Preparing nurses and other health professionals to provide quality health care in the increasingly multicultural and global society of the 21st century requires a comprehensive approach that emphasizes cultural competence education throughout professional education and professional life. Nurses and other health care providers, educators, administrators, professional association leaders, managers, and researchers are called upon to: _ Provide optimal care for the large number of culturally diverse patient populations; _ Implement cultural competence education strategies in academic and hospital settings for diverse learners; _ Evaluate outcomes of cultural competence education; _ Prevent multicultural workplace conflict and promote multicultural workplace harmony; _ Personally engage in lifelong cultural competence education.

These tasks can seem daunting and overwhelming without appropriate resources. If you want to develop optimal cultural competence in yourself and others, Teaching Cultural Competence in Nursing and Health Care, and the Cultural Competence Education Resource Toolkit are the how-to resources for you. These hands-on, user friendly resources reveal a systematic 7-step approach that takes nurses, educators, administrators, professional association leaders, managers, educators, students, and other health care providers from their own starting points toward the pinnacle—optimal cultural competence. Appropriate for all levels and settings (academic, health care institutions, employee education, professional associations, and continuing education), the book and toolkit end the struggle to find ready-to-use materials for planning, implementing, and evaluating cultural competence education strategies and programs.  Users of the book and toolkit will find the following: _ A model to guide cultural competence education _ Questionnaires for measuring and evaluating learning and performance _ A guide for identifying at-risk individuals and avoiding pitfalls _ A wide selection of educational activities _ Techniques for diverse learners _ Chapters detailing employee orientation, in-services, and continuing education _ Chapters detailing multidimensional strategies for undergraduates and graduates _ Vignettes, case examples, illustrations, tables, and assessment tools _ Abstracts and sample research reports from researchers evaluating strategies Based on the results of several post-doctoral grant-funded studies, practical teaching experience with academically and culturally diverse learners across all levels, and multidisciplinary literature, the book and toolkit provide resources and a wealth of information for all user groups.

Essential background information about the multidimensional process of teaching cultural competence offers a valuable guide for educators at all levels who are planning, implementing, and evaluating cultural competence education. Educators and researchers are continually challenged to measure outcomes following educational interventions. By introducing several quantitative questionnaires and assessment tools [to be found in the toolkit] and discussing implementation and data interpretation strategies in a detailed, user-friendly approach that is easily adapted by novice and advanced researchers.  Questionnaires, assessment tools, a cultural competence documentation log, and a research report template are easily accessed in the accompanying Cultural Competence Education Resource Toolkit. (See details concerning toolkit access in the final section of the preface.) Part III offers a wide selection of educational activities that can easily be applied by educators everywhere. Three chapters (6, 10, and 13) provide a general overview and a menu of activities and strategies for use in three areas: the academic setting, the health care institution, and professional associations. Chapter discussions, supplementary diagrams, and descriptions of toolkit items explore the 7 steps essential for optimal cultural competence development: _ Self-assessment _

Active promotion _ Systematic inquiry _ Decisive action _ Innovation _ Measurement _ Evaluation In Part III creatively link strategies via detailed case exemplars that spotlight various populations and settings. The final chapter presents important implications for educators everywhere. Educators are challenged to commit to a focused and transformational change that will not only advance the science and art of cultural competence education, but will also result in culturally congruent care, ultimately benefiting health care consumers worldwide.  The urgent expansion of educational research specifically focused on the teaching and learning of optimal cultural competence is emphasized, and areas for further inquiry and research, and future goals are proposed. Extensive references are provided at the end of the lesson. Unquestionably, implementing creative, evidence-based educational activities that promote positive cultural competence learning outcomes for culturally diverse students and health care professionals continues to be a challenge. A new challenge is to reach beyond competence (a minimum expectation) toward optimal cultural competence. This new quest recognizes that all individuals, groups, and organizations have the potential for “more.” Optimal cultural competence embraces the diversity of diversity, requires ongoing active learning, fosters multicultural workplace harmony, and promotes the delivery of the highest level of culturally congruent patient care.

Why optimal cultural competence? First, culture is a crucial factor in promoting wellness, preventing illness, restoring health, facilitating coping, and enhancing quality of life for all individuals, families, and communities. Unfortunately, the two main goals of the U.S. Department of Health and Human Services report Healthy People 2010 have not been met.  The first goal—to increase quality and years of healthy life for all—can only be achieved when an examination of “quality of life” and the meaning of “health and wellbeing” within a cultural context are put into service. The second goal was to eliminate health disparities among different segments of the population, which necessitated culture-specific and competent actions designed to eliminate disparities; however, health disparities remain overwhelming. As such, customized health care that responds to a client’s cultural values, beliefs, and traditions (culturally congruent care) remains urgent (Giger et al., 2007; Leininger, 2002a, 2002b; Rosal & Bodenlos, 2009; Whitt-Glover et al., 2009). For health care professionals with some cultural competence skills, the challenge now is to go beyond mere cultural competence toward optimal cultural competence. It is also imperative that health professionals without cultural competence education actively begin their journey to develop optimal cultural competence.  Second, culturally congruent health care is a basic human right, not a privilege, and therefore every human is entitled to it. The International Council of Nurses (ICN) Code for Nurses (ICN, 1973), the American Nurses Association (ANA) Code of Ethics (ANA, 2001), and the National Standards for Culturally and Linguistically Appropriate Service in Health Care (Office of Minority Health, 2001) are important documents that serve as reminders.  Criteria devised by accreditation and credentialing agencies such as the Joint Commission on Accreditation of Healthcare Organizations, the National Committee on Quality Assurance, the American Medical Association, and the National League for Nursing strive to ensure that culturally competent health care series and education are provided. The essential inclusion of cultural competence as viewed from an ethical and legal standpoint is addressed on varying levels within the disciplines of physical therapy, occupational therapy, speech language pathology, dentistry, medicine, psychology, and social work (AAMC, 2005; ADA, 2005, 2007; APA, 1994; APTA, 2008; Lubinski & Matteliano, 2008; NASW, 2001, 2007, 2009; Nochajski & Matteliano, 2008; Panzarella & Matteliano, 2008). Not only are nurses, physicians, other health care providers, and institutions ethically and morally obligated to provide the best culturally congruent care possible (optimal cultural competence), they are also legally mandated to do so. Within the scope of professional practice, nurses and other health professionals are expected to actively seek out ways to promote culturally congruent care at optimal levels. The AJN award-winning first edition of Teaching Cultural Competence in Nursing and Health Care introduced readers to easy-to-use teaching–learning strategies for cultural competence education.  Positive comments about the first edition, along with a surge of requests for “more” from academic and employee educators, researchers, practicing health professionals, and students from around the world and in various disciplines, inspired the writing of the expanded second edition and the creation of the Cultural Competence Education Resource Toolkit. The ideas and suggestions presented here are not meant to be exhaustive, but are offered to stimulate new ideas and invite health professionals to explore new paths on the journey to developing cultural competence in oneself and others. Readers are encouraged to pause, reflect, and question throughout the book in order to gain new insights and perspectives.  Everyone is empowered to contribute to a transformational change in health care that prioritizes optimal cultural competence development and embraces diversity.

About the Cultural Competence Education Resource Toolkit

As mentioned previously, this book includes a valuable and ready-tousle Cultural Competence Education Resource Toolkit. The Toolkit consists of three sets of tools and a total of 21 distinct tools. The three sets of tools are: Resources for Academic Settings; Resources for Health Care Institutions; and Resources for Professional Associations. Taken together, the tools provide a comprehensive set of materials for planning, implementing, and evaluating cultural competence education strategies and programs.  These tools may be used alone or in conjunction with other tools and will be of use to a broad range of readers at all levels: nurses, educators, administrators, association leaders, managers, researchers, students, and other health care providers. The tools and this book will enable you to achieve optimal cultural competence. All of these tools are to be found on a special website. You can download and print the tools from this website and you can also distribute them electronically.

An important note: Any use of the toolkit or portions of the toolkit beyond individual, personal use (such as within an institutional setting and/or in a research study) will require a license from Springer Publishing Company and payment of a modest fee for a one year unlimited use license. The practical part concludes with a discussion of factors influencing cultural competence development among culturally diverse learners and proposes that confidence, or in the context of this lesson trans-cultural self-efficacy (TSE), is a major component in cultural competence development and a strong influencing factor in achieving culturally congruent care. Creating environments that embrace diversity, meeting the culture specific needs of patients, preventing multicultural workplace conflict, and promoting multicultural workplace harmony are portrayed. These endeavours begin with diversity awareness of self and others, with each defined at the beginning of the chapter. Several poignant clinical and workplace examples illustrate the significance of actively weaving cultural competence throughout all aspects of health care settings.  The acronym “COMPETENCE” assists health care professionals in remembering essential elements for optimal cultural competence development. They must introduces a model to guide cultural competence education—the Cultural Competence and Confidence (CCC) model. The underlying assumptions, principles, concepts, and terms associated with the model’s development are concisely presented.  A unique feature of the model (and the book) is that its major concepts, propositions, and constructs are supported by several quantitative studies using a questionnaire also discussed in this book and available in the Jeffreys Cultural Competence Education Resource Toolkit (Jeffreys, 2010). The visual illustration of the model enhances understanding of the text.  A second illustration expands on the CCC model illustration by tracing the proposed influences of TSE (confidence) on a learner’s actions, performance, and persistence for learning associated with cultural competency development and culturally congruent care. The model has relevance to other disciplines recognizing the essential inclusion of cultural competence within clinical practice and in initial and/or ongoing educational preparation, such as physical therapy, occupational therapy, speech-language pathology, dentistry, medicine, psychology, and social work.  The model is brought to life through a realistic “Educator-In-Action” vignette featuring cultural competence education in the health care institution (hospital setting). Meeting the health care needs of culturally diverse clients has become even more challenging and complex. In addition to acknowledging the cultural evolution (growth and change) occurring in the United States (and other parts of the world), it is imperative that nursing and other health care professions appreciate and understand the impending cultural revolution. The term cultural revolution implies a “revolution of thinking” that seeks to embrace the evolution of a different, broader worldview (Jeffreys & Zoucha, 2001). Both cultural evolution and cultural revolution have the potential to bring about a different worldview regarding cultural care and caring by including key issues previously nonexistent, underrepresented, or invisible in the nursing and health care literature.  This new vision challenges all health care professionals to embark upon a new journey in the quest for cultural competence and culturally congruent care for all clients (Jeffreys & Zoucha, 2001). This new journey also challenges health care professionals and organizations to go beyond the goal of achieving “competence” (minimum standard) toward the goal of achieving “optimal” cultural competence (standard of excellence). Educators everywhere are additionally challenged to learn how to lead the quest for culturally congruent health care by implementing creative, evidence-based educational activities that promote positive cultural competence learning outcomes for culturally diverse students and health care professionals, aiming to reach beyond minimal competence to the achievement of optimal cultural competence.

Professional goals, societal needs, ethical considerations, and legal issues all declare the need to prioritize cultural competence development, Overview of Key Issues and Concerns 13 necessitating a conscious, committed, and transformational change in current nursing practice, education, and research (Jeffreys, 2002). Although nursing and other health care professions can be transformed through the teaching of trans-cultural nursing (Andrews, 1995; Leininger, 1995a, 1995b; Leininger & McFarland, 2002, 2006), two major barriers prevent a rapid effective transformation.  One major barrier is the lack of faculty and advanced practice nurses formally prepared in trans-cultural nursing and in the teaching of trans-cultural nursing (AACN, 2008, 2009; Andrews, 1995; Jeffreys, 2002; Leininger, 1995b; Ryan, Carlton, Ali, 2000).  The second major barrier is the limited research evaluating the effectiveness of teaching interventions on the development of cultural competence (Jeffreys, 2002). These two barriers are further complicated by the (a) changing demographics of students and health care professionals and (b) severe shortage of nurses and nursing faculty. Other health professions have also acknowledged the lack of diversity within their respective fields as well as the lack of faculty prepared to incorporate substantive cultural competence education within professional education as severe barriers to effective transformation. Several of these factors are highlighted in the following sections. Present action strategies, innovations, and practical examples for cultural competence education and evaluation aimed at overcoming barriers and invigorating an effective transformation that reaches beyond competence to “optimal” cultural competence. The goal of optimal cultural competence recognizes that cultural competence is not an end product, but an ongoing developmental process; therefore individuals, groups, and organizations can continually “improve,” striving for “peak performance” outcomes or standards of excellence. Steps essential for optimal cultural competence development include: self assessment, active promotion, systematic inquiry, decisive action, innovation, measurement, and evaluation.

CHANGING DEMOGRAPHICS OF STUDENTS AND HEALTH CARE PROFESSIONALS The projected increase in immigration, globalization, and minority population growth has the potential to enrich the diversity of the nursing profession and to help meet the needs of an expanding culturally diverse society What has actually occurred is that the dramatic shift in demographics, the restructured workforce, and a less academically prepared college applicant pool have created a more diverse nursing applicant pool.  Nursing students today represent greater diversity in age, ethnicity and race, gender, primary language, prior educational experience, family’s educational background, prior work experience, and enrolment status than ever before. Today’s student profile characteristics can be examined to predict the potential future impact on the nursing profession. For example, recent nursing enrolment trends suggest a steady increase among some minority groups, yet no increase has been noted among Hispanic groups Ramirez, 2009; Villaruel et al., 2001). As a result, the number of Hispanic nurses is grossly disproportionate to client populations, demanding urgent and innovative recruitment efforts. Recruitment of diverse, nontraditional student populations does not assure program completion, licensure, or entry into the professional workforce. In fact, attrition is higher among nontraditional student populations (Bosher & Pharris, 2009; Braxton, 2000; Jeffreys, 2004; Seidman, 2005, 2007). Therefore, intensive recruitment efforts must be partnered with concentrated efforts aimed at enhancing academic achievement, professional integration, satisfaction, retention, graduation, and entry into the nursing professional workforce. Unfortunately, current employment trends in nursing indicate high turnover rates, with nurses moving from workplace to workplace. High attrition rates for new nurses leaving the nursing profession are also a major concern. The nursing shortage, high acuity of patient care, diminished resources, and an aging society emphasize the need to prioritize retention of nurses in the workplace. Alleviating the nursing shortage, optimizing opportunities for career advancement, offering incentives for educational advancement, and striving to promote professional (and workplace) satisfaction are broad objectives aimed at facilitating nurse retention. The recruitment of foreign nurses has been one strategy implemented to alleviate the nursing shortage that has contributed to the changing profile characteristics of professional nurses. Foreign nurses are a heterogeneous group, representing much diversity in profile characteristics and in prior work experience as a registered nurse.



Goals of culturally congruent health care and multicultural workplace harmony can only be achieved by preparing health care professionals to actively engage in the process of cultural competence. Adequate preparation necessitates a diagnostic–prescriptive plan guided by a comprehensive understanding of the teaching–learning process of cultural competency development. Such a comprehensive plan must incorporate a detailed assessment and understanding of learner characteristics.

Each learner characteristic provides vital information that is integral to determining special needs and strengths. Meeting the needs of culturally diverse learners is a growing challenge in academia, the professional workplace, and within professional associations. Because all students, nurses, and other health professionals belong to one or more cultural groups before entering professional education, they bring their patterns of learned values, beliefs, and behaviors into the academic and professional setting.

Values are standards that have eminent worth, meaning, and importance in one’s life; values guide behavior. These cultural values are the “powerful directive forces that give order and meaning to people’s thinking, decisions, and actions” (Leininger, 1995a). Cultural values guide thinking, decisions, and actions within the student and/or nurse role as well as other aspects of their lives. Students, nurses, and other health professionals also hold numerous beliefs (ideas, convictions, philosophical opinions, or tenets) that are accepted as true without requiring evidence or proof.

Beliefs are often unconsciously accepted as truths (Purnell & Paulanka, 2008). Cultural values and beliefs unconsciously and consciously guide thinking, decisions, and actions that ultimately affect the process of learning and the outcomes of learning. High levels of cultural congruence serve as a bridge to promote positive learning experiences and positive academic and/or psychological outcomes; high levels of cultural incongruence are proposed as inversely related to positive learning experiences and academic and/or psychological outcomes (Jeffreys, 2004). Cultural congruence refers to the degree of fit between the learner’s values and 18 GETTING STARTED beliefs and the values and beliefs of their surrounding environment (Constantine, Robinson, Wilton, & Caldwell, 2002; Constantine & Watt, 2002; Gloria & Kurpius, 1996). Here, the surrounding environment refers to the environment of nursing education within the nursing profession and the educational institution, workplace, or professional association setting.

Nursing is a unique culture that reflects its own cultural style. Cultural styles are the “recurring elements, expressions, and qualities that characterize a designated cultural group through their series of actionpatterns, beliefs, and values” (Leininger, 1994a, p. 155). The dominant values and norms of a cultural group guide the development of cultural styles (Leininger, 1994a, p. 155). Currently (within the United States), the culture of nursing reflectsmany of the dominant societal values and beliefs held in the United States. Similarly, nursing education reflects many of theWestern European value systems predominant in U.S. universities. Because nursing has its own set of CVB, students must become enculturated into nursing. Enculturation is a learning process whereby students learn to take on or live by the values, norms, and expectations of the nursing profession (Leininger, 2002a). Sufficient assistance during enculturation adjustment can minimize acculturation stress and enhance enculturation.

Another unique challenge facing nurse educators is to enculturate foreign-educated physicians and other second-career individuals who are entering nursing programs (Grossman&Jorda, 2008; Hegge&Hallman, 2008; Johnson & Johnson, 2008). Unfortunately, cultural competence as a priority professional value received delayed popularity among the nursing profession overall, with little emphasis or inclusion in nursing curricula, practice, research, theory, administration, and the literature.

Consequently, today’s nurse educators may be inadequately prepared to enculturation students into the new era of the nursing profession that embraces cultural diversity and supports cultural competence development. Similarly, within other health disciplines, cultural competence as a priority or even as an essential professional value received delayed attention in professional practice settings and professional curricula, thereby contributing to a multidisciplinary health care culture poorly equipped to meet the culture-specific care needs of diverse patients in a multicultural workplace environment.

Although increases in culturally diverse students have been noted in higher education and in nursing, the values and beliefs underlying nursing education have been slow to change in accordance with changing student population needs. Ethnocentric tendencies and cultural blindness have been major obstacles to the needed changes in nursing education. Ethnocentric tendencies refer to the belief that the values and beliefs traditionally held within nursing education are supreme. Consequently, Overview of Key Issues and Concerns 19 traditional teaching–learning practices are upheld.

Too often, cultural blindness exists in nursing education. Within the context of nursing education, cultural blindness is the inability to recognize the different CVB that exist among diverse student populations. Because cultural blindness does not acknowledge that differences exist, cultural imposition of dominant nursing education values and beliefs undoubtedly occur. Cultural imposition can cause cultural shock, cultural clashes, cultural pain, and cultural assault among students whose CVB are incongruent with the dominant nursing CVB (Jeffreys, 2004). Nurse educators are challenged to explore various CVB within nursing, nursing education, higher education, and student cultures and to make culturally sensitive and appropriate decisions, actions, and innovations. Table 1.2 selectively compares and contrasts CVB of nursing education, higher education, and four other cultural groups. Based on a review of the literature, traditional views within the identified cultures were included but are in no way meant to stereotype individuals within the cultures. Readers are cautioned about making stereotypes and are reminded to explore CVB of individual learners. It is beyond the scope of this book to provide in-depth explanations about each category, yet the importance of an in-depth understanding must be recognized. The selective approach is meant to spark interest, stimulate awareness, and encourage further exploration among educators before attempting the design of culturally relevant and congruent educational strategies.

This approach is critical, because the need to understand, respect, maintain, and support the different CVB of culturally diverse learners is a precursor to culturally relevant and competent education.

The teaching–learning process of cultural competence must consider the various philosophies and approaches to learning. Whether the teacher is perceived to be an authority figure, partner, coach, mentor, professional, or member of a service occupation will influence the teaching– learning process (see Table 1.2). Preferred teaching–learning styles may be active (learner-centred) or passive (teacher-centred). Although student centred learning has long been advocated, nursing curricula have been slow to embrace this philosophy and to address the needs of diverse learner styles (Bellack, 2008). Teaching–learning strategies perceived as fun and likable by some may be perceived as aggressive (debate), competitive (gaming), threatening (Web-based, role-playing, or small group activity), boring (rote memorization), and/or irrelevant by others. Learner goals and philosophies that emphasize the “process” of learning focus on the journey of “becoming” culturally competent through the integration of cognitive, practical, and affective learning. Process learners recognize that the journey itself is the “learning”; obstacles, mistakes, and hardships along the way are part of the expected developmental process that requires extra effort, sincere commitment, motivation, and persistence.

Process learners realize that there is no final end product labelled “cultural competence,” rather cultural competence is dynamic and ongoing. In contrast, “product” learners are focused on obtaining an end product through the mastery of content.

Memorizing a multitude of “facts” about a culture becomes important rather than comprehensively understanding, applying, and appreciating the cultural context or rationale behind the “fact.” There is less concern with how to learn to apply knowledge and develop skills, and even less concern with affective learning (values, attitudes, and beliefs).

Product learners would be greatly disturbed, dissatisfied, and poorly motivated with an approach that views the end point for becoming culturally competent as infinite. Perceived barriers to learning, mismatches in teacher–learner expectations, and poor learning experiences will hinder the learning process of cultural competence. For example, faculty beliefs that nonminority students are less confident in caring for culturally different clients than minority students is stereotypical and inaccurate (Jeffreys, 2000; Jeffreys &Smodlaka, 1998, 1999a, 1999b; Lim, Downie,&Nathan, 2004). Similarly, the belief that minority nurses are intrinsically equipped to care for culturally diverse clients is also inaccurate and negates the uniqueness of the many cultures that comprise the federally recognized “minority” group categories and disregards the many cultures that comprise nonminority groups. The danger is that minority students’ and nurses’ special educational needs with respect to providing culturally congruent care for many different groups of culturally different clients (different in culture from care provider) may be ignored.

The nursing profession has the challenging opportunity to meet the unique needs of various populations of nurses, improve nurse retention, decrease the nursing shortage, and promote cultural competence. Evidence-based transitional programs, specialized orientation programs, ongoing employee workshops, refresher courses that integrate the values, skills, and knowledge needed for cultural competence in the workplace have the potential to address these needs. Unfortunately, state and certifying boards/associations have varied continuing education (CE) and competency requirements for license renewal and reentry (Yoder-Wise, 2009) and none require documentation of CE programs in cultural competence.

Among other health professionals, inconsistencies in licensure renewal, certification, CE, and practice requirements also exist. For example, physicians licensed in New Jersey are now required to complete CE in cultural competence, yet this is not a universal medical requirement throughout the United States. Professional inconsistencies (in any discipline) may translate into questioning the need for the requirement, decreased motivation, resentment, and lack of commitment on the part of the professional, thereby defeating the overall goal of actively engaging the health professional in lifelong commitment to cultural competence development.


Despite the numerous complexities, changes, and challenges faced by many nursing students and nurses today, some individuals are more actively engaged in cultural competence development whereas others are not. Some individuals are more motivated to pursue cultural competence development and are more committed to the goal of culturally congruent care than others. Therefore, the evaluation of factors that may influence motivation, persistence, and commitment for cultural competency development is a necessary precursor to any educational design strategy. Confidence (self-efficacy) is one such factor that is emphasized in this book. According to Bandura (1986), the construct of self-efficacy is the individuals’ perceived confidence for learning or performing specific tasks or skills necessary to achieve a particular goal. Furthermore, self-efficacy is the belief that one can perform or succeed at learning a specific task, despite obstacles and hardships, and will expend whatever energy is necessary to accomplish the task (Bandura, 1986). Consequently, confidence is Overview of Key Issues and Concerns 25 inextricably linked as amajor component in cultural competence development and an influencing factor in the achievement of culturally congruent care. Confidence is an integral component in the action-strategy acronym “COMPETENCE,” introduced and illustrated in the next chapter. The acronym may be used by the multidisciplinary health care team to: (a) guide clinical practice with culturally diverse patients and (b) promote multicultural workplace harmony and prevent multicultural workplace conflict among culturally diverse health care workers. Later, Chapter 3 proposes a new conceptual model to understand and guide cultural competence education, research, and practice.

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