1. Caring for Refugees: Measuring Cultural Competence in Nursing Andrea Addington RN, EdD

2. Objectives Cultural competence in nursing education I. Define Cultural competence II. Describe rationale for cultural competence III. Review of literature regarding teaching techniques IV. Analyze research on measuring cultural competence

3. “ Culturally-based care knowledge, acts, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully fit the cultural values, beliefs, and lifeways of clients for their health and well-being, or to prevent illness, disabilities, or death” (Leininger & McFarland, 2006, p. 15). Culturally Congruent Care:

4. Cultural Competence: “ Is a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective), involves transcultural self- efficacy (confidence) as a major influencing factor, and aims to achieve culturally congruent care” (Jeffries, 2007, p.29).

5. Rationale The Institute of Medicine has reported that “bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care” (Institute of Medicine (IOM), 2002, p.1).

6. The US population is becoming increasingly diverse, and requires healthcare professionals to be educated in culturally competent care. (Davidhizar & Giger, 2001).

7. Rationale The National League for Nursing Accrediting Commission (NLNAC, Inc. in 2008) has standards that require cultural competency in practice as well as standards for nursing schools to include cultural diversity concepts in the curriculum.

8. Leininger Theory Culture Care Diversity and Universality Theory Cultural values beliefs and practices Not ethnocentric Individualistic vs. stereotypical May cause conflict, stress, and racial bias (incompetence) Self reflection

9. Review of the literature Canales and Bowers (2001) described “a lack of progress in teaching and evaluating cultural competence” (p. 102). Few studies have used tools to measure effects on student learning

10. Experiences to enhance CC food, field trips, interviews, music (Hughes & Hood, 2007); international immersion experiences (Caffrey, Neander, Markle, & Stewart, 2005); exchange programs within the United States to areas with different cultures- immersion (Huttlinger & Keating, 1991); experiences of ethnic activities such as pow-wows and cultural festivals (Wendler & Struthers, 2002); interviews (Flood, 2007); caring for persons of a different culture in clinical settings (Lundberg, Backstrom, & Widen, 2005, Addington, 2010). Classroom-theory, journals, games, cultural content

11. Literature Review Doutrich and Storey (2004) 13 nursing students Partnered with public health nurses for 16 weeks Used Capina-Bacote’s Cultural Competency Assessment tool Significant increase in mean scores

12. Caffrey, Neander, Markle, and Stewart's (2005) Two groups of students compared: Both groups showed an increase in cultural competence Classroom learning does have an effect 5-week international immersion provided better learning experience, higher change in mean scores

13. Griswald, et al. (2006) Evaluated medical students Two days of interactions with refugee clients in a clinic Demonstrated a gain in cultural competency knowledge and communication skills

14. How do we teach CC? Knowledge-books, research, lecture Experience-clinical Theory of change

15. Barriers to change (beliefs) Fear  other culture  Stems from family beliefs, political beliefs, peers, religious beliefs Fear  can cause anger, distrust What is the fear of another culture? Don’t understand, loss of control

16. Steps to Cultural competence Get rid of fear-takes away barriers to change In healthcare, this takes openness, willingness Change beliefs Meeting someone from another culture Cultural assessment Self assessment Ability to communicate-translators

17. Being immersed in another culture appears to develop changes in ethnocentric thinking as well as provide a basis for cultural knowledge that is not attainable by classroom alone.

18. Research Questions At the conclusion of a community health rotation, do nursing students who worked with refugee clients, as compared to those students who did not work with refugee clients, have an increased level of cultural competence as measured by the Caffrey Cultural Assessment Tool? Is there a significant difference in cultural competence in all students after taking a Community Health course? Is there a significant difference between nursing students’ self perceived level of cultural competence after working with refugee clients than before working with refugee clients? What is the relationship between demographic factors and nursing students' level of self perceived cultural competence?

19. Design This study was a two group pretest posttest quasi- experimental design to compare students in the Community Health Refugee group (CHR) and students in the Community Health group (CH).

20. Instrument The tool to assess the students cultural competence was the Caffrey Cultural Competence in Healthcare Scale (CCCHS). It has 28 items using a 5 point Likert scale.

21. Instrument How comfortable are you in interacting socially with members of a cultural group other than your own? In general, how would you evaluate your comfort level in caring for clients from a culture other than your own? How knowledgeable are you about the healthcare beliefs of a cultural group other than your own?

22. Sample Sampling was a random sample to divide students into two groups: the students enrolled in the Community Health clinical group assigned to refugee clients (CHR), and the control group: students enrolled in the Community Health course who did not take care of refugee clients (CH).

23. Delimitations The study was done with a group of nursing students from a small Midwestern Catholic Health Sciences College. The results may not be generalized to all colleges with nursing schools. The students were enrolled in the BSN Community Health course.

24. Limitations Sample size- 20 students, refugee group only 6 Assessment tool-perceptions of their cultural competency skills and attitudes. The researcher is a faculty member

25. Significance of the Study “Not only are nurses, physicians, other healthcare providers, and institutions ethically and morally obligated to provide the best culturally congruent care possible, but they are also legally mandated to do so” (Jeffries, 2006. p. xiv).

26. Learning cultural competent skills may result in decrease in health disparities Nurse educators understanding of student perceptions Curriculum implications

27. Population and setting Private college BSN nursing students taking the Community Health course Refugee Center Two groups of students CHR- working with refugee clients CH-working with clients from the Visiting Nurse Services

28. Data Analysis The demographic data and the Caffrey Cultural Competence in Healthcare Scale (CCCHS) was analyzed using summary, descriptive, and inferential statistics. Inferential included t-tests and ANOVA

29. Interventions In addition to students working with refugee clients to increase cultural competence, the following were used as teaching tools in the classroom and clinical setting: Heritage self assessment Client cultural assessment Journals

30. Chapter 4 Results: Demographic Worked with refugee client Status in nursing program Gender Age Ethnic heritage Religious background English primary language Previous time out of country Fluency in second language Contact with other cultural group Work history as RN in years Contact with clients from another culture Contact with health care workers from another culture Fluency in second language Contact with other cultural group Work history as RN in years Contact with clients from another culture Contact with health care workers from another culture

31. Contact with clients from another culture. Only 10% (n=2) of the students had a moderate or great amount of contact with clients from another culture, with 90% (n=18) categorized as only ‘little’ or ‘some’ contact.

32. Contact with healthcare workers from another culture. Most students (70%, n=16) had minimal amount of contact with health care workers from another culture. Four students (20%) had a moderate to great deal of contact.

33. Descriptive statistics for CCCHS Cultural competence: level of comfort, knowledge, and awareness in providing care to persons from cultures other than their own Pretest scores 56-108 Posttest 64- 116 Highest gain 32 points Lowest gain loss of 14 points 14 students showed a gain

34. Question scores Question 10 “How comfortable are you / would you be in working with a translator in a healthcare setting?” (82 total points) Question 16 “How knowledgeable are you about another culture’s beliefs and practices related to organ donation?” (44)

35. Question 19Awareness of own limitations providing culturally competent care. Question 20Comfort in advocating for clients of another culture with other healthcare providers. Question 21General evaluation of comfort level in caring for clients from another culture. Question 23 Comfort in working with another member of healthcare team from another culture. Question 25Interest in working with culturally diverse staff. High scores >70, average 3.5/5 per student

36. Scores 2.5 average per student (out of 5) Lower scores How knowledgeable are you about the healthcare beliefs of a cultural group other than your own? How knowledgeable are you about the health care practices of a cultural group other than your own?

37. Inferential statistics Hypothesis one was “students working with refugee clients will have an increased level of self perceived attitudes, skills’ and knowledge of cultural competence after they worked with refugee clients than students who did not work with refugee clients.”

38. ANOVA CHR pretest mean 2.79, posttest 3.13 CH pretest mean 2.77, postest 2.99 CHR Difference.33 CH Difference.22 Posttest ANOVA (F [1,18] =.236, p=.632) Null accepted-not statistically significant

39. T-test refugee status (t =.486, df = 18, p=.633) Null accepted So between the 2 groups of students, did not see statistically significant differences in scores I believe that with a larger sample size, it would have shown significant differences

40. Outcomes t-test

41. Change is possible! We have more in common as humans than difference, but none of us is more human than another” Maya Angelou

42. “Working with refugees stretched me to reach beyond my comfort zone. Coming from a small town, I had never had contact with another culture. I am so glad I had this experience I may otherwise never have had.” Nursing student