Caring for Refugees: Measuring Cultural Competence in Nursing

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

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Culturally Congruent Care

• 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).

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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).

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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).

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

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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.

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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

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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

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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

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Literature Review

• Doutrich and Storey (2004)
• 13 nursing students
• Partnered with public health nurses for 16 weeks
• Used Capina-Bacotes Cultural Competency
  Assessment tool
• Significant increase in mean scores

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• 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

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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

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How do we teach CC?

• Knowledge-books, research, lecture
• Experience-clinical
• Theory of change

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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?
• Dont understand, loss of control

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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

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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.

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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?

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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).

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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.

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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?

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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).

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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.

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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

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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).

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

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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

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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

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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

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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

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Contact with clients from another culture

• . Only 10 (n2) of the students had a moderate
  or great amount of contact with clients from
  another culture, with 90 (n18) categorized as
  only little or some contact.

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Contact with healthcare workers from another
culture

• . Most students (70, n16) had minimal amount
  of contact with health care workers from another
  culture. Four students (20) had a moderate to
  great deal of contact.

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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
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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 cultures beliefs and practices related
  to organ donation? (44)

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High scores gt70, average 3.5/5 per student

• Question 19 Awareness of own limitations
  providing culturally competent care.
• Question 20 Comfort in advocating for clients of
  another culture with other healthcare
  providers.
• Question 21 General 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 25 Interest in working with culturally
  diverse staff.

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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?

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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.

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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

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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

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Outcomes t-test
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Change is possible!

• We have more in common as humans than difference,
  
• but none of us is more human than another
• Maya Angelou

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• 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