n

M

SD

General education experience

85

4.00 0.98

83

3.73

1.06

168 3.87 1.01

Cognitive awareness

91

3.95 1.22

85

4.00

1.17

176 3.97 1.19

Research Issues

88

3.87 1.22

83

3.62

1.38

171 3.75 1.19

Behaviors/comfort with interactions

90

1.97 1.16

85

1.85

1.15

171 4.79 1.15

Care/clinical issues

86

4.72 1.16

85

4.86

1.55

171 4.79 1.15

Cultural competence

77

3.68 0.74

81

3.61

0.86

158 3.67 0.80

Table 19 One Way ANOVA Summary Table for the Independent Variable Course Source

Df

SS

MS

F

p

Between groups

1

0.32

0.32

0.49

0.49

Within groups

154

100.45

0.65

Total

155

100.75

59 Table 20 Means and Standard Deviations for CAS Subscales, by Curriculum CAS Subscales

CC Course Was Taken n

M

SD

CC Course Was Not Taken n

M

SD

Total n

M

SD

General education experience

130 3.96 0.98

37

3.67 1.06 167 3.90 1.00

Cognitive awareness

137 4.01 1.20

38

3.93 1.18 175 4.00 1.19

Research Issues

132 3.89 1.34

37

3.49 1.10 169 3.80 1.30

Behaviors/comfort 139 1.86 0.83 with interactions

39

2.09 0.97 175 1.91 0.87

Care/clinical issues

132 4.88 1.10

38

4.67 1.33 170 4.82 1.16

Cultural competence

120 3.70 0.83

36

3.59 0.74 156 3.67 0.81

CHAPTER 5: DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS This study explored whether differences in students’ racial and ethnic backgrounds significantly influenced their cultural competency while enrolled in the nursing program at Fresno State. The Cultural Awareness Student (CAS) Survey was used to measure cultural competency awareness and the data collected were analyzed using the SPSS one-way analysis of variance test. The variables examined were students’ race/ethnicity; admission status as first-, second-, or third-generation; bilingual ability; and immigrant status. The literature reviewed suggested that all the variables mentioned were factors in cultural competency. This chapter discusses the sample of Fresno State nursing students as compared to the general population of nursing students and describes limitations of this study and recommendations for future research. Sample The study used a convenience sample. A sample size of 150 was anticipated; the final number of participants was 182. At the time of the study, 360 BSN students and 80 MSN students for a total of 440 were enrolled at Fresno State. The following table shows the Fall 2014 semester race demographics of the nursing student population. The sample size for the current study had a similar demographic break down for race/ethnicity and this is represented in Table 21. The major groups were students from non- Hispanic white and Hispanic/Latino backgrounds. This population is also comparable to the university as a whole. As of Fall 2014, Hispanic students make up 43.4 % of the total student population, followed by Whites (24.4%), Asians (14.5%), African Americans (3.5%), American Indians (0.4%) and Pacific Islanders (0.2%) (Fresno State University, Office of Institutional Effectiveness, 2014).

61 Table 21 Race/ Ethnicity of Fresno State Nursing Students and of Study Sample Nursing Sample

Race/ethnicity

Study Sample

n

%

BSN Students Non-Hispanic White Asian/Asian American Hispanic/Latino African American/Black Hawaiian/Pacific Islander American Indian/Alaskan Native Multi-Racial Other

126 90 92 5 1 4 12 17

29.5 21.1 21.5 1.2 0.2 .94 2.8 4.0

MSN Students Non-Hispanic White Asian/Asian American Hispanic/Latino African American/Black Hawaiian/Pacific Islander American Indian/Alaskan Native Multi-Racial Other

24 25 17 2 0 1 1 9

5.6 5.9 4.0 0.5 0.0 0.2 0.2 2.1

10 10 10 1 0 0 0 3

5.5 5.5 5.5 0.5 0.0 0.0 0.0 1.6

426

100

182

100

Total

n

%

59 32.4 41 22.0 32 17.6 1 0.5 3 1.6 1 0.5 3 1.6 8 4.4

Overall, students scored average with a total mean of 3.67. Rew et al. (2003) reported a total mean score was 5.32. In comparison, other studies that have used the CAS (Krainovich-Miller et al., 2008; Rew et al., 2003) reported students having high mean scores on all dimensions of CAS. The present study’s lowest rated subscale was a 1.91 for Behaviors/Comfort Interactions. It is important to acknowledge that the process of attaining cultural competency is a constant cycle of reflection and development, referring to Campinha-Bacote’s

62 (2002) theory; it is an ongoing journey with constant cultural encounters. Therefore, having a high score only denotes the fact that a person has had strong experiences, but the state of actually being culturally competent is never achieved. Results from this study indicated concerns with the Hawthorne effect. This effect occurs when participants improve performance when they know they are being observed. Sampling Bias The response rate for this study was 41.3%. This response rate is consistent with other studies using electronic survey methodologies (Nulty, 2008). In addition, the study survey response rate exceeded that of other studies of college students. The National College Health Association – National College Health Survey (ACHA – NCHS) reported a 19.1% response rate for electronic survey administration. Response rates to e-mail surveys have decreased since the late 1980s (Fincham, 2008). This study’s response rate is good for the college population and electronic surveys. In comparison to another college study, the response rate on the spring 2013 Fresno State ACHA was 19.2% (763 respondents) and this was an acceptable rate. A bias in this study is that it was only done electronically; studies have shown that instruments administered face to face have higher response rates. All students enrolled in the BSN and MSN programs were e-mailed over a span of a month, producing multiple waves of responses that increased response rates. Self-selection bias occurred; that is, the students had control over whether to participate in the study. The self-selection may affect the study, making the sample non-representative because students most likely to have participated were highly motivated to respond with strong opinions. Self-selection bias can lead to under

63 representation of certain groups in the study population. Participants were from a single university; therefore, findings cannot be generalized to all nursing students. Also missing data from students who did not finish the CAS compromised descriptive statistics when conducting cross tabulation of the population. These biases should be taken into consideration prior to making generalizations regarding this study. The sample was comparable of the demographic population of nursing students at the university. Nurses are exposed to a wide array of ethnic and crosscultural care and work with people of different ethnic groups. Attempts have been made in nursing schools to cover cross-cultural health issues (Mareno & Hart, 2014). Nursing accreditation requirements acknowledge the importance of implementing cultural competence in curricula in order to enable the newly graduated nursing workforce to succeed in a multiethnic work environment (ACEN, 2013; American Association of Colleges of Nursing, 2008). However, there is a dearth of literature that does not examine the relationship of a nursing curriculum’s training in cultural competency and how it influences the preparedness of students. Comparison to Rew et al., Study (2003) Table 22 shows the difference of CAS mean scores between the present study and the original study. Rew et al. (2003) had a higher mean score of 5.32 for the overall score of the instrument. Because the current study had a 0 through 6 scale, the means are lower in comparison to the Rew et al. study which had a scale from 1 through 6. The scores are comparable, but the current study’s results are limited due to the sampling biases that were expressed in the previous section. Three fourths of the participants from the Rew et al. (2003) study were BSN

64 students while only 17% of the sample was MSN students; these proportions are true for the current study as well. Overall, participants in the Rew et al. study had high mean scores on the five dimensions of the instrument. This is because the Rew et al. study was conducted at the completion of the 3-year nursing program where the study was done. The current study was conducted with a sample that had students from different cohorts. It is possible that since the other study was conducted at the program’s end, cultural awareness was raised because of the training and education received from the program. Table 22 Participants’ CAS Mean Scores by Subscale for Rew et al., 2003 Study Section

Rew Study

Current Study

General Educational Experience Cognitive Awareness Research Issues Behaviors/Comfort with Interactions Patient Care/Clinical Issues

5.18 5.54 4.41 5.39 5.99

3.88 3.98 3.78 1.91 4.80

Total

5.32

3.67

Discussion of Hypotheses Hypothesis 1 The first hypothesis stated there was no statistically significant difference between students of different class standings in the nursing program and cultural competence. Results revealed no statistical difference in cultural competence among nursing students of different academic years or between BSN and MSN students. The p value of .82 attained for graduation year did not indicate a trend

65 toward significance. MSN students did score higher on the CAS than BSN students. A probable reason may be because of the additional schooling and exposure to a more rigorous curriculum. The literature suggested a difference would be found between BSN and MSN students. Krainovich-Miller et al. (2008) found significant differences between these groups of student but also reported that BSN students at the beginning of their nursing program exhibited lower cultural competence than at the end of the program. This observation suggests that cultural competence is an ongoing process rather and an outcome for students (Bednarz et al., 2010). Campinha-Bacote’s construct of awareness emphasizes that the important element in cultural competence is awareness. Healthcare provider should reflect in depth on their professional backgrounds to discover whether they have biases towards any cultural groups. Several studies (Ahmed & Bates, 2012; Calhoun, Rider, Meyer, & Stewart, 2009; Epner & Baile, 2012; Sargent et al., 2005) support the layering approach of teaching cultural competency by starting with building awareness. Cultural competence cannot be taught in one class and should be an area of focus for all students, building a foundation early on that should grow during their time in nursing school (Paez, 2009). Hypothesis 2 The second hypothesis stated there were no statistically significant differences between the students' racial/ethnic and immigrant background and the students' cultural competence. This study revealed a difference between the CAS mean score for students born in the United States those who immigrated. Students born in the United States had lower CAS scores (3.63) than those born outside of the United States (3.75). The variables of race/ethnicity and second language

66 spoken both had trends toward significance with p values of 0.35 and 0.26, respectfully. Although no statistically significance was found between cultural competency and race/ethnicity, second language and student admission status, it is important to acknowledge that there are far more factors from a person’s ethnic and racial background that can impact competency. The majority of students from the study identified as non-Hispanic white. The data collected are as follows: non-Hispanic White (37.9%), Hispanic/Latino (28%), African American (23.1%), Asian/ Asian American (1.11%), American Indian/Alaskan Native (0.5%). Students from Hispanic/Latino backgrounds scored an overall 3.81 and were the racial/ethnic group that had students with the highest scores for four out of the five subscales of the CAS. Literature reviewed explained that the growth of diversity within the nursing student body is recognized as an advantageous goal that will guarantee to benefit the discipline and the patients that are served by nurses (Bednarz et al., 2010). Fresno State’s student demographics can allow for a more diversified group. Bilingualism was not found statistically significant, but students with multi-lingual skills did score higher on the CAS with a score of 3.74 compared to their monolingual colleagues who scored 3.60. Literature supports the importance of having health professionals who possess skills in more than one language (Kalist, 2005). Campinha-Bacote’s construct cultural skill emphasizes identifying a patient’s need without stereotypical judgments. An important component of this construct is communication. Being bilingual in a patient’s language can greatly influence the experience the patient has while receiving care. A nurse must be able to accurately perform assessments during consultation, being bilingual can be a promising factor to working with underserved ethnic groups. Nursing students that

67 experience more cross cultural medicine develop stronger cultural skills that will follow them into their professional career. Nursing schools must be attentive in creating and sustaining programs which individuals from diverse backgrounds feel supported, encouraged, and valued for the richness they bring to the university setting (Milone-Nuzzo, 2007). The expansion of diversity within the nursing student profession is a desirable goal that promises to benefit both the practice discipline and the people nurses serve (Bednarz et al., 2010). Hypothesis 3 The third hypothesis stated there was no statistically significant difference between the students' participation in the nursing program's integration of cultural competence and the students' cultural competence. Results from the study showed that there was no statistical significant between the student’s participation and cultural competence. Although there was not a statistical difference, students that reported taking advantage of opportunities to increase cultural competency did have higher scores on the CAS than those who reported no engagement. The reviewed literature indicated that trans-cultural teaching strategies in class greatly impacted students. Opportunities to reflect in class on behaviors and feelings about cultural diversity reinforced self-assessments that could be used to evaluate a student’s biases (Hughes & Hood, 2007). Research has supported that students must be willing and encouraged to take advantage of the opportunities that nursing program exposes them to (Amerson, 2010; Caffrey et al., 2005; Fitzpatrick, 2007; Jarrell et al., 2014; Jeffers & Ferry, 2014; Wehling, 2008). The more knowledge accrued from cultural competent courses would allow for a

68 stronger grasp on a student’s level of comfort when working with ethnically diverse populations. Campinha-Bacote’s construct knowledge emphasizes the importance of learning about the community’s cultural beliefs that impact an individual’s health. The purpose of acquiring knowledge about diverse backgrounds is to ensure patient-centered care and personalization (Saha et al., 2008). The classroom is a strong setting that should allow students to question and critically assess their knowledge about the community they will be working with. Nurse educators should be readily able to fix conflicts of understanding. And to explain more developing complex issues, nurse educators need to increase their cultural competence in order to help students transition from a classroom setting to working with patients (Ume-Nwagbo, 2012). Results from the CAS subscale Care/Clinical Issues showed that students from this study reported they have the knowledge and of working with patients from different cultural backgrounds, but the reported lowest scores across the board from the subscale Behaviors/Comfort with Interactions indicates that students do not have enough experience and exposure working with multi ethnic populations. This can allow for a transition in the program to enhance opportunities in classes for students to gain further knowledge and practice to gaining an understanding of multicultural issues. The statistical findings were not consistent with the reviewed literature. A factor that may have contributed to the significance of these results is selection bias. Students may have felt the need to answer based on what they perceived their fellow peers would answer rather than their own personal opinions. There may have been response bias in that participants did not answer truthfully. Students may not have aware if classes presented materials considered as culturally competent coursework.

69 Implications for Public Health Due to the variations in the results, there are public health implications for cultural competency among nursing students. The results of this study were not consistent with all of the conclusions from previous studies discussed in the literature review regarding cultural competency curriculum in nursing programs. The study determined that cultural competency is impacted by race/ethnicity. The study also determined that cultural competency is not impacted by how long the student is enrolled in the program and classes taken that teach cultural competency. The variations of results of this study may be due to the diversity of students in the Fresno State nursing program, random variation, selection bias or response bias. Fresno State has a diverse student population. As of Fall 2014, Hispanic students make up 43.4 % of the total student population, followed by Whites (24.4%), Asians (14.5%), African Americans (3.5%), American Indians (0.4%) and Pacific Islanders (0.2%) (Fresno State University, Office of Institutional Effectiveness, 2014). Efforts made by the nursing program to increase minority students can enrich the nursing labor force. Nursing programs can have intervention efforts that can bring awareness to students’ risks of developing judgmental habits that can be produced by unchecked biases that inhibits care. As mentioned before, research is lacking regarding how nursing programs implement cultural competency training into nursing courses; thus identifying the deficits of students in this area is difficult. Instruments that measure cultural competence in nursing students and nursing professionals have been inadequate (Loftin et al., 2013). There is a dearth of information on how a student’s racial and ethnic background shapes their cultural competency while in a nursing program. Nursing schools and other relevant groups need to create programs to enroll and maintain

70 more individuals from racial and ethnic minorities; the nursing workforce is not reflective of the general population of the United States (Institute of Medicine, 2010; Rew et al., 2003) The research literature indicated a deficit in cultural competency training, the results from this study demonstrated that a majority of the students surveyed, no matter what their ethnic and racial background, across all independent variables scored the lowest on comfort with people from different cultural backgrounds. This can be interpreted that the students may have inadequate training as seen in the scores from the CAS subscale of Behaviors/Comfort with Interactions. With this study, more attention should be given to cultural sensitive teaching and to minority nursing students and how their racial ethnic background can shape their attitudes and skills. Another area of concern for implementing cultural competence training in curriculum is that nursing faculty should be adequately prepared to role model expected behaviors for students as they can the most frequent and direct contact with students. Nursing school curricula needs to consider the makeup of the patient population. Providing training to increase cultural encounters will mold attitudes, awareness and knowledge. The study findings show that students who matriculated through the program took advantage of classes and opportunities that emphasized the importance of cultural competence. Conclusions and Recommendations Overall, the results of this study demonstrate the importance of cultural competency in nursing curriculum. The population of nursing students and factors associated with cultural competency were not consistent with the findings from the literature. However, the literature identifying and describing instruments that

71 measure cultural competence in nursing students and nursing professionals is inadequate (Loftin et al., 2013). More studies need to be conducted with a reliable instrument that can measure cultural competence. The impact of cultural competency and its associated factors are significant among the population of nursing students that more studies need to be conducted to explore this issue. Students provided the highest rating for the Care/Clinical Issues subscale, this measured how culturally aware students felt while working with patients. Students may have felt they were culturally apt, but differences may exist between their perceptions and that of the patient’s. It would be valuable to measure the patient’s perception of the nurses’ cultural awareness and compare it to how the nurse scored themselves. This researcher further recommends that future studies be done with larger sample sizes that can be reflective of the student nursing populations being studied. A pilot study was not done; one should be done to clarify different perceptions. The response rate for this study was small and may have altered the results for this study. Future studies can examine how culturally competent recently graduated students are to see if skills learned in program are being used in their professional career. Another recommendation for future studies would be to administer the CAS to students preprogram and post-program to see if there was an increase in awareness because of program experience. In-depth studies on how ethnic minorities approach nursing based off their inherited and cultural background can be explored to find factors that influence awareness. In the future, dissemination of the instrument can be done in a hybrid effort; both email and paper can be used maximize student response rates. The electronic process took place over several weeks. Cooperation from several members from

72 the nursing faculty can allow for extra credit to be given for the completion of the survey as an incentive. In a conversation with Dr. Ndidi Griffin (N. Griffin, personal communication, November 5, 2014) Fresno State’s Director/Chair for the School of Nursing, no classes in the current curriculum have been earmarked as courses that provide culturally competent training. Further recommendations are for the School of Nursing to provide specific courses that are geared towards cultural training. In regards to students scoring the lowest on the Behaviors/Comfort with Interactions subscale, it is proposed that service learning courses be constructed to train with patients from different cultural backgrounds. Students scored lower than previous studies and this can be used as an opportunity to increase awareness, skill and knowledge that will ultimately impact the comfort of interactions students feel with the population they serve. The Fresno State’s School of Nursing currently does not implement a model of nursing; one would strengthen the curriculum in forming courses for cultural competency training. Campinha-Bacote’s model has been implemented into nursing programs in the state of California such as Loma Linda and San Jose State University (as cited in Lipson & Desantis, 2007). Following a model can perhaps help in reaching the goal of educating nurses on culturally competent practices and monitoring progress. Summary The purpose of this research is to identify differences in levels of cultural competence in students from different racial and ethnic immigrant backgrounds, while focusing on skills, attitudes, and knowledge (constructs of CampinhaBacote’s theory) among nursing students in a program that integrates cultural content into its curriculum. The utilized primary data was collected using the CAS

73 survey that was administered during the spring 2015 semester and was analyzed using the analysis of variance in SPSS for significance. The results of this study did not support the hypotheses: which was that there was statistically significant difference in racial/ethnic background and cultural competence; that class standing and the students' participation in the nursing program's integration of cultural competence. More studies should be conducted among the student nursing population to find differences in racial/ethnic backgrounds that shape skills and attitudes developed while in nursing school. Recommendations for future studies included having a larger sample size that would be more representative of the population being studied, as well as conducting in-depth studies on how ethnic minorities approach nursing based off their inherited and cultural background.

REFERENCES

REFERENCES Abbey, J. (2006). The impact of education and experience on physician assistant students’ perception of cultural awareness, knowledge and skills. Journal of Allied Health, 35(1), 24E-36E. Accreditation Commission for Education in Nursing. (2013). Accreditation manual standards and criteria. Retrieved from http://www.acenursing.net/ manuals/SC2013.pdf Adam, J. (2008). Transcultural nursing courses online: Implications for culturally competent care. Nursing Clinics of North America, 43(4), 567-574. Adams, K. (2010). Indigenous cultural competence in nursing and midwifery practice. Australian Nursing Journal, 17(11), 35-38. Aggarwal, N., & Desilva, R. (2013). Developing cultural competence in health care professionals: A fresh approach. Medical Education, 47(11), 1143-1144. Ahmann, E. (2002). Developing cultural competence in health care settings. Pediatric Nursing, 28(2), 133-137. Ahmed, R., & Bates, B. (2012). Development of scales to assess patients’ perception of physicians’ cultural competence in health care interactions. Journal of Transcultural Nursing, 23(3), 287-296. Alexander, G. (2008). Cultural competence models in nursing. Critical Care Nursing Clinics of North America, 20(4), 415-421. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Retrieved from http://www.aacn.nche.edu/educationresources/baccessentials08.pdf American College Health Association. (2011). ACHA guidelines: Cultural competency statement. Retrieved from https://www.acha.org/documents/ resources/guidelines/ACHA_Cultural_Competency_Statement_Feb2011.pdf American Heart Association. (2010). Patients in stroke belt satisfied with care, but many doctors lack cultural awareness. Cardiovascular Week, 922-1843. Retrieved from http://phys.org/news/2010-05-patients-belt-doctors-lackcultural.html

76 American Nurses Association. (2015). What nurses do. Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/ToolsYou-Need/RNsAPNs.html Amerson, R. (2010). The impact of service-learning on cultural competence. Nursing Education Perspectives, 31(1), 18-22. Angood, P. (2013). Demographics, shifting models of care and physician leadership. Physician Executive, 39(3), 4-5. Aponte, J. (2009). Addressing cultural heterogeneity among Hispanic subgroups by using Campinha-Bacote’s model of cultural competency. Holistic Nursing Practice, 23(1), 3-12. Association of American Medical Colleges. (2010, September 30). AAMC releases new physician shortage estimates post-reform. Retrieved from https://www.aamc.org/newsroom/newsreleases/2010/150570/100930.html Axtell, S., Avery, M., & Westra, B. (2010). Incorporating cultural competence content into graduate nursing curricula through community—university collaboration. Journal of Transcultural Nursing, 21(2), 183-191. Barrow, S. (2010). Treating patients from diverse populations. Access, 24(8), 3033. Bednarz, H., Schim, S., & Doorenbos, A. (2010). Cultural diversity in nursing education: Perils, pitfalls, and pearls. Journal of Nursing Education, 49(5), 253-260. Benkert, R., Templin, T., Schim, S., Doorenbos, A., & Bell, S. (2011). Testing a multi‐group model of culturally competent behaviors among underrepresented nurse practitioners. Research in Nursing & Health, 34(4), 327-341. Betancourt, J., Green, A., Carrillo, J., & Park, E. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs, 24(2), 499-505. Bloch, C. (2012). Cultural competency intervention program for healthcare Workers (Doctoral dissertation). Retrieved from ProQuest, UMI Dissertations Publishing. Bowen D., Haras, M., & Holman P. (2006). Cultural competence in a convenience sample of registered nurses in New Jersey. Union, NJ: Kean University.

77 Brennan, A., & Cotter, V. (2008). Student perceptions of cultural competence content in the curriculum. Journal of Professional Nursing, 24(3), 155-160. Burgess, D., Warren, J., Phelan, S., Dovidio, J., & van Ryn, M. (2010). Stereotype threat and health disparities: What medical educators and future physicians need to know. Journal of General Internal Medicine, 25(S2), S169-S177. Buscemi, C. (2011). Acculturation: State of the science in nursing. Journal of Cultural Diversity, 18(2), 39-42. Caffrey, R., Neander, W., Markle, D., & Stewart, B. (2005). Improving the cultural competence of nursing students: Results of integrating cultural content in the curriculum and an international immersion experience. Journal of Nursing Education, 44(5), 234-240. Calhoun, A. W., Rider, E. A., Meyer, E. C., Lamiani, G., &Truog, R. D. (2009). Assessment of communication skills and self-appraisal in the simulated environment: Feasibility of multi-rater feedback with gap analysis. Simulation in Healthcare, 4(1), 22-29. Calvillo, E., Clark, L., Ballantyne, J., Pacquiao, D., Purnell, L., Villarruel, A. (2009). Cultural competency in baccalaureate nursing education. Journal of Transcultural Nursing, 20(2), 137-145. Campinha-Bacote, J. (1998). Cultural diversity in nursing education: Issues and concerns. Journal of Nursing Education, 37(1), 3-4. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: The journey continues (5th Ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates. Campinha-Bacote, J. (2006). Cultural competence in nursing curricula: How are we doing 20 years later? Journal of Nursing Education, 45(7), 243-244. Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. Online Journal of Issues in Nursing, 16(2). Retrieved from http://www.nursingworld.org/ MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofCont ents/Vol-16-2011/No2-May-2011/Delivering-Patient-Centered-Care-in-theMidst-of-a-Cultural-Conflict.html Campinha-Bacote, J., Yahle, T., & Langenkamp, M. (1996). The challenge of cultural diversity for nurse educators. Journal of Continuing Education in Nursing, 27(2), 59-64.

78 Carnevale, F., Vissandjée, B., Nyland, A., & Vinet-Bonin, A. (2009). Ethical considerations in cross-linguistic nursing. Nursing Ethics, 16(6), 813-826. Chuang, C., Hwang, S., McCall‐Hosenfeld, J., Rosenwasser, L., Hillemeier, M., & Weisman, C. S. (2012). Primary care physicians’ perceptions of barriers to preventive reproductive health care in rural communities. Perspectives on Sexual and Reproductive Health, 44(2), 78-83.doi:10.1363/4407812 Clark, L., Calvillo, E., dela Cruz, F., Fongwa, M., Kools, S., Mastel-Smith, B. (2011). Cultural competencies for graduate nursing education. Journal of Professional Nursing, 27(3), 133-139. Comas-Diaz, L. (2011). Multicultural care: A clinician’s guide to cultural competence. Washington, DC: American Psychological Association. Coomer, N. (2011). Returns to bilingualism in the nursing labor market: Demand or ability? Journal of Socio-Economics, 40(3), 274-284. Cortese-Peske, M. (2013). Improving cultural competency and disease awareness among oncology nurses caring for adult t-cell leukemia and lymphoma patients. Retrieved from ProQuest, UMI Dissertations Publishing. Cowan, D., & Norman, I. (2006). Cultural competence in nursing: New meanings. Journal of Transcultural Nursing, 17(1), 82-88. Cuellar, N., Brennan, A., Vito, K., & de Leon Siantz, M. (2008). Cultural competence in the undergraduate nursing curriculum. Journal of Professional Nursing, 24(3), 143-149. de Leon Siantz, M., &Meleis, A. (2007). Integrating cultural competence into nursing education and practice: 21st century action steps. Journal of Transcultural Nursing, 18(1), 86S-90S.doi:10.1177/1043659606296465 Douglas, M., Rosenkoetter, M., Pacquiao, D., Callister, L., Hattar-Pollara, M., Lauderdale, J., …Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109-121. Duerksen, J. (2013). Retention and success of culturally diverse nursing students. The Oklahoma Nurse, 58(3), 4-5. Eva, K., & Regehr, G. (2005). Self-assessment in the health professions: A reformulation and research agenda. Academic Medicine, 80(10), S46-S54.

79 Epner, D., & Baile, W. (2012). Patient-centered care: The key to cultural competence. Annals of Oncology, 23(Suppl 3), 33-42. Fincham, J. E. (2008). Response rates and responsiveness for surveys, standards, and the Journal. American Journal of Pharmaceutical Education, 72(2), 43. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2384218/ Fitzpatrick, J. (2007). Cultural competence in nursing education revisited. Nursing Education Perspectives, 28(1), 5. Foronda, C. (2010). Associate degree nursing students’ thoughts, feelings and experiences of short study abroad in a low-income country (Doctoral dissertation). Marquette University, Milwaukee, WI. Retrieved from http://epublications.marquette.edu/dissertations_mu/51 Fresno State University, Office of Institutional Effectiveness. (2014). Quick facts fall 2014. Retrieved from http://www.fresnostate.edu/academics/oie /quickfacts/ Geiger, H. (2001). Racial stereotyping and medicine: The need for cultural competence. Canadian Medical Association Journal, 164, 1699-1700. Giger, J., Davidhizar, R., Purnell, L., Harden, J., Phillips, J., & Strickland, O. (2007). American academy of nursing expert panel report: Developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. Journal of Transcultural Nursing, 18(2), 95102. Gilbert, M. J. (2003). Principles and recommended standards for cultural competence education of health care professionals. Woodland Hills, CA: California Endowment. Retrieved from https://www.oakland.edu/upload/ docs/SOM/Diversity/principles_standards_cultural_competence-1.pdf Gilchrist, K., & Rector, C. (2007). Can you keep them? Strategies to attract and retain nursing students from diverse populations: Best practices in nursing education. Journal of Transcultural Nursing, 18(3), 277-285. Giles, E. (2008). Application of the interactional model of cultural diversity to identify diversity climate factors associated with organizational effectiveness in accredited U.S. physical therapist education programs (Doctoral dissertation). Norfolk, VA: Old Dominion University. Gordon, M. (1992). Self-assessment programs and their implications for healthprofessions training. Academic Medicine, 67(10), 672-679.

80 Graham, I., & Norman, L. (2008). A reflective discussion: Questions about globalization and multiculturalism in nursing as revealed during a student/staff exchange programme. International Journal of Nursing Practice, 14(3), 189-194. Grilo, A., Santos, M., Rita, J., & Gomes, A. (2014). Assessment of nursing students and nurses' orientation towards patient-centeredness. Nurse Education Today, 34(1), 35-39. Grossman, S., Mager, D., Opheim, H., & Torbjornsen, A. (2011). A bi-national simulation study to improve cultural awareness in nursing students. Clinical Simulation in Nursing, 8(8), e341-e346. Halloran, L. (2009). Teaching transcultural nursing through literature. Journal of Nursing Education, 48(9), 523-528. Halstead, J. (2012). Building faculty capacity in nursing education. Nursing Education Perspectives, 33(4), 220. Hempel, M. (2013). The United States of changing demographics. Policy & Practice, 71(2), 24. Hoffmann, R., Messmer, P., Hill-Rodriguez, D., & Vazquez, D. (2005). A collaborative approach to expand clinical experiences and cultural awareness among undergraduate nursing students. Journal of Professional Nursing, 21(4), 240-243. Holland, A. (2015). The lived experience of teaching about race in cultural nursing education. Journal of Transcultural Nursing, 26(1), 92-100. Horevitz, E., Lawson, J., & Chow, J. (2013). Examining cultural competence in health care: Implications for social workers. Health& Social Work, 38(3), 135-145. Hudelson, P. (2005). Improving patient-provider communication: Insights from interpreters. Family Practice, 22(3), 311-316. Hughes, K., & Hood, L. (2007). Teaching methods and an outcome tool for measuring cultural sensitivity in undergraduate nursing students. Journal of Transcultural Nursing, 18(1), 57-62. Ingram, R. (2012). Using Campinha‐Bacote’s process of cultural competence model to examine the relationship between health literacy and cultural competence. Journal of Advanced Nursing, 68(3), 695-704.

81 Institute of Medicine Committee on Quality of Health Care in America (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine. (2010). The future of nursing, leading change, advancing health. Retrieved from https://iom.nationalacademies.org/~/media/Files/Report%20Files/2010/TheFuture-ofNursing/Future%20of%20Nursing%202010%20Recommendations.pdf Jarrell, K., Ozymy, J., Gallagher, J., Hagler, D., Corral, C., Hagler, A. (2014). Constructing the foundations for compassionate care: How service-learning affects nursing students' attitudes towards the poor. Nurse Education in Practice, 14(3), 299-303. Jeffers, S., & Ferry, D. (2014). Nursing care at the end of life: A service learning course for undergraduate nursing students. Nurse Educator, 39(6), 307-310. Jimenez, T. (2010). Affiliative ethnic identity: A more elastic link between ethnic ancestry and culture. Ethnic and Racial Studies, 33(10), 1756-1775. Jhutti-Johal, J. (2013). Understanding and coping with diversity in healthcare. Health Care Analysis, 21(3), 259-270. Kalist, D. (2005). Registered nurses and the value of bilingualism. Industrial and Labor Relations Review, 59(1), 101-118. Kardong-Edgren, S., Bond, M., Schlosser, S., Cason, C., Jones, M., Warr, R., Strunk, P. (2005). Cultural attitudes, knowledge, and skills of nursing faculty toward patients from four diverse cultures. Journal of Professional Nursing, 21(3), 175-182. Kardong-Edgren, S. (2007). What kind of curricula produce the most culturally competent BSN graduates? A multi-site study (Unpublished manuscript). Washington State University, Pullman. Kattner, M. (2006). Creating an educational template to enhance cultural competence (Unpublished doctoral dissertation). Buntain School of Nursing, Northwest University, Kirkland, WA. Kirsch, R. (2013). The politics of Obamacare: Health care, money, and ideology. Fordham Law Review, 81(4), 1737-1747.

82 Krainovich-Miller, B., Yost, J., Norman, R., Auerhahn, C., Dobal, M., Rosedale, M., Moffa, C. (2008). Measuring cultural awareness of nursing students: A first step toward cultural competency. Journal of Transcultural Nursing, 19(3), 250-258. Krajic, K., Strassmayr, C., Karl-Trummer, U., Novak-Zezula, S., & Pelikan, J. (2005). Improving ethno-cultural competence of hospital staff by training. European Journal of Public Health, 15, 126-127. Larsen, R., & Reif, L. (2011). Effectiveness of cultural immersion and culture classes for enhancing nursing students’ transcultural self-efficacy. Journal of Nursing Education, 50(6), 350-354. Larson, K., Ott, M., Miles, J. (2010) International cultural immersion: En vivo reflections in cultural competence. Journal of Cultural Diversity 17(2), 4450. Laws, T., & Chilton, J. (2013). Ethics, cultural competence, and the changing face of America. Pastoral Psychology, 62(2), 175-188. Leuning, C., Swiggum, P., Wiegert, H., & Mccullough-Zander, K. (2002). Proposed standards for transcultural nursing. Journal of Transcultural Nursing, 13(1), 40-46. Lifshitz, A. (2006). Cultural awareness: A prescription for more effective medicine. Medscape General Medicine, 8(1), 17. Like, R.C. (2001). Clinical cultural competency questionnaire (pre-training version). Center for Healthy Families and Cultural Diversity, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School. http://rwjms.umdnj.edu/departments_institutes/family_medicine/chfcd/grants _projects/documents/Pretraining.pdf. Lima, S., Newall, F., Kinney, S., Jordan, H., & Hamilton, B. (2014). How competent are they? Graduate nurses self-assessment of competence at the start of their careers. COLLEGIAN, 21(4), 353-358. Lipson, J., &Desantis, L. (2007). Current approaches to integrating elements of cultural competence in nursing education. Journal of Transcultural Nursing, 18(1), 10S-20S. Loftin, C., Hartin, V., Branson, M., & Reyes, H. (2013). Measures of cultural competence in nurses: An integrative review. Scientific World Journal, 1-10.

83 Long, T. (2012). Overview of teaching strategies for cultural competence in nursing students. Journal of Cultural Diversity, 19(3), 102-108. Long, T. (2014). Influence of international service-learning on nursing student self-efficacy toward cultural competence. Journal of Nursing Education, 53(8), 474-478. Maier-Lorentz, M. (2008). Transcultural nursing: Its importance in nursing practice. Journal of Cultural Diversity, 15(1), 37-43. Majumdar, B., Browne, G., Roberts, J., & Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal of Nursing Scholarship, 36(2), 161-166. Marcinkiw, K. (2003). A goal for nursing education. Nurse Education Today, 23(3), 174-182. Mareno, N., & Hart, P. (2014). Cultural competency among nurses with undergraduate and graduate degrees: Implications for nursing education. Nursing Education Perspectives, 35(2), 83-88. Markova, T., & Broome, B. (2007). Effective communication and delivery of culturally competent health care. Urologic Nursing, 27(3), 239. Martin, C. (2008). Cultural competence. Kentucky Nurse, 56(1), 10. McNeal, G. (2012). The nurse faculty shortage. The ABNF Journal: Official Journal of the Association of Black Nursing Faculty in Higher Education, Inc, 23(2), 23. Mich, C., & Keillor, B. (2011). Ethnic identity: Understanding cultural differences within a culture. Marketing Management Journal, 21(2), 1-9. Milone-Nuzzo, P. (2007). Diversity in nursing education: How well are we doing? Journal of Nursing Education, 46(8), 343-344. Mkandawire-Valhmu, L., & Doering, J. (2012). Study abroad as a tool for promoting cultural safety in nursing education. Journal of Transcultural Nursing, 23(1), 82-89. Montenery, S., Jones, A., Perry, N., Ross, D., & Zoucha, R. (2013). Cultural competence in nursing faculty: A journey, not a destination. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 29(6), e51-e57.

84 Moxley, A., Mahendra, N., & Vega-Barachowitz, C. (2004). Cultural competence in health care. ASHA Leader, 9(7), 6-10. Narayanasamy, A. (2006). The impact of empirical studies of spirituality and culture on nurse education. Journal of Clinical Nursing, 15(7), 840-851 National Alliance for Hispanic Health (2001). A Primer for cultural proficiency: Towards quality health care services for Hispanics. Washington, DC: Author. National Center for Cultural Competence. (n.d.). Rationale for self-assessment. Retrieved from http://nccc.georgetown.edu/orgselfassess.html National Center for Cultural Competence. (n.d.). Conceptual frameworks / models, guiding values and principles. Retrieved from: http://nccc.georgetown.edu/foundations/frameworks.html National Institute on Minority Health and Health Disparities. (n.d.). Vision and mission. Retrieved from http://nimhd.nih.gov/about/visionMission.html National Institutes of Health. (2013). Cultural competency. Retrieved from http://www.nih.gov/clearcommunication/culturalcompetency.htm Noble, L. (2007). Effect of a cultural competence educational intervention on pediatric residents (Unpublished manuscript). Mount Sinai School of Medicine, Elmhurst, NY. Nulty, D. (2008). The adequacy of response rates to online and paper surveys: What can be done? Assessment & Evaluation in Higher Education, 33(3), 301-314. Olaivar, O. (2014). Transcultural self-efficacy perceptions of nurse practitioners in Fresno, California (Master’s thesis). Retrieved from ProQuest, UMI Dissertations Publishing. Ong, L., de Haes, J., Hoos, A., & Lammes, F. (1995). Doctor-patient communication: A review of the literature. Social Science & Medicine, 40, 903-918. Overman, V. (2009). National Center for Minority Health and Health Disparities. International Journal of Dental Hygiene, 7(2), 153.doi:10.1111/j.16015037.2008.00354.x

85 Pacquiao, D. (2007). The relationship between cultural competence education and increasing diversity in nursing schools and practice settings. Journal of Transcultural Nursing, 18(1), 28S-37S. Paez, K. (2009). Cultural competence and the patient-clinician relationship (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses. Pepper, G., Beck, S., Mooney, K., Clark, L., & Keefe, M. (2010). Enhancing diversity of nursing faculty using distance technology. Nursing Outlook, 58(2), 24-e25 Plotnikoff, G., & Barnes, L. (2000). Cross-cultural primary care. Annals of internal medicine, 132(2), 164. Purnell, L., & Paulanka, B. (2008). Transcultural health care: A culturally competent approach. Philadelphia: F.A. Davis. Reeves, J. (2001). Weaving a transcultural thread. Journal of Transcultural Nursing, 12(2), 140-145. Rew, L., Becker, H., Cookston, J., Khosropour, S. & Martinez, S. (2003). Measuring cultural awareness in nursing students. Journal of Nursing Education, 42(6), 249-257. Riley, D., Smyer, T., & York, N. (2012). Cultural competence of practicing nurses entering an RN-BSN program. Nursing Education Perspectives, 33(6), 381385. Robinson, B. (2005). Minority faculty: Another nursing shortage. The ABNF Journal: Official Journal of the Association of Black Nursing Faculty in Higher Education, Inc, 16(1), 3-4. Rudd, B., & Leimer, C. (2009). First generation students: First in the family, less likely to succeed. Retrieved from http://www.fresnostate.edu/academics/ oie/documents/documents-research/fgscgs_brief.pdf Sargent, S., Sedlak, C., & Martsolf, D. (2005). Cultural competence among nursing students and faculty. Nurse Education Today, 25(3), 214-221. Saha, S., Beach, M., & Cooper, L. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association, 100(11), 1275-1285.

86 Schneider, M. (2011). Health disparities persist in minority groups. Skin & Allergy News, 42(2), 44. Schouten, B., & Meeuwesen, L. (2006). Cultural differences in medical communication: A review of the literature. Patient Education and Counseling, 64(1), 21-34. Sealey, L., Burnett, M., & Johnson, G. (2006). Cultural competence of baccalaureate nursing faculty: Are we up to the task? Journal of Cultural Diversity, 13(3), 131-140. Shattell, M., Nemitz, E., Crosson, N., Zackeru, A., Starr, S., Hu, J., & Gonzales, C. (2013). Culturally competent practice in a pre-licensure baccalaureate nursing program in the United States: A mixed-methods study. Nursing Education Perspectives, 34(6), 383-389. Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Retrieved from http://coe.stanford.edu/courses/ethmedreadings06/em0601garcia2.pdf Stein, K. (2010). Moving cultural competency from abstract to act. Journal of the American Dietetic Association, 110(2), 180-184,187. Taylor, R., & Alfred, M. (2010). Nurses’ perceptions of the organizational supports needed for the delivery of culturally competent care. Western Journal of Nursing Research, 32(5), 591-609. Terry, M., & Leary, M. (2011). Self-compassion, self-regulation, and health. Self and Identity, 10(3), 352-362. Thomas, S., Fine, M., & Ibrahim, S. (2004). Health disparities: The importance of culture and health communication. American Journal of Public Health, 94(12), 2050. Tulman, L., & Watts, R. (2008). Development and testing of the blueprint for integration of cultural competence in the curriculum questionnaire. Journal of Professional Nursing, 24(3), 161-166. Ume-Nwagbo, P. (2012). Implications of nursing faculties’ cultural competence. Journal of Nursing Education, 51(5), 262-268. Unger, J., & Schwartz, S. (2012). Conceptual considerations in studies of cultural influences on health behaviors. Preventive Medicine, 55(5), 353-355.

87 U.S. Census Bureau. (n.d.). U.S. and world population clock. Retrieved from http://www.census.gov/popclock/?intcmp=home_pop U.S. Census Bureau. (2012). The 2012 Statistical Report. Retrieved from http://www.census.gov/compendia/statab/cats/population.html U.S. Census Bureau. (2013a). ACS Demographic and housing estimates. Retrieved from http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml? pid=ACS_14_1YR_DP02&prodType=table U.S. Census Bureau. (2013b). State and county quick facts: Fresno County, California. Retrieved from http://quickfacts.census.gov/qfd/states/06/ 06019.html U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. Retrieved from http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf U.S. Department of Health and Human Services, Office of Minority Health. (2013). What is cultural competency? Retrieved from http://www. minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=34 Vandenberg, H., & Kalischuk, R. (2014). Conceptualizations of culture and cultural care among undergraduate nursing students: An exploration and critique of cultural education. Journal of Cultural Diversity, 21(3), 99-107. Waite, R., & Calamaro, C. (2010). Cultural competence: A systemic challenge to nursing education, knowledge exchange, and the knowledge development process. Perspectives in Psychiatric Care, 46(1), 74-80. Ward, M., Gruppen, L., & Regehr, G. (2002). Measuring self-assessment: Current state of the art. Advances in Health Sciences Education, 7(1), 63-80. Wehling, S. (2008). Cross-cultural competency through service-learning. Journal of Community Practice, 16(3), 293-315. Whittemore, R. (2007). Culturally competent interventions for Hispanic adults with type 2 diabetes: A systematic review. Journal of Transcultural Nursing, 18(2), 157-166. Wiegerink-Roe, E., Rucker-Shannon, M. (2008). Immersion in China: Lessons learned. Nurse Educator, 33(2), 71-74.

88 Wilbur, V. (2008). Factors that influence the cultural competence of nurse students (Doctoral dissertation). Widener University, Chester, PA. Zoucha, R., & Broome, B. (2008). The significance of culture in nursing: Examples from the Mexican-American culture and knowing the unknown. Urologic Nursing, 28(2), 140-142.

APPENDIX: THE CULTURAL AWARENESS STUDENT SURVEY

90 California State University Fresno School of Nursing Cultural Awareness Student survey Developed by: Shirin Catterson, Jeff Cookston, Stephanie Martinez, Lynn Rew

This survey is voluntary. In an effort to learn more about the cultural competency of current Fresno State nursing students, we would appreciate your participation to hear about your attitudes, beliefs and experiences. Thank you in advance for taking time to fill out this survey. This information will be kept confidential.

Gender: Male Female Age: _____ Race: Non-Hispanic White Hispanic/Latino Black Asian/Asian American Hawaiian/Pacific Islander American Indian/Alaska Native Racial:__________ Other Were you born in the United States? Yes No Were your parents born in the United States? Yes Do you speak a language other than English at home? If yes, please specify: _______________

African American/ Multi-

No Yes

No

By attending this institution, you are a: First Generation Student Second Generation Third Generation Student Have you taken a course that emphasizes cultural competence?

Yes

No

Have you engaged in opportunities the program has established to enhance learning of multicultural health? Yes No If yes, please specify: _______________________________________________________ The current location of your practicum site is: ___________________ The nursing program you are in is: BSN MOS DNP Expected year of graduation: 2015 2016 2017 2018 Use the scale of 0 to 7 (0=Strongly Disagree, 3=No Opinion, 6=Strongly Agree) to indicate how much you agree or disagree with each statement. Please note that the questionnaire is only about your experiences at this school of nursing, not the entire University.

91

2.

1

3.

1

4.

Strongly Agree

1

The instructors at this nursing school adequately address multicultural issues in nursing This nursing school provides opportunities for activities related to multicultural issues. Since entering this school of nursing my understanding of multicultural issues has increased. My experiences at this nursing school have helped me become knowledgeable about the health problems associated with various racial and cultural groups.

No Opinion

1.

Strongly Disagree

1

Does Not Apply

General Experiences at this School of Nursing

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

General Awareness and Attitudes 2

5.

2

6.

2

7.

4 RC

8.

4 RC 4

9.

2

11.

4 RC

12.

10.

I think my beliefs and attitudes are influenced by my culture. I think my behaviors are influenced by my culture. I often reflect on how culture affects beliefs, attitudes, and behaviors. When I have an opportunity to help someone, I offer assistance less frequently to individuals of certain cultural backgrounds. I am less patient with individuals of certain cultural backgrounds. I feel comfortable working with patients of all ethnic groups. I believe nurses’ own cultural beliefs influence their nursing care decisions. I typically feel somewhat uncomfortable when I am in the company of people from cultural or ethnic backgrounds different from my own. Nursing Classes/Clinicals

4 RC

13.

1

14.

I have noticed that the instructors at this nursing school call on students from minority cultural groups when issues related to their group come up in class. During group discussions or exercises, I

92

2

15.

1 RC

16.

2

17.

1

18.

1

19.

2

20.

1

21.

1 RC

22.

5

23.

1

24.

1

25.

1

26.

1

27.

have noticed the nursing instructors make efforts to ensure that no student is excluded. I think that students’ cultural values influence their classroom behaviors (for example, asking questions, participating in groups, or offering comments.) In my nursing classes, my instructors have engaged in behaviors that may have made students from certain cultural backgrounds feel excluded. I think it is the nursing instructor’s responsibility to accommodate the diverse learning needs of students. My instructors at this nursing school seem comfortable discussing cultural issues in the classroom. My nursing instructors seem interested in learning how their classroom behaviors may discourage students from certain cultural or ethnic groups. I think the cultural values of the nursing instructors influence their behaviors in the clinical setting. I believe the classroom experiences at this nursing school help our students become more comfortable interacting with people from different cultures. I believe that some aspects of the classroom environment at this nursing school may alienate students from some cultural backgrounds. I feel comfortable discussing cultural issues in the classroom My clinical courses at this nursing school have helped me become more comfortable interacting with people from different cultures. I feel that this nursing school’s instructors respect differences in individuals from diverse cultural backgrounds. The instructors at this nursing school model behaviors that are sensitive to multicultural issues. The instructors at this nursing school use examples and/or case studies that incorporate information from various

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

93 cultural and ethnic groups. Research Issues 3

28.

3

29.

3

30.

3

31.

5

32.

5

33.

5

34.

5

35.

4 RC

36.

The faculty at this school of nursing conducts research that considers multicultural aspects of health-related issues. The students at this school of nursing have completed theses and dissertation studies that considered cultural differences related to health issues. The researchers at this school of nursing consider relevance of data collection measures for the cultural groups they are studying. The researchers at this school of nursing consider cultural issues when interpreting findings in their studies. Clinical Practice I respect the decisions of my patients when they are influenced by their culture, even if I disagree. If I need more information about a patient’s culture, I would use resources available on site (for example, books, videos, etc.). If I need more information about a patient’s culture, I would feel comfortable asking people I work with. If I need more information about a patient’s culture, I would feel comfortable asking the patient or a family member. I feel somewhat uncomfortable working with the families of patients from cultural backgrounds different than my own.

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

Fresno State Non-Exclusive Distribution License (to archive your thesis/dissertation electronically via the library’s eCollections database) By submitting this license, you (the author or copyright holder) grant to Fresno State Digital Scholar the non-exclusive right to reproduce, translate (as defined in the next paragraph), and/or distribute your submission (including the abstract) worldwide in print and electronic format and in any medium, including but not limited to audio or video. You agree that Fresno State may, without changing the content, translate the submission to any medium or format for the purpose of preservation. You also agree that the submission is your original work, and that you have the right to grant the rights contained in this license. You also represent that your submission does not, to the best of your knowledge, infringe upon anyone’s copyright. If the submission reproduces material for which you do not hold copyright and that would not be considered fair use outside the copyright law, you represent that you have obtained the unrestricted permission of the copyright owner to grant Fresno State the rights required by this license, and that such third-party material is clearly identified and acknowledged within the text or content of the submission. If the submission is based upon work that has been sponsored or supported by an agency or organization other than Fresno State, you represent that you have fulfilled any right of review or other obligations required by such contract or agreement. Fresno State will clearly identify your name as the author or owner of the submission and will not make any alteration, other than as allowed by this license, to your submission. By typing your name and date in the fields below, you indicate your agreement to the terms of this distribution license. Embargo options (fill box with an X). X

Make my thesis or dissertation available to eCollections immediately upon submission. Embargo my thesis or dissertation for a period of 2 years from date of graduation. Embargo my thesis or dissertation for a period of 5 years from date of graduation.

Bessie Yang Type full name as it appears on submission

November 11, 2015 Date