Status of cultural competence in nursing education: A literature review

Status of cultural competence in nursing education: A literature review

Grant, LaVerne F

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

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

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

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

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


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

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

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

Teaching Strategies Using Local Experiences and Resources

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

Teaching Strategies Using International Focus and Experiences

Unlike methods using local resources, schools that used methods involving international experiences did not vary. Almost all were elective courses. Since the majority required foreign travel, it appears most institutions did not want to make such travel required. Table 2 summarizes these programs.

Efforts to Measure Cultural Competence

In addition to actual curriculum changes to impart cultural competence to nursing students, other researchers have tried to measure the cultural competence of nurses, nursing students, or both. Most of the studies used the Cultural Self-Efficacy Scale (CSES), which examines nurses’ and student nurses’ confidence level in delivering cultural care. Another study used the Transcultural and International Nursing Inventory (TINKI), which examined the transcultural practices of nurses and student nurses across the US. The remaining studies either used a created survey with little information on its creation, or used open-ended questions to ascertain the level of cultural competence the nurses or nursing students had acquired. Table 3 summarizes these studies.


How can nurse educators determine if students have learned cultural competence? The literature indicates cultural educational activities are occurring in many schools of nursing. However, in this review of literature, no author made an effort to determine the level of cultural competency of students before the learning situation. None documented outcome studies to determine the level of cultural competence of graduates and practicing nurses. Whether the student’s experience is local or international, nurse educators need to know if the experience teaches the intended learning. Unless outcomes are validated, educators will continue to fumble in the dark.

Lack of outcomes research may be related to the lack of appropriate instrumentation to measure the concept. There are few instruments available and none seem to measure cultural competence. With survey data, the researcher is dependent on subjects returning the survey. It is doubtful the return rate reflects the entire population being surveyed. The CSES is a less than optimal tool. Self-report data can be misleading. Subjects may have an exaggerated opinion of their cultural knowledge level as well as their level of care. This instrument does not measure cultural competence, but rather measures an aspect of cultural competence. According to St. Clair and McHenry (1999), “self-efficacy is not cultural competence. . . [however] cultural awareness, sensitivity, and self-efficacy” (p. 234) will likely continue to be synonymous with cultural competency until the phenomena is further clarified.

A dilemma nursing education must deal with relates to the lack of expert faculty to teach culturally competent care. Three studies were found that address this critical deficit.

Grossman, et al. (1998) surveyed deans and directors in Florida, a very culturally diverse state. They found that schools lacked awareness, knowledge, and sensitivity toward cultural differences and similarities.

Realizing there were few faculty with adequate knowledge about cultural competence, Chrisman (1998) developed a program intended to increase the cultural knowledge base of nursing faculty. Because of this lack of expertise, the nursing program was unable to incorporate the content in the classroom or in clinical experiences. Through grant funding, Chrisman developed a three-phase project designed to “broaden faculty . . expertise . . . in diversity education” (p. 45). Phase one involved the development of videotapes depicting appropriate interaction between the nurse and clients from diverse cultures or portrayed clients talking about their health problems. Phase two involved developing an extensive bibliography of articles related to cultural competence. The third phase involved four 2-hour seminars. One requirement, to be eligible to participate in the seminars, was to have a past immersion experience with a culture different from self. Some participants attended religious ceremonies and others visited a local Indian pow-wow. The immersion experience helped participants realize the feeling of being the outsider. Only five faculty participated in the seminar sessions. The seminars were deemed successful even though there was no formal evaluation done. The disappointment with phase three was the low number of participants. A great deal of effort was expended to enhance the cultural expertise of faculty in this institution, yet there were few faculty willing to put forth the effort to gain the needed expertise.

Ryan, Carlton, and Ali (2000) examined the preparatory education and abilities of faculty in the area of culturally competent care. Surveys were sent to 610 baccalaureate and higher degree National League of Nurses (NLN) accredited nursing schools. Only 217 responded, a return rate of 36%. The respondents included 197 baccalaureate programs and 86 graduate programs. Eighty schools reported that no faculty were prepared, formally or informally, in this field of study. Only one third of the schools reported offering faculty development programs in transcultural care. These data suggest a serious shortage of faculty prepared in the area of culturally appropriate nursing care.

If we are to believe DeSantis (1991), Leininger (1995) and Campinha-Bacote (1998), cultural competence takes time to develop. It is not developed in a one or two day workshop nor is it likely to develop in a few short years in school. But nurse educators can attempt to instill certain attitudes and encourage the development of certain characteristics in graduates to enhance their abilities to develop into culturally competent nurses. Attitudinal qualities described by Ronnau in 1994, as cited in Black (2001), include the 1) belief in equality of every individual, 2) appreciation of the differences that exist between people, 3) belief that the differences are not inferior nor bad, 4) full awareness of self and pride in one’s own culture, and 5) commitment to continuous learning. In addition, students can learn to be aware of the need to be sensitive to the needs of others and to communicate appropriately, seeking information from clients about their cultural preferences and health care beliefs and practices. There is also a need for exposure to and multiple contacts with others. In addition, the desire to be culturally competent and an openness to learn from others is needed (Brown, 2001; DeSantis, 1999; Leininger, 2000; McKenna, 1999).


While many nurse educators have acknowledged the importance of cultural competence, nursing schools are still a long way from providing evidence that nurses can practice culturally competent care. The literature is replete with examples of programs, classes, seminars that attempt to make nursing students culturally competent, but the literature is also vacant of assessment measures to determine if these methods achieve their purpose. Assessment has become a key term within all aspects of education and nursing education is not exempted from this movement. As a part of the greater accountability for the cost of educating, all institutions of higher learning must constantly assess their programs to make sure the goals are being achieved. If, as the literature has stated, cultural competence is so important to the effective work of a nurse, then schools of nursing must assess what ever means they use to impart this skill to make sure their graduates have attained cultural competence.


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LaVerne F. Grant, MS, RN

Timothy D. Letzring, JD, EdD

LaVerne F. Grant, MS, RN, Assistant Professor, University of Mississippi School of Nursing, Jackson, MS, and Timothy D. Letzring, JD, EdD, Associate Professor and Coordinator of Higher Educations, University of Mississippi, Department of Higher Education Leadership, University, Mississippi.

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