EXAMINING THE CHANGE IN CULTURAL AWARENESS OF SENIOR NURSING STUDENTS WHO PARTICIPATE IN A SEMESTER-LONG CULTURALLY BASED ASSIGNMENT AT A LARGE PUBLIC UNIVERSITY
by
Amanda Veesart, MSN, RN
A Dissertation
In
Higher Education Research
Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of
DOCTOR OF PHILOSOPHY
Approved
Dave A. Louis, PhD Chair of Committee
Andrew Koricich, Ph,D
Sharon Cannon, EdD
Mark Sheridan Dean of the Graduate School
August, 2016
Copyright 2016, Amanda Veesart
Texas Tech University, Amanda Veesart, August 2016
ACKNOWLEDGEMENTS
First of all, I would like to thank my dissertation committee. Not only did I forge great professional relationships, I discovered a sense of belonging and friendship. Dr. Louis, you have shown me what a true journey entails. Thank you for the life-long lessons. Dr.
K, thank you for the wisdom and the ability to pursue what I wanted to achieve. Dr.
Cannon, I cannot describe how your support has kept me in the game. The three of you will always play an important role in my future research. I hope you will pick up one of my publications and find a piece of your guidance hidden.
I also have to thank my leadership team at work for putting up with my stress, covering days that I needed to be away, and just pushing me through when I wanted to give up! Thank you Ann, Kyle, and Ruth for always ‘having my back.’ To Brenda Stone, you have read every page of this dissertation, sometimes multiple times, as well as most of my doctoral assignments. You are an amazing editor, coworker and friend. Thank you!
Last but not least, I need to thank my family. To my parents for teaching me to be independent and always push to the next level. To my sister, niece and nephew for understanding the times I was doing homework.
To the most important people in my life and that deserve this degree as much as I do, Jason, Nate, and Lexi. Nathaniel (Bud), you are an amazing son. Thank you for understanding the days I couldn’t throw a baseball with you because I had to do homework or the times you made mom hot tea, just to get through another night of writing. I love you bud. Little Bit (Lexi), what an incredible daughter you have been!
Thank you for understanding when mom couldn’t read another book with you or play
ii Texas Tech University, Amanda Veesart, August 2016 knock out all the time. The two of you understand that hard work pays off, and you were witnesses to that during this dissertation. Mom loves you!
Jason, wow, what can I say, other than thank you? It does not seem like enough.
You have picked up the pieces, set me straight, been the shoulder to cry on, been a single parent at times, the banker, the cook, and the maid, all because you love me. We did it!
You are an amazing father, husband, and man. Thank you for knowing that I had it in me to finish and making sure that I know every day you were supporting me. I love you, J.
iii Texas Tech University, Amanda Veesart, August 2016
TABLE OF CONTENTS ACKNOWLEDGEMENTS ...... ii ABSTRACT ...... viii CHAPTER I: INTRODUCTION ...... 1 History of Nursing and American Higher Education ...... 4 Nursing Curriculum...... 6 Culture and the Learning Process ...... 9 Cultural Differences and the Impact on Health and Healthcare...... 10 Developing a Culturally Based Assignment ...... 11 Problem Statement ...... 12 Purpose Statement ...... 13 Research Questions ...... 14 Significance of the Study ...... 15 Summary of Theoretical Framework ...... 15 Summary of Methodology ...... 17 Assumptions of the Study ...... 17 Limitations of the Study ...... 18 Definitions ...... 19 Summary ...... 20 CHAPTER II: REVIEW OF LITERATURE ...... 22 History of Education and Nursing: An Intertwined Social Evolution ...... 22 The Beginning of Formal Nursing ...... 23 The Effects of Moving West ...... 24 Nursing in the Civil War ...... 25 Standardization of Nursing ...... 27 Curriculum Development ...... 29 Era of Segregation ...... 30 Nursing during the Era ...... 32 Impact of Desegregation on Higher Education ...... 33 Era of Consolidation ...... 35 Impact on Nursing Education ...... 36 Overview of Cultural Competence ...... 38
iv Texas Tech University, Amanda Veesart, August 2016
Importance of Cultural Awareness in Healthcare ...... 39 Healthcare Disparities among Cultures ...... 40 Inadequate Access to Healthcare ...... 41 Quality of Care ...... 41 Cultural Awareness in Nursing Education ...... 43 Call to nursing education reform ...... 44 Nursing Education Reform...... 45 Theories in Cultural Care ...... 46 Cultural Care Theory ...... 47 Multicultural Learning Theory ...... 49 Culturally Based Assignments...... 50 Summary ...... 53 CHAPTER III: METHODOLOGY ...... 54 Paradigms ...... 54 Postmodernism ...... 55 Constructivist ...... 55 Application of Paradigms ...... 56 Theoretical Framework ...... 57 Research Questions ...... 58 Research Design ...... 59 Pre-CBA Completion ...... 60 Phases of the CBA ...... 61 The Voice ...... 65 Post-CBA completion ...... 66 Study Setting and Population ...... 66 Instrumentation ...... 67 Discussion on Survey Content ...... 69 Data Collection ...... 70 Quantitative Collection ...... 71 Qualitative Collection ...... 71 Data Analysis Plan ...... 72 Quantitative Analysis ...... 72
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Qualitative Analysis ...... 73 Positionality ...... 74 Limitations ...... 75 Summary ...... 75 CHAPTER IV: RESULTS ...... 76 Restatement of the research purpose ...... 76 Restatement of the Research Questions ...... 77 Research Design ...... 77 Participants ...... 78 Gender ...... 78 Race/ethnicity ...... 79 Age...... 80 Socioeconomic Status ...... 81 Data Analysis Results...... 82 Quantitative Data Analysis ...... 82 Cognitive Attitudes Results ...... 83 Summary for Cognitive Attitudes ...... 84 Behavior and comfort levels ...... 85 Summary for behaviors and comfort ...... 86 Cognitive Awareness ...... 87 Summary for Cognitive Awareness ...... 87 Patient Care and Clinical Issues ...... 89 Summary for Patient Care and Clinical Issues ...... 89 Comparison of Cohort A and Cohort B ...... 90 Cohort A vs Cohort B cognitive attitudes ...... 91 Cohort A vs Cohort B Behaviors and Comfort Issues...... 92 Cohort A vs Cohort B Cognitive Awareness...... 93 Cohort A vs Cohort B Patient Care and Clinical Issues ...... 94 Qualitative Data Analysis ...... 95 Theme 1-Discovery of Unconscious Biases ...... 97 Theme 2-Impacts on Cultural Awareness ...... 100 Theme 3- Impact on Nursing Practice ...... 103
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Theme 4- Cultural Interactions beyond the Classroom ...... 105 Qualitative Summary ...... 107 Summary ...... 107 CHAPTER V: DISCUSSION AND CONCLUSION...... 109 Summary of Study ...... 110 Positionality Influence on Qualitative Analysis and Reflection ...... 111 Major Quantitative and Qualitative Findings ...... 113 Discussion of Nonsignificant Results from Quantitative Analysis ...... 113 Discussion of Significant Results from Quantitative Analysis ...... 115 Summary of Quantitative Results ...... 116 Discussion of Participants Perceptions and Themes from Qualitative Analysis ...... 117 Theme 1- The Discovery of Unconscious Biases ...... 119 Theme 2-Impact on Cultural Awareness ...... 121 Theme 3-Impact on Nursing Practice ...... 123 Theme 4-Cultural Interactions beyond the Classroom ...... 124 Discussion on Irregularities between Quantitative and Qualitative Results ...... 125 Other Outcomes ...... 126 Implications for Nursing Education ...... 127 Healthcare Disparities ...... 128 Recommendations for Nursing Education ...... 128 Recommendations for Future Research ...... 129 Geographic Proximity...... 130 Conclusion ...... 130 References ...... 133 Appendix ...... 142 Cultural Awareness Scale...... 142 IRB Letter ...... 146
vii Texas Tech University, Amanda Veesart, August 2016
ABSTRACT
The United States (U.S) has experienced a massive growth in population over the
last two decades, increasing the diversity of the nation’s population. The last census
conducted in 2010, revealed a rapidly growing population in the U.S. among all
categories of minority groups. Increased diversity creates differing healthcare needs for
the nation, including nursing care. The nursing profession has made substantial progress
towards delivering cultural care but has yet to achieve competency in all areas of nursing practice. In fact, failure to provide cultural specific healthcare has been linked to increase in healthcare disparities. The solution to avoid an unhealthy nation is delivery of cultural competent nursing care. Cultural competent care was first introduced in the early 1970s as a theory but has yet to be established as a standard in nursing education. Nursing education identified the need for cultural education in 2008 and mandated all baccalaureate nursing programs implement cultural education into their curricula.
However, the cultural education requirements have not been studied for effectiveness.
The purpose of the research project was to examine the impact of a culturally based assignment on student’s self-reported levels of cultural awareness. The project used a mixed methods approach to evaluate both quantitative data and qualitative data.
The results revealed significant changes in some areas of cultural awareness, while other areas showed a nonsignificant change. The narrative analysis showed a significant impact to participant’s cultural awareness levels after completing the cultural based assignment. Overall, the research supported the use of a culturally based assignment in nursing curricula to improve the levels of cultural awareness in baccalaureate nursing students.
viii Texas Tech University, Amanda Veesart, August 2016
LIST OF TABLES
4.1: Table for Gender and Race/Ethnicity Data for Cohort A and Cohort B ...... 79
4.2: Table Showing Cohort A Age Ranges ...... 80
4.2: Table Showing Cohort B Age Ranges ...... 81
4.4: Comparison of Participant’s Cognitive Attitude Levels Pre and Post-CBA ...... 85
4.5: Comparison of Participant’s Behaviors/Comfort Levels Pre and Post-CBA ...... 87
4.6: Comparison of Participants Cognitive Awareness Levels Pre and Post-CBA ...... 89
4.7: Comparison of Participant’s Patient Care/Clinical Issue Levels Pre and Post-CBA 90
4.8: Comparison of Cohort A and B Cognitive Attitude Levels Pre-CBA and Post-CBA
...... 92
4.9: Comparison of Cohort A and B Behavior/Comfort Levels Pre-CBA and Post-CBA 93
4.10: Comparison of Cohort A and B Cognitive Awareness Levels Pre-CBA and Post-
CBA ...... 94
4.11: Comparison of Cohort A and B Patient Care/Clinical Levels Pre-CBA and Post-
CBA ...... 95
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CHAPTER I
INTRODUCTION
The United States (U.S.) has experienced massive population growth over the last
two decades. The large increases in people have occurred across all demographics
increasing the diversity (United States Census, 2015). Consequently, the U.S. population has been referred to as a melting pot. (Munoz, DoBroka, & Mohammad, 2009;
Rosenbaum & Becker, 2011; Trivedi, Grebla, & Wright, 2011; Wathington, 2013). The census conducted in 2010, revealed a rapidly growing population in the U.S. among all categories of minority groups. Therefore, services, including healthcare, must reflect the changes within the U.S. society.
One of the most prominent growths occurred among racial minority groups as defined by the U.S. Census Bureau. The increase in the racial minority population was predicted to result in a non-White majority between the years 2030 and 2050 (United
States Census, 2010). In 2014, the population had more non-White Americans under the age 5, creating a majority-minority sub-population (United States Census, 2015). The report was the first in U.S. history to identify the White population was not the dominant race. Race was a term historically founded on unique physical characteristics of a group of people and considered an ill-utilized and non-scientific category (Spradlin, 2012).
However, for the purpose of the current study, racial minority was used as an identifying demographical group based on the U.S. Census Bureau definitions (United States Census,
2010).
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The U.S. Census predicted shifts in other cultural venues such as sexual orientation, age, socioeconomic status, and gender identification (United States Census,
2015). Additionally, the lesbian, gay, bisexual, and transgender (LGBT) communities
reported increases over the last decade with social norms and laws being adjusted to
reflect the changes. For example, in 2013, 252,000 same-sex couples were awarded a
marriage license (United States Census, 2015). The growing complexity of the population
is accompanied by unique languages, differing beliefs, worldviews, and healthcare
practices different from the majority or dominant population beliefs.
The differing beliefs demand a more culturally competent population, especially
in the fields of education and healthcare. According to Leininger (2007), cultural
dimensions influencing how a person responds to situations include religious beliefs,
social structures, political/legal concerns, economics, educational trends, technologies,
cultural values, and ethnohistory. The failure to recognize cultural influences as a driving
force for patient decisions in healthcare or student decisions in education could be
detrimental to overall success or health of the individual (Long, 2012).
The nursing workforce adds to the complexity of the country’s changing
demographic landscape. The average nurse in the U.S. is White, female, 55 years old and
many report not having immediate plans to retire (American Association of Colleges of
Nursing, [AACN], 2014). The complete opposite of the changing population. The
median age of nation is 40 years old (United States, 2015). The lack of cultural training
prior to entering the nursing practice paired with differing cultural interactions creates the
perfect environment for cultural challenges in healthcare delivery, eventually leading to
healthcare disparities (Trivedi et al., 2011). Healthcare disparities are not novel
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discoveries and the absence of cultural education in nursing has been deliberated as a
solution for decades (Leininger, 2007). However, the call to mandate cultural awareness
within the nursing curricula was not released until 2008 and the best placement within
nursing curricula has yet to be decided (AACN, 2008; Long, 2012).
The diversity of the population results in differing needs of individuals in certain
environments such as educational settings, religious settings, or healthcare settings. In the
nursing profession, differing healthcare needs are one of the most discussed concerns
(Leininger, 2007). Multiple studies have shown culturally uneducated healthcare
providers significantly impact the quality of care delivered to patients (AACN, 2008;
Soto, Martin, & Gong, 2013; Trivedi et al., 2011). Thus, creating a necessity for
healthcare providers to become more knowledgeable and accepting about differing needs
of a diverse population (Munoz et al., 2009).
Multiple solutions have been identified to address the nonexistent diversity
education in nursing such as financial rewards for working clinics in underrepresented
areas, educational reforms in curricula, and recruitment of underrepresented populations
into the nursing profession (Rosenbaum & Becker, 2011; Trivedi et al., 2011;
Wathington, 2013). The reforms have provided a temporary fix but formal evaluations of the interventions are minimal, specifically educational reforms in nursing curricula
(Long, 2012). In fact, healthcare disparities have increased thus, insinuating failure of the interventions (Soto et al., 2013). Consequently, cultural awareness placement in nursing education should be reevaluated. Cultural awareness should be incorporated into nursing education curricula in a manner that impacts the nursing student’s perception of other cultures, developing a foundation of cultural awareness (Campinha-Bacote, 2006;
3 Texas Tech University, Amanda Veesart, August 2016
Krainovich-Miller et al., 2008). The creation of culturally based assignments within the
nursing curricula may have the potential to impact the manner in which nursing students
interact with patients of different cultures, eventually translating into culturally competent nursing practice as the student progresses into the workforce.
History of Nursing and American Higher Education Prior to the nineteenth century, opportunities for underserved students to attend higher education institutions were denied and formal nursing education did not exist. The
first university, Harvard College was founded in 1636 and limited degree offerings to the
field of ministry (Altbach, Berdahl & Gumport, 2011). At this time, attending a higher
education institution was not considered a right but rather a privilege. Typically, the
privilege was extended to a select group of White, affluent, socially connected males.
(Kahlenberg, 2010). Medical education would not emerge until decades later, and the
absence of formal nursing education created a need for women to provide nursing care
without training. Women were expected to care for all healthcare needs of their family
and within the church community (Larson, 1997). Providing nursing care to individuals
outside of the church or who were not related was considered distasteful. In fact, women
who provided nursing care were considered mistresses or prostitutes (Keating, 2011).
At the start of the Civil War, male students left higher education to fight in the
war and females who had nursing care experience inside the home were drafted to the
battlefields (Fealy, Hallett, & Dietz, 2015; Keating, 2011). The untrained, females were
called to battlefields to provide nursing care to sick or injured soldiers (Altbach et al.,
2011; Keating, 2011). The extent of the need for nursing care was unfathomable; but for
the first time in history, nursing was viewed as a needed service or potential career
(Larson, 1997). Although seen as a potential career, nursing education was not
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formalized until after the Civil War in 1873 with the inaugural admission cohorts of
White women (Fealy et al., 2015, Keating, 2011).
Following the Civil War, several movements prompted the process of disbanding
segregation across the nation. In 1875, the U.S. government passed the first of many
Civil Rights Acts mandating equal opportunities for all population groups (Cohen &
Kisker, 2010). However, some of the nation, particularly the Southern states, disagreed
with desegregation. Instead, the Southern states formed informal laws known as Jim
Crow Laws. The purpose of the Jim Crow Laws was the continuation of separation of minorities while espousing equal opportunities for all (Rosenbaum & Becker, 2011).
Higher education campuses, including nursing schools, offered educational opportunities
for minorities but used different facilities or buildings (Kaplin & Lee, 2014). Although admission criteria were mandated to change across campuses, cultural division still existed.
The new admission criteria changed the cultural composition of higher education institutions. The nursing schools experienced the same shift in student population (Fealy et al., 2015). The changes regarding admission restrictions resulted in more minorities attending college, eventually creating a more culturally diverse environment at higher education institutions. The insufficiency in cultural competency training and the diverse population on campuses created problems (Soto et al., 2013). Violence and discourse among students ensued due to a lack of understanding or awareness regarding different cultures (Cohen & Kisker, 2010). By the late 1960s riots on college campuses were commonplace (Altbach et al., 2011). The increased activism, violence, and discriminatory lawsuits that occurred in higher education institutions after desegregation
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laws were mandated provided evidence that cultural discord existed (Kaplin & Lee,
2014). Furthermore, providing education regarding different cultures was not seen as necessary and resulted in a workforce unable to effectively address people with cultural differences (Spradlin, 2012).
During the late 1980s and early 1990s, the increased diversity had made a tremendous impact on the nation’s demographics. Healthcare disparities became prevalent and research was conducted on the correlation between culture and health
(Calvillo, et al., 2009; Soto et al., 2013; Trivedi et al., 2011). Nursing schools across the nation were graduating nursing students without cultural competence training with the expectation to care for a culturally diverse patient population. At the end of the twentieth century, the absence of culturally competent care in nursing practice was directly linked to the lack of education in nursing programs and eventually, an increase in healthcare
disparities (AACN, 2008; Loftin, Hartin, Branson, & Reyes, 2013).
Nursing Curriculum As the composition of the nation’s population began to change, nursing
organizations such as AACN noticed unchanging trends in the demographics of the
nursing workforce (AACN, 2008). A significant trend contributing to racial and ethnic
disparities in healthcare was the shortage of people entering the nursing workforce who
identified with a non-dominant, ethnic or racial minority group. The nursing workforce
did not reflect the diversity of the population served. A nine percent national dropout rate
among minorities in nursing professions contributed to the dominant, White nursing
population (Beacham, Askew, & Williams, 2009; Department of Health and Human
Services (HHS), 2010). In fact, racial and ethnic minority groups were reported as the
least represented in all of healthcare professions
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Further research has shown the recruitment of different races or ethnicities for the
nursing workforce is not sufficient enough to address the diversity of the population
(Soto et al., 2013). Studies have shown patients who receive care from a nurse who
identifies with the same demographical group have better healthcare outcomes (AACN,
2008; McGill & Kennedy, 2009; Renzaho, Romios, Crock, & Sonderlund, 2013). The identified shortages of minority groups in the nursing workforce have been directly correlated to the increase in healthcare disparities that resulted in recruitment of
underrepresented populations into the nursing profession (Betancourt & Maina, 2004;
Calvillo et al., 2009). Nevertheless, recruitment efforts were not extensive enough to
provide a significant workforce of nurses to care for the demographical shift across the
nation.
Research revealed another problem directly linked to ethnic and racial disparities.
Nurses who are not adequately trained to provide culturally competent care increase
cultural related health and healthcare disparities (Campinha-Bacote, 2011; Soto et al.,
2013). The inability to appropriately assess a patient’s unique needs or preferences can
compromise treatment and extend hospital stay (McGill & Kennedy, 2009). Culturally
competent nurses have the ability to identify specific cultural needs and develop an
individual care plan for a patient (Leininger, 2007). Despite the research supporting the
importance of cultural competency in healthcare, multiple studies have shown
baccalaureate of science in nursing (BSN) students reported feeling unprepared or
uncomfortable when caring for culturally diverse populations (Kardong-Edgren &
Campinha-Bacote 2011; Rew, Becker, Chontichachalalauk, & Lee, 2014; Reyes, Hadley,
7 Texas Tech University, Amanda Veesart, August 2016
& Davenport, 2013). These studies support the identified deficit of cultural awareness in
nursing education curricula.
In order to address the gaps in nursing education, the accrediting bodies in nursing
education released a mandate to accredited nursing schools across the nation requiring
cultural competence as part of the curriculum (AACN, 2008). Though cultural
competence was identified as an essential piece of the nursing curricula, the
standardization nor the placement within the curricula have not been mandated. This is
problematic for faculty who are responsible for curriculum development because
guidelines do not exist. The intent of culturally competent care (CCC) training is to
educate nursing students in a cultural assessment for each patient (Leininger, 2007).
Nursing researchers have shown multiple teaching strategies previously implemented across the nation to teach cultural competence (Long, 2012; Rew et al., 2014; Reyes et
al., 2013). Minimal evaluation of the effectiveness of these teaching strategies are found
in the literature. Hence, the current study adds more information to the field of nursing
about CCC in nursing education by examining the impact on a student’s cultural
awareness level after a cultural assignment is completed during a senior nursing course.
Cultural competence is described as an evolving process requiring ongoing self-
assessments, skill adjustments and continued learning (Campinha-Bacote, 2006). Thus,
the probability a novice nursing student would exhibit cultural competence upon
graduation from a BSN program is debatable. In fact, Campinha-Bacote (2011) suggests
an achievement of cultural awareness should be the goal for novice nursing students.
Cultural awareness is defined as the ability to recognize personal uniqueness in another
person’s beliefs, values, preferences, or needs (Campinha-Bacote, 2011).
8 Texas Tech University, Amanda Veesart, August 2016
Culture and the Learning Process A student’s ability to learn is influenced by the ability to interact and maintain relationships in the learning environment (Pai, Adler, Shadiow, 2009). Learners’ decisions in regards to study habits, desire to work in groups, or class selections are heavily influenced by the individual’s culture (Oguntoyinbo, 2013; Sadler, 2012). For example, the desire to complete coursework in a group or through cooperative learning instead of individually, is a preferred method of learning for cultural groups such as
Hispanic Americans. However, life experiences can create a different cultural lens through which a person may view his or her needs or environment. In order to be most effective, educators must have knowledge regarding cultural differences and the ability to assess cultural influences in the learning environment (Pai et al, 2009). The understanding of different learning styles among cultural groups is essential when developing culturally based assignments to teach the importance of cultural awareness.
Moreover, cultural groups rely on different sensory modalities for learning based on the ethnohistory of their culture. For example, Native Americans tend to be visual learners (Pai et al., 2009). The ability to understand how cultural groups learn differently is an essential piece of teaching, nursing education, and patient education regarding healthcare. When a nurse cares for a Native American patient who prefers visual education, the nurse should provide visual education to enhance the patient’s healthcare understanding. Thus, culturally based education is necessary to teach nursing students how to assess cultural needs of patients in all healthcare settings.
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Cultural Differences and the Impact on Health and Healthcare The hesitation by many to accept cultural differences and the effects culture has
on healthcare has resulted in an unhealthy nation (Betancourt, Green, Carrillo, & Park,
2005). Laws had been passed against segregation before the 1960s, but some educational
institutions, as well as healthcare systems, refused to change, particularly in the southern states (Cohen & Kisker, 2010). The societal behaviors have changed since the 1960s, but
cultural differences still impact the health of the population. For example, disparities in health and healthcare became prevalent in the 1990s citing cultural differences between healthcare providers and the patient as a significant cause (Aronshon, Burgess, Phelan, &
Juarez, 2013; National Center for Cultural Competence [NCCC], 2013). Healthcare disparities are defined as differences in access to healthcare facilities or services while health disparities refer to the unbalanced occurrence of diseases or disabilities between the dominant population and identified minority groups (Betancourt et al., 2005).
Examples of health disparities include cardiovascular disease, diabetes mellitus II, premature birth rates, mental illness, or obesity (Aronshon et al., 2013). These disease processes are more prevalent in certain racial and ethnic minority groups. Multiple factors have been identified as contributing factors of health and healthcare disparities.
Low socioeconomic status is the most prevalent connection to health and healthcare disparities (HHS, 2010). Patients who are considered to have a low socioeconomic status have been shown to not have health insurance or funding, which decreases access to certain healthcare facilities. Another common occurrence for the uninsured patient is the choice to prolong healthcare visits due to funding issues
(Aronshon et al., 2013; Renzaho et al., 2013). The vicious cycle of funding issues and not seeking medical attention created the prime environment for a disease to become
10 Texas Tech University, Amanda Veesart, August 2016
uncontrollable. Health disparities then emerged from the identified minority group.
Other factors beyond financial burdens can contribute to health disparities. Communities
in which people choose to reside are considered cultural domains. The choice to live in a
region without healthcare facilities creates a health disparity (Aronshon et al., 2013).
The multicultural composition of the U.S. has created a great need for the
healthcare professions to reevaluate how cultural considerations should be addressed
when making healthcare decisions. Healthcare decisions are heavily impacted by culture
(Renzaho et al., 2013; Spradlin, 2012). Considerations regarding a patient’s culture can
have major impact on health outcomes. When culture is not addressed the results are poor outcomes, decreased health, and financial devastations for government funded agencies (Calvillo, et al., 2009). According to the HHS, the damage is monumental and requires an in-depth evaluation of how healthcare is being delivered in regards to cultural considerations (2010). Furthermore, an assessment of the nation’s healthcare providers is needed to evaluate the ability to provide unbiased care based on culture (HHS, 2010).
The ability to provide healthcare based on cultural considerations begins with
education about cultural differences. Once the foundation of cultural knowledge is
accomplished, the healthcare provider begins the process of cultural competence
(Campinha-Bacote, 2011). Cultural competence is an ongoing process that teaches
healthcare providers the appropriate skills to care for all patients without barriers to
culture.
Developing a Culturally Based Assignment A culturally based assignment (CBA) was created to address the need for
increased cultural education in nursing curricula. The CBA examined cultural awareness
in senior nursing students enrolled in a BSN program. The assignment met the objective
11 Texas Tech University, Amanda Veesart, August 2016 of cultural education required for the senior level nursing course. The CBA was referred to as the Voice Project and was modified from a multicultural project developed in the education field by Alston and Strange (Strange & Alston, 1998). The Voice Project addressed three basic elements regarding culture and diversity training. The first step in cultural learning required the learner to interact with someone outside of their own culture. The second step of the project required the nursing student to listen with intent to the person outside of his or her own culture. The third and final step required the nursing student to internalize the needs and desires of the patient. The combination of these three steps is the basis for cultural learning (Strange & Stewart, 2011).
The semester-long CBA contained six components for completion. Prior to starting the CBA the nursing students were required to complete a cultural awareness survey (CAS). The CAS is an instrument designed to assess levels of cultural awareness in nursing students (Rew et al., 2014). The intention of administering the CAS prior to the CBA was to simulate thoughts on personal levels of cultural awareness. The results of the CAS were not used as part of the graded assignment. The six components of the
CBA included (a) a self-identified culture demographics reflection paper; (b) a reflection activity of preconceived expectations; (c) expected results; (d) selection of a patient with a different culture for the interview; (e) reflective journaling during the interview; (f) a reflective journal after the interview; and (g) completion of a PowerPoint presentation with digital storytelling via audio. Students were required to complete the CAS again after the completion of the CBA.
Problem Statement Nursing is considered the forefront of healthcare and the last line of defense for patient outcomes (AACN, 2014). Therefore, nurses must be well versed in cultural
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competence to address healthcare disparities caused by cultural incompetence. Cultural competence is an ongoing, developmental process which is recognized by the AACN as an essential part of the educational programs for BSN degree programs (AACN, 2008).
Despite the large quantities of evidence supporting the need for cultural competence in nursing curriculums, a standard for cultural curriculum has not been established for nursing programs. On the contrary, research reveals a large variation in the delivery of cultural competence education or absence of cultural competency within BSN programs across the nation (Betancourt et al., 2005; Campinha-Bacote, 2011; Long, 2012). The predictions by the United States Bureau regarding the nation’s shift in demographics to a
non-White majority will affect the patient population and the manner in which nursing is
practiced. The previously reported demographics of the nursing workforce coupled with
the lack of cultural education in nursing curricula is problematic because culturally
diverse patients demand cultural competent care. Providing nursing care without
addressing cultural needs results in healthcare disparities, thus, decreasing the overall
health of the nation (Aronshon et al., 2013; Beacham et al., 2009; Soto et al., 2013).
Purpose Statement The purpose of the current research study was to examine the differences in levels
of self-reported, cultural awareness of senior nursing students who completed a semester-
long CBA while enrolled at a large, public university located in the southwestern region
of the United States. In preparation to answer the research questions, an academic
literature review was conducted using multiple databases. The intent of the literature
review was to garner a full knowledge of the content area including relevant and recent
research. ERIC database was utilized for educational research using keywords such as
multicultural education, nursing education guidelines, cultural awareness, cultural
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competency in nursing, cultural competence in healthcare, student diversity, diversity, and multicultural learning. MEDLINE, PubMed, and EBSCO host were utilized using the following keywords: cultural competence, health care disparities, multicultural health, and nursing school curriculum. The search returned multiple articles within the purposed
timeframe of 2009 to 2015.
The articles selected for the literature review were narrowed using an identified
combination of relevant topics. The articles chosen acknowledged cultural competence in
healthcare or nursing and the relevance to health care disparities. Multicultural learning
articles with relevance to the application of higher education were selected as well.
Government and nursing specific agency websites were reviewed for relevant data to
support the need for cultural competence in nursing school curriculums. The study will
act as one data point in the discourse of the impact of a CBA on cultural awareness levels
reported by BSN students which may influence the manner in which nursing care is delivered.
Research Questions The study was guided by six research questions:
1. How does the level of self-reported cognitive attitudes regarding cultural
awareness differ before and after the CBA?
2. How does the level of self-reported behaviors and comfort regarding cultural
awareness differ before and after the CBA?
3. How does the level of self-reported cognitive awareness levels regarding cultural
awareness differ before and after the CBA?
4. How does the level of self-reported patient care and clinical issues regarding
cultural awareness differ before and after the CBA?
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5. How do the levels of self-reported cultural awareness factors differ between
Cohort 1 and Cohort 2 before and after completion of the CBA?
6. What is the perception of the students on the change in levels of cultural
awareness they experienced by participating in the CBA?
Significance of the Study The current study will contribute to the body of research by providing an evaluation on the effectiveness of using a CBA within a nursing education curriculum.
Curricular interventions impact the manner in which nursing students deliver patient care within nursing school and eventually, nursing practice (Loftin et al., 2013; Reyes et al.,
2013). Predictions regarding cultural changes to the population across the nation support the need for culturally diverse nursing curricula (AACN, 2008; Sadler, 2012). The change in demographics of the population results in an increased need to educate the nursing workforce on cultural assessments and the impact culture has on decisions made by patients regarding healthcare. The current nursing workforce is predominately White, fifty-five year old females of mid- to upper-socioeconomic status. The exact opposite of the diverse population of the nation. The significant cultural differences create a large cultural gap between patients of different ethnic, race, gender, age or socioeconomic status and the nurses who care for them. Delivery of CCC in nursing practice begins at the most basic level of nursing education. The study hypothesizes that completing a CBA during nursing school will increase levels of cultural awareness among nursing students, eventually translating into culturally sensitive nursing practice.
Summary of Theoretical Framework The current research project used multicultural learning theory and cultural care theory. The theoretical framework is based on two paradigms: postmodernism paradigm
15 Texas Tech University, Amanda Veesart, August 2016
and constructivist paradigm. Postmodernism paradigm is based on the idea that a single reality does not exist. Rather, individuals may react to the same situation in different ways and culture significantly influences the decisions made by individuals (Rodgers,
2005). Constructivist paradigm is based on the idea that one creates their own reality
based on interactions and situations, including but not limited to observation, interaction,
inquiry, or conversation (Patton, 2014). The research project utilized two separate
theories.
Cultural care theory (CCT) is constructed on the postmodernism paradigm that a
single reality does not exist for every patient in a healthcare setting. Rather, healthcare
should be provided based on cultural beliefs and patient preferences. CCT was first
defined in 1971 and redefined in 2007 as the healthcare provider’s ability to provide care
in relation to a patient’s culture (Leininger, 2007). The CCT provides a basis for
healthcare providers to understand patient requests based on cultural beliefs. The CCT
states a patient will make certain decisions regarding one’s own health based on cultural
experiences or beliefs (Leininger, 2007). Multicultural learning theory was constructed
from the constructivist paradigm. Multicultural learning theory is a subcategory of
critical theory that states that one should challenge the status quo of culture and learning
behaviors by observing, interacting, or conversing with different cultures with the intent
to construct a perception of the cultural influences (Patton, 2014). Multicultural learning
theory is defined as the education of students about cultures different from self-identified
cultures (Beacham et al., 2009). The theory is the foundation for developing culturally
based assignments throughout education.
16 Texas Tech University, Amanda Veesart, August 2016
Summary of Methodology The current research project utilized a mixed methods study to evaluate both
quantitative and qualitative date. The research project used a retrospective, descriptive
research design to evaluate previously collected data (Creswell, 2014). For the purpose of
the current research project, self-reported levels of cultural awareness among senior nursing students before and after the completion of a semester-long CBA were evaluated.
For the qualitative data, narrative inquiry was used to examine student’s reflections on
the impact of the CBA. The quantitative, descriptive design allows the researcher to
identify relationships between the concepts of cultural awareness and the CBA. The use
of narrative analysis allows the researcher to identify themes within the written student
reflections. The qualitative data were used to report the impact of the completion of the
CBA on student’s cultural awareness. Narratives provide the researcher with the ability to
capture ethical concerns or situations (Creswell, 2014). Understanding the impact of
culturally based assignments is essential in addressing the scarcities of cultural education
in nursing (Calvillo, et al., 2009).
Using a survey design with numeric description, the researcher examined trends or
attitudes of self-reported, cultural awareness levels by BSN students. The study used a
retrospective review of student surveys and reflections completed as part of an
assignment in prior coursework.
Assumptions of the Study The study assumed culturally appropriate interventions and teaching strategies
would result in increased cultural awareness levels among senior nursing students. The
development of culturally aware nursing graduates would generate positive patient
outcomes in nursing practice. Additionally, the study assumed nursing students who
17 Texas Tech University, Amanda Veesart, August 2016
completed the CBA would genuinely reflect on the cultural interactions with patient
interviewees. The completion of the pre-survey and post-survey did not impact the
student’s grade, therefore, a vested interest was not present. Lastly, the study assumed the
surveys and reflections completed before and after the implementation of the CBA were
honest, self-reported reflections of the nursing students’ cultural awareness levels.
Limitations of the Study Limitations of the study included the differing levels of cultural awareness in nursing students. Each student who participated in the study began the pre-survey assessment with a different baseline of exposure to cultures. A control group was not used to evaluate differences among self-identified cultural awareness levels. Another limitation included the availability of requested interviewees. Clinical selection of the interviewees were limited to the patient admission populations at the time of the CBA assignment. Therefore, nursing students were limited in selection of interviewees.
It was stated that CCT historically, has been misused throughout nursing education. For example, stereotypical religious or dietary habits have been assigned to specific racial/ethnic groups and placed in a chart to provide an umbrella-like teaching to students (Lancellotti, 2007). The generalizations create unfounded assumptions about patients. Studies have shown nursing students experience interactions with patients such as the aforementioned and feel misguided by the generalizations (Lancellotti, 2007;
Long, 2012). The continued misuse of the CCT has created an environment of untrusting nursing students in regards to cultural care. Nursing students are educated to evaluate for specific beliefs based on color, gender, or race; and when the beliefs are not present, the nursing student begins to mistrust the system. CCT was developed with the intent to individualize nursing care to the patient (Lancellotti, 2007).
18 Texas Tech University, Amanda Veesart, August 2016
Definitions The listed terms are used throughout the current research study and have been defined as follows:
Culture: Culture is defined as a broad concept referring, but not limited to, common beliefs, traditions, language, styles, values, and basic agreement about norms of living
(Spradlin, 2012). For the purpose of the current study, culture also includes race, social class, ethnicity, gender, age, sexual orientation, and family traditions.
Culturally based assignment (CBA): For the purpose of the current research project,
CBA is defined as a semester-long assignment with six components related to identification of self-awareness.
Cultural competence: Cultural competence is the integration of cultural awareness, cultural knowledge, cultural skill, and cultural desire into one system (Campinha-Bacote,
2011).
Culturally competent care: Culturally competent care is defined as the delivery of healthcare with deference to a patient’s culture, traditions, or decisions (Leininger, 2007).
Cultural awareness: Cultural awareness is the first step in the process of cultural competence. Cultural awareness is the ability to recognize personal uniqueness in another person’s beliefs, values, preferences, or needs (Campinha-Bacote, 2011). When used in the context of nursing care, cultural awareness is the ability to recognize the aforementioned qualities of a patient while delivering care.
Cohort 1: Cohort 1 was enrolled in the senior nursing level in fall of 2013.
Cohort 2: Cohort 2 was enrolled in the senior nursing level in fall of 2014
Demographics: Demographics is the study of changes within a society’s population such as age, gender, and birth rate, occurring within an identified population (Pai et al., 2009).
19 Texas Tech University, Amanda Veesart, August 2016
For the purpose of this study, demographical data of the U.S. population is based on the
reports of the (United States Census, 2010).
Minority: Minority, in reference to population groups, is defined as any population with less than 50% representation (Spradlin, 2012). In the context of cultural competency in nursing, minority refers to any group identification among race, social class, gender, age, or sexual orientation that is represented by less than 50% of the U.S. population.
Traditional undergraduate students: Traditional undergraduate students are defined as full-time, students entering college immediately following high school graduation and completing in four to five years. The average age of traditional undergraduate students is
19 to 22 years of age (Spradlin, 2012).
Summary The need for diversity in the nursing workforce has been known for many years.
The lack of diversity or the ability to care for a socially and culturally diverse population of patients is directly linked to healthcare disparities (Lancellotti, 2007). Cultural competence has been identified as a lifelong process and an essential component in addressing the gap in healthcare diversity. Cultural awareness is the first step in cultural competence (Betancourt et al., 2005). The development of a culturally aware nursing
practice is a process that must be taught at the beginning level of nursing. The integration
of cultural awareness into nursing curricula has been mandated by accrediting bodies
across the nation (AACN, 2008). Although most nursing programs have complied with the mandate, a standardized curricula for addressing and evaluating cultural awareness in nursing education has not been developed (Calvillo et al., 2009; Long, 2012). Thus, nursing educators are developing cultural assignments to educate nursing students in cultural awareness. Using a mixed methods design, the current research project
20 Texas Tech University, Amanda Veesart, August 2016 examined the effectiveness of a CBA developed for a nursing education course in a BSN program.
21 Texas Tech University, Amanda Veesart, August 2016
CHAPTER II
REVIEW OF LITERATURE
Chapter 2 presents a review of literature on the need for increasing diversity in
education, specifically nursing curricula. The chapter is divided into six sections: history of education and nursing, overview of cultural competence, cultural awareness in nursing education, nursing education reform, theoretical frameworks, and summary.
History of Education and Nursing: An Intertwined Social Evolution The start of higher education in the United States (U.S.) is defined as the Colonial
Era. The first college to be established was Harvard College which was founded in 1636 and known today as Harvard University (Cohen & Kisker, 2010). The aim of Harvard
College and other higher education institutions was to prepare select, White men of prestige and privilege for careers in ministry. The colleges were modeled after the Old
World institutions, and formal nursing education did not exist. Nursing education in the
U. S. would not surface until 230 years later (Larson, 1997). During the Colonial Era, eight other higher education institutions were established with similar curriculum and admissions to Harvard College (Cohen & Kisker, 2010). The curriculum was based on the 500-year old, European model which focused on the seven liberal arts: grammar, rhetoric, logic, astronomy, arithmetic, geometry, and music. Only White men of affluent families were allowed to attend a higher education institution with the intent to secure a career in the ministries (Cohen & Kisker, 2010). Although not formally trained in areas other than the ministry, some graduates chose careers in law, business, and medicine.
Interestingly enough, over one hundred years after Harvard College was founded, the nation’s first hospital was established in Philadelphia in 1751 and was thought of
22 Texas Tech University, Amanda Veesart, August 2016
primarily as an asylum or poorhouse (Fealy, et al., 2015). The hospital did not employ
nursing staff. Women were expected to become experts by providing nursing care to
family members within the home (American Nurses Association [ANA], 1965; Larson,
1997). Women who became experts at nursing were asked to care for members of the church communities and became known as deaconesses (Fealy, et al., 2015; Keating,
2011). The values of caring for others was viewed as charitable contributions of time and aligned with the Christian church. The church recognized the service of the women who cared for the members, yet nursing was not seen as a viable or respected career rather a service to address the needs of the church members. However, the need for nursing the public outside of the church members became more evident with societal changes over the following era (Fealy et al., 2015).
The Beginning of Formal Nursing The era following the Colonial Era is referred to as the Emergent Nation Era
(Cohen & Kisker, 2010). The Emergent Nation Era (1790-1869) was a time when the
nation was experiencing many changes in society, higher education, and nursing
education. The changes helped in reshaping higher education. Some of the most notable
events include the expansion of the nation to the West, Thomas Jefferson serving as
President, the ratification of the Constitution, and the wake of the Civil War (Cohen &
Kisker, 2010). Higher education experienced a massive expansion in small colleges, and
the attempt to increase access for more students was encouraged by the President,
Thomas Jefferson (Kahlenberg, 2010). The President desired a nation led by educated,
talented, qualified leaders in place of leaders who were chosen because of surname or
wealth. According to multiple reports, Jefferson believed an educational system of free
and unlimited access was the critical step in producing these type of leaders (Cohen &
23 Texas Tech University, Amanda Veesart, August 2016
Kisker, 2010). Interestingly enough, Thomas Jefferson was not referring to racial
minorities, ethnic minorities, nor women when discussing access and equity, rather,
White men who were not affluent (Kahlenberg, 2010).
The Effects of Moving West The Industrial Revolution was in full force by 1810 (Cohen & Kisker, 2010).
Factories were being built in cities across the nation. The expansion to the West had
great impact on the health of the nation. Americans began to relocate to the cities to secure jobs in the factories. Higher education institutions were being built to train and educate students for the industrial business (Cohen & Kisker, 2010). The colleges are
referred to as technical schools in today’s higher education pyramid. Technical
institutions were established to aid the industrial workforce and the Morrill Land Grant
Act of 1864 contributed to the growth (Cohen & Kisker, 2010). Morrill Land grant Act of
1864 gifted land for the technical colleges to be built in the Western portion of the nation.
The migration of students and factory workers increased the population rapidly. In
fact, the population had more than doubled in a short time resulting in crowded living
conditions in the cities. Crowded living conditions in the cities often fostered the spread
of diseases and industrial accidents resulted in the need for reassessment of healthcare
access (Fealy et al., 2015; Keating, 2011; Larson, 1997). By the end of the Industrial
Revolution in 1840, higher education institutions had discovered the need for educational
curricula different from the Puritan religion (Cohen & Kisker, 2010). In 1839, Horace
Mann, a Massachusetts politician, established the first formal school for teacher training.
Mann asserted education was a right for everyone and society benefited from an educated
society thus, educational institutions were needed to educate teachers. The Civil War
was the next societal event that would prove to change the nation.
24 Texas Tech University, Amanda Veesart, August 2016
Nursing in the Civil War The Civil War started in 1861 and was the catapulting force leading to the
establishment of formal education for nursing and hospital facilities (ANA, 1965; Larson,
1997). Females who were considered experts in nursing care in the church or home
brought wounded soldiers back to health (Fealy et al., 2015). Providing nursing care for who men who were not family or church members was considered improper behaviors.
Thus, in 1861, a private relief agency named the United States Sanitary Commission
(USSC), was established to care for the sick and wounded soldiers (Keating, 2011;
Larson, 1997). The USSC would be the precursor for the development of the Red Cross organization. Under the leadership of the USSC superintendent Dorthea Dix and the soon to be president of Red Cross, Clara Barton, the need for the nursing role in healthcare was unveiled. In 1868, three years after the end of the Civil War the president of the
American Medical Association endorsed the formation of training schools for nurses
(Keating, 2011; Larson, 1997). However, the first nursing school was not formally established until 1873 (Keating, 2011).
The end of the Emergent Nation Era witnessed a growing economy, societal changes, and an unnerved nation placing additional demands on higher education. The
U.S. government experienced multiple changes. The changes included the signing of the
Thirteenth Amendment of the U.S. Constitution in 1865 that abolished slavery and the
Fourteenth Amendment in 1868 that supported equal rights of all men (Cohen & Kisker,
2010). The population of many U.S. cities had nearly doubled during each decade from
1880 until 1920 resulting in the start of healthcare disparities. The increased health and
healthcare disparities created an essential need for professional colleges, including
25 Texas Tech University, Amanda Veesart, August 2016 nursing schools which began to rely on national licensing boards (Fealy et al., 2015).
Nursing schools multiplied rapidly and activists, such as women’s rights lobbyists, were protesting in full force (Keating, 2011). Although women did not win the right to vote until 1920, lobbyists for women’s rights dominated the nation in 1830-1890 supporting topics such as antislavery and voting for women (Cohen & Kisker, 2010). By 1883, thirty-five nursing schools had been established. By 1900, over 350 nursing schools existed, the Association of American Universities (AAU) had formed, and standards for graduate or research studies were established (Cohen & Kisker, 2010; Pai et al., 2009).
Around 1910, the women’s suffrage movement was peaking, and the number of women pursuing higher education exploded (Women’s Rights Movements, 2014).
The role of professional education had become essential for healthcare, as well.
In 1904, a nurse by the name of Lillian Wald reported on the impact nurses could have on public schools (Wald, 1934). The migration and growing population had caused a growing epidemic of diseases among Americans. Wald and a classmate developed a home visit program to aid anyone who fell ill in the community (Keating, 2011). The model is known today as public health nursing or home health care. Wald sent nurses to elementary schools for one month to examine further need for public health nursing
(Wald, 1934). The reduction in student absences was so prominent, a school nurse was appointed to the Board of Health and given 12 nurses to oversee the public education system. The change of nursing presence impacted the wellness of the population’s health in such a way that the National
26 Texas Tech University, Amanda Veesart, August 2016
Organization for Public Health Nursing (NOPHN) was founded in 1912, and a set of
standards was developed for the expansion of community-based nursing services
(Keating, 2011; Wald, 1934).
Standardization of Nursing The ANA developed the nurse practice guidelines regarding healthcare delivery for patients (ANA, 1965). The general practice guidelines for nurses were not mandatory but 48 states had adopted the guidelines by 1921 (Larson, 1997; Renzaho et al., 2013).
However, mandatory licensure by a board was not required meaning anyone could work under the title of nurse without being licensed. As a result, businesses began to replace educated nurses with lay nurses to save money during the Great Depression of 1929
(Keating, 2011; Wald, 1934). Standardized nursing curricula did not exist with varied length of programs and course offerings (Kokko, 2011; Smith, Brown & Crookes, 2015).
As the threat for World War II approached, the ANA had established intense recruiting methods to ensure nurses would be trained and available if the war ensued (ANA, 1965).
The growth in U.S. population was not slowing when World War II started in
1939. The mission of higher education was more student focused and institutions were
more involved in assisting the student’s entry into society (Cohen & Kisker, 2010).
Following the Great Depression, the purpose of higher education shifted to serve a more
diverse workforce but the nursing field had experienced a lull in recruitment (Larson,
1997). The National Council of Nursing teamed with a U.S. Representative in Ohio to
present a legislative bill to provide government funding for nursing education to help
address the shortage of nurses.
The Bolton Act of 1942 was the first bill for nursing support and resulted in
creation of the U.S. Cadet Nurse Corp (Keating, 2011; Smith et al., 2015). According to
27 Texas Tech University, Amanda Veesart, August 2016
Edith Aynes (1973), a nurse in World War II, by the end of the war 59,000 trained nurses
had served for the United States.
The nursing field appeared to be catching up with the rest of the nation with the number
of nursing graduates comparable to the number of graduates from other disciplines in
higher education (Keating, 2011).
Over the next few decades, student demographics shifted from affluent White
men to working class White men, but the population of women in higher education
remained small and the presence of Black students was almost non-existent (Cohen &
Kisker, 2010; Pai et al., 2009). The demographic composition of healthcare and
healthcare workers was very similar (Beacham et al., 2009). During World War II while
the nation was fighting for freedom, physicians in the U.S. were fighting for equal
medical care for Blacks. For example, a well-known African American physician by the
name of Charles Drew was lobbying to allow Blacks the ability to give and receive blood
transfusions (Wynes, 1988). Drew was attempting to show racial or ethnic identities
would not impact the transfusion of blood and only blood types should be used in
determining blood transfusions.
Between 1932 and 1975, the Tuskegee Experiment was being conducted in
partnership with a historically Black college (Katz, et al., 2008). The Tuskegee
Experiment recruited Black men and poor sharecroppers by promising free healthcare
from the U.S. government. The men studied were infected with syphilis, a deadly,
sexually transmitted disease. Some men were never treated for the disease even though medical professionals knew treatment was needed. The Tuskegee Experiment was designed to evaluate the natural progression of the disease, without treatment (Katz et al.,
28 Texas Tech University, Amanda Veesart, August 2016
2008). The project was terminated on grounds of ethical violations in 1972, forty years
after the first recruits were left untreated.
The experiment led to the establishment of the Office for Human Resources Protection
and standardization of healthcare practice, research, and education (Altbach et al., 2011;
Cohen & Kisker, 2010).
Curriculum Development The changing populations on campuses forced institutions to develop new
curricula for differing majors such as journalism, sociology, art, engineering, forestry,
and the professional subdivisions of institutions (Cohen & Kisker, 2010; Pai et al., 2009).
The curricula addressed the new desires of the nation to expand education but avoided the changing culture in the population of higher education environments. The change in
curricula to address the student preference indirectly contributed to a cultural change (Pai
et al., 2009; Sadler, 2012). By providing more opportunities or educational choices and
increasing access, the composition of students on campuses was different. The new
students were considered minorities or non-dominant culture members (Wathington,
2013). The acculturative process into higher education institutions caused conflict among
differing cultures (Pai, et al.; 2009; Sadler, 2012). The conflicts became a stage for
students to argue for changes and student activism became commonplace (Cohen &
Kisker, 2010; Kaplin & Lee, 2014). The change of focus in curricula to occupational and
preferential caused critics to blame the institutions accusing them of the conflicts
occurring on campuses (Altbach et al., 2011; Sadler, 2012). By the end of the University
Transformation Era in 1944, the expansion of higher education and the number of
graduates had exceeded 50,000 per year making a significant impact on the nation, both
29 Texas Tech University, Amanda Veesart, August 2016 positive and negative (Cohen & Kisker, 2010). The progress and expansion would prove to be even more challenging during the Mass Higher Education Era.
Era of Segregation The Mass Higher Education Era was one in which the nation’s industry and workforces began to change. The Era lasted thirty years (1945-1975) and was coined the golden years of education (Kahlenberg, 2010; Wathington, 2013). Several trends were noted during the Mass Higher Education Era including the shift in heavy industry, overseas industrial production, decrease in agricultural based jobs, and the decline of technical positions (Altbach et al., 2011; Cohen & Kisker, 2010; Pai et al., 2009). The population of the nation surged 60% following the victory of World War II, and the citizens of the nation had a strong desire to obtain post-secondary education (Kahlenberg,
2010). However, segregation in education and society still existed. In fact, nurses who served in World War II did not receive military benefits until after the war had ended in
1945 (Keating, 2011). Other racial minorities groups, such as Blacks, continued to experience discrimination in education as well. Professional schools, such as law schools, had created separate buildings for Black students to attend law school. The higher education institutions claimed equal but separate education from the dominant population was still considered equal opportunity (Cohen & Kisker, 2010; Lowe, 2012; Wathington,
2013). In an attempt to conquer the separate but equal battle, lobbyists and societal groups began to form.
One of the most prominent groups of the era was the National Association for the
Advancement of Colored People (NAACP). During the 1940s, the NAACP attempted to gain equal employment and educational opportunities for Black people (Rosenbaum &
30 Texas Tech University, Amanda Veesart, August 2016
Becker, 2011). At the same time, Congress felt compelled to aid the servicemen after the war and passed the Readjustment Act of 1944, better known as the GI Bill (Cohen &
Kisker, 2010). The bill allowed servicemen to return to college. Both efforts by the
NAACP and Congress increased the number of students who qualified to attend higher education institutions. The increase in eligibility began to increase the student population, thus, shifting the demographics on college campuses.
Postsecondary education had few advances in desegregation in 1950 when the
Supreme Court ruled in two separate cases, Sweatt v. Painter and McLaurin v. Oklahoma
State Regents for Higher Education. Both cases found separate facilities was not truly equal (Cohen & Kisker, 2010; Kaplin & Lee, 2014). The cases were individualized to the institution, thus minimally impacting other educational institutions across the nation. The breakthrough case of Brown v. Board of Education in May 1954 (347 U.S. 483) was the catalyst case in which segregation in education was truly addressed (Altbach et al., 2011;
Rosenbaum & Becker, 2011). The Supreme Court outlawed racial segregation in
American public schools but relied on local or state courts to set the deadline for the desegregation to occur which resulted in de facto, racism segregation (Cohen & Kisker,
2010; Kaplin & Lee, 2014). The landmark decision attempted to eliminate segregation in all schools in the United States but without deadlines, educational institutions were not forced to conform. In fact, the majority of educational institutions remained segregated, especially in the Southern states (Altbach et al., 2011; Lowe, 2012).
One of the major events regarding educational reform with segregation was the
Supreme Court order to desegregate a secondary school in Arkansas. By 1957, most postsecondary schools in the State of Arkansas had desegregated but public, state high
31 Texas Tech University, Amanda Veesart, August 2016
schools had not conformed (Lowe, 2012). In September of 1957, the Supreme Court
ordered the Central High School in Little Rock, Arkansas to allow nine Black students to
attend school (Altbach et al., 2011). The governor outwardly defied the order by deploying National Guard to block the entering of the students into the high school
(Lowe, 2012).
A few weeks later, the students were escorted by federal troops into the high school.
Known as the Little Rock Nine, the movement is considered one of the largest victories
toward equal educational opportunities (Cohen & Kisker, 2010).
The federal government passed the Civil Rights Act of 1964 with the intent to
allow federal reprimand for acts of inequality (Cohen & Kisker, 2010). The Civil Rights
Act of 1964 has been amended several times and prohibits discrimination based on race, color, religion, sex, or national origin. One of the most prominent changes for women was Title IX of the Education Amendments of 1972. The amendment prohibited sex bias in any educational program or activity (Kahlenberg, 2010). Additionally, congress became more involved in environmental concerns and passed more than twenty new laws in relation to air, water, waste, and toxins in an attempt to address the healthcare disparities (Cohen & Kisker, 2010).
Nursing during the Era Nursing education experienced similar growth and changes during the Mass
Higher Education Era. The war gave the profession of nursing a positive image. Nursing leaders capitalized on the image, and began collective bargaining for education and benefits (Keating, 2011). The growth was short lived and the next decade would prove to be a transitional decade for the nursing profession. Nurses who served in the war returned home to the role of wife and mother. The shift of roles left the U.S. in one of the
32 Texas Tech University, Amanda Veesart, August 2016 largest nursing shortages in history (AACN, 2008; ANA, 1965; Larson, 1997). The role shift was due to discrimination in the workplaces.
A nurse was expected to resign a position in a hospital or clinic when she married.
The mindset caused hesitation for nurses who were returning from autonomous roles in the war (Aronshon et al., 2013). The nurses who returned to hospitals in the late 1940s earned a salary equivalent to a hotel maid or seamstress, furthering the hesitation to return to the profession (Keating, 2011; Larson, 1997). The ANA and other representatives began lobbying for equal pay for nurses. In 1949, the ANA approved state nurses associations as collective bargaining agencies but a revision of the Taft-
Hartley Labor Act in 1947 exempted not-for-profit institutions such as hospitals from the requirement to enter into labor negotiations (Larson, 1997). During the 1950s, community colleges began to experiment with the offering of associate degrees in nursing, and accreditation programs were in full force (Larson, 1997). The nursing profession was growing but salaries and benefits had become stagnant. It was not until
1966 when the ANA revoked the no-strike clause that nurses began to earn a decent salary (Keating, 2011). By the end of the Mass Higher Education Era, specialists in nursing were developing but not fast enough to keep up with the growing population.
Impact of Desegregation on Higher Education Desegregation in higher education was not favored especially in the southern states. Many states and institutions avoided the process by implementing separate but equal opportunities (Kahlenberg, 2010). The higher education institutions that conformed to the new standards were not prepared for the multicultural environment (Pai et al., 2009). Hostility and violence across campuses became common. One of the most famous stories was the aforementioned, Little Rock Nine. School districts were redefined
33 Texas Tech University, Amanda Veesart, August 2016 to maintain separate boundaries and busing systems continued to be separate. Student activism was prevalent and took the higher education environment by storm. Students aligned with churches to protest desegregation on campuses (Cohen & Kisker, 2010;
Kahlenberg, 2010). The higher education institutions seemed more vulnerable than prior to segregation laws.
After the passing of the Civil Rights Acts of 1964 financial benefits were denied to federally funded institutions not abiding by the desegregation laws and changes finally started to occur (Altbach et al., 2011). Student protests slowed, and institutions slowly adapted to unification within facilities (Pai et al., 2009). However, the need to change curriculum offerings was not addressed. Faculty controlled the curriculum, and the expectation of acculturation remained. Acculturation is defined as the adaptation to the dominant culture (Pai et al., 2009). The expectation of students in higher education, despite private culture, was to adapt to the curriculum developed 100 years prior to the
Mass Higher Education Era.
Another concern occurring during the transformation to desegregation was the massive growth of students on campuses. The increased student attendance, secondary to increased access, proved to be financially beneficial to the institutions but posed issues with course offerings (Cohen & Kisker, 2010). The increased enrollment made necessary the separation of discipline offerings. The more courses offered in each area, the greater variation of courses occurred (Spradlin, 2012). The variations did not address the cultural needs of the student body, but allowed an assortment of selections imparting a more cultural friendly environment (Pai et al., 2009). The need for diversity in education and cultural friendly curricula was addressed in the following era.
34 Texas Tech University, Amanda Veesart, August 2016
Era of Consolidation The Era of Consolidation lasted from 1976 to 1993 (Cohen & Kisker, 2010).
Participation in higher education became more accessible by previously implemented
laws. Litigations regarding discrimination against women, differing races, older people, or disabled were frequent but often defended (Kaplin & Lee, 2014). The ability for minority groups to attend college was made possible by federal acts such as the
Rehabilitation Act of 1973, Americans with Disabilities Act of 1990, Age Discrimination
Act of 1975, the approval of financial aid, and the passing of the GI Bill (Cohen &
Kisker, 2010; Kahlenberg, 2010; Wathington, 2013). By the end of the Era of
Consolidation, access to higher education was slowly becoming less of an issue.
The availability of financial assistance and increased access to secondary education created other issues in higher education. Financial assistance created increased debt across the nation, resulting in the need to return to the workforce as soon as possible.
Students who received financial aid enrolled in the minimum amount of hours needed to complete degrees (Cohen & Kisker, 2010; Cohen & Kisker, 2010). The majority of students receiving financial aid were categorized as minority or underserved, adding to the need for cultural awareness in higher education institutions. Cultural awareness is the understanding, appreciation and acceptance of the existence in cultural differences
(Westwood & Westwood, 2010).
The continuous changes to curriculum caused an accumulation of programs and courses (Cohen & Kisker, 2010). Multiculturalism or diversity studies became popular majors, much to the dismay of critics. Required traditional curricula or core curricula, began to evolve to include courses that covered diversity or culture (Spradlin, 2012).
However, the course content involving cultural education lacked variation by
35 Texas Tech University, Amanda Veesart, August 2016
marginalizing cultural experiences into one definition based predominantly on the race of
people. Education on the ability to view cultural experiences as individualized despite
gender, race, ethnicity, sexual orientation or family traditions was nonexistent (Pai et al.,
2009; Spradlin, 2012). Interestingly enough, the same conversation regarding liberal arts
occurred 146 years prior and was reported in the infamous Yale Report of 1828
(Westwood & Westwood, 2010). The educational arena debated the need for liberal arts
versus training in Greek or Latin. Towards the end of the Era of Consolidation,
commissions were assigned to assess the quality and delivery of core curriculum (Cohen
& Kisker, 2010). The commissions discovered the need to emphasize multicultural
learning and the impacts on student outcomes. The result of many studies during the
following era supported the need for integration of cultural awareness into education to
improve outcomes of diverse students (Wathington, 2013).
Impact on Nursing Education Desegregation in higher education effected nursing education as well. As the demographics of the nation began to change, the demographics of healthcare and nursing changed. At the beginning of the Era of Consolidation in 1974, federal funds were allotted to build new healthcare facilities and agencies for healthcare planning became
prominent (Trivedi et al., 2011). The agencies were developed to assist in financing
concerns, regulations of healthcare in organizations, and legislative guidance. The
agencies for financial assistance are known today as health insurance companies. The
result of the movement was increased access to healthcare for anyone seeking care but
increased costs to alleviate the federal debt (Munoz et al., 2009). In 1974, the
government passed the National Health Planning and Resources Development Act to
assist the agencies in a new delivery and financing of healthcare (ANA, 1965). The
36 Texas Tech University, Amanda Veesart, August 2016 victory for access to healthcare was achieved and the entire population was able to seek healthcare if needed.
The triumphant progression for unlimited access and financial assistance created a slightly different problem for nursing. Nurses were not trained to take care of patients other than the dominant culture (Kumagai & Lypson, 2009; Leininger, 2007). Madeline
Leininger discovered the issue prior to the Era of Consolidation because of experiences with children of different cultures in the 1960s (Leininger, 2002). The children reacted to care differently based on cultural experiences but the theory was overlooked. Leininger’s cultural care theory (CCT) was reconsidered after the demographics of the healthcare system began to change with increased healthcare disparities in 1974 (Lancellotti, 2007).
According to the CCT, nurses who provide care in synchronization with the patient’s culture and beliefs will result in better patient outcomes, supporting the importance of liberal education previously reported in 1828 (Leininger, 2002). The typical form of nursing care resulted in cultural inversion. Cultural inversion is the process of identifying certain behaviors inappropriate because the behavior does not meet the standards of the dominant culture, or White culture prior to desegregation (Spradlin,
2012). The choice to ignore cultural needs was no longer acceptable and the need to implement the cultural care theory into practice was immediate. However, education on teaching culturally competent care did not exist (Keating, 2011).
The first curricula for nursing was developed on a medical model. In fact, nursing education did not make changes to curricula without medical research until around 1971, the same time Leininger was trying to refuel the CCT (Reyes et al., 2013). One of the first changes started with the integration of cultural knowledge within the curriculum.
37 Texas Tech University, Amanda Veesart, August 2016
The shift to provide care based on cultures was slow and required nursing educators to
revisit previously completed education. The education on culture was minimal and typically listed in a textbox (Keating, 2011). The generalizations of culture and biases did not address the cultural needs of the population, but were positive steps in addressing the need of diversity in nursing education. In 2002, Leininger published a differing
approach to cultural care that included individualized care based on patient’s preferences,
not visible or assumed culture. Although the need was identified early in the Era of
Consolidation, AACN did not release the call for reform in nursing education until 2008.
The reform mandated cultural competence by all baccalaureate in science nursing (BSN)
programs and provided a framework and toolkit for facilitation of cultural competent
education (AACN, 2008).
Overview of Cultural Competence Creating a healthier pluralistic society, including physically and emotionally,
requires an understanding of cultural competence. Cultural competence has been
described as the process of personal awareness in observing how individuals may react
differently because of heritage, ethnicity, gender, socioeconomic status or cultural
background (Calvillo et al., 2009; NCCC, 2013). Others have defined cultural
competence as the integration of culture awareness, cultural knowledge, cultural skill and
cultural desire into one system (Campinha-Bacote, 2011; Renzaho et al., 2013). Both
definitions have been used to train professionals to become culturally competent across
many disciplines.
A form of cultural competence is ingrained in daily practices in a variety of
different development areas. For example, training on culture sensitivity can be found in
student development courses (Wathington, 2013), student affairs offices (Rosenbaum &
38 Texas Tech University, Amanda Veesart, August 2016
Becker, 2011) and healthcare (Campinha-Bacote, 2011). Kokko (2011) has described cultural competence as a process in self-development from ethnocentric to the development of ethnorelativism. Competence involving culture is an ongoing process and may never be fully achieved or maintained but ethnorelativism can be achieved.
Ethnorelativism relates to the ability to observe behaviors, values, and decisions differing from self as culturally influenced, rather than universally influenced (Beacham et al.,
2009). The desired outcome is an understanding and awareness of how different cultural backgrounds can affect a person’s well-being, positively or negatively.
Importance of Cultural Awareness in Healthcare The health professions workforce does not reflect the diversity of the population it
serves. Beacham et al.(2009) reported a nine percent national dropout rate among
minorities in healthcare professions. In fact, minorities are the least represented in
healthcare. For example, African Americans represented 12.2 percent of the United
States (US) population in 2013 but only accounted for 3.3 percent of the nation’s
physicians (US Census, 2015). The lack of representation of diversity poses a need for a
different approach.
Historically, the proposed solution was to recruit more minorities into healthcare
(AACN, 2008; IOM, 2004). The continued efforts to increase the number of minorities
choosing a healthcare profession have not been proven to be beneficial (Beacham et al.,
2009; HHS, 2010; Wathington, 2013). The recruitment efforts for minorities into
healthcare should not be eliminated. A supplemental and possibly more realistic approach
is educating all healthcare professionals on culture. Therefore, cultural competence
becomes a foundational principle in providing individualized patient care.
39 Texas Tech University, Amanda Veesart, August 2016
Healthcare Disparities among Cultures Despite efforts, such as recruitment of healthcare workers to underserved areas, to improve the overall health of society, many issues still remain. Healthcare disparities are among the most significant due to the complexity of the solution. Health disparities can be defined as differences in the disease, health outcomes, quality of health care, and access to health care services among populations with similar racial, socioeconomic or ethnic groups (NCCC, 2013). For example, a survey of nonelderly adult’s showed 17 percent of Hispanic and 16 percent of Black Americans reported personal health as fair or poor. A significant difference appears when compared to the same survey of White
Americans who had 10 percent report fair or poor health (NCCC, 2013).
The reasons for healthcare disparities are multifactorial and are directly related to lack of cultural competence. Multiple studies have identified key contributing factors of health care disparities, including inadequate access to healthcare, poor quality of care, and personal behaviors (AACN, 2008; Soto et al., 2013). HHS (2010) identified key reasons on how culturally competent care can address health disparities. The first result in implementing cultural competence is the increased trust among ethnic minority and socioeconomically disadvantaged populations. Although healthcare providers may not agree or understand each culture entirely, the acknowledgment and attempt to respect cultural differences or behaviors increases trust between the served population and healthcare providers (Spradlin, 2012). Secondly, increasing the willingness to serve racial and ethnic minority has been shown to help improve quality of care (Betancourt, et.al, 2005). The correlations between the HHS rationales and the AACN contributing factors have been well supported in the literature (Campinha-Bacote, 2011; Renzaho et
40 Texas Tech University, Amanda Veesart, August 2016
al., 2013). Thus, creating strategies to increase cultural competence among healthcare
providers will aid in decreasing health care disparities.
Inadequate Access to Healthcare Historically, the Civil Rights Act of 1964 prompted a movement to increased access to federally funded bodies, including healthcare (Cohen & Kisker, 2010). The most recent efforts to increase access to healthcare began in March 2010 with the signing of the Affordable Care Act (National Institute of Health [NIH] (HHS, 2010). However, gaps remain in underserved communities. Underserved communities are defined using seven-point categories based on characteristics including race, ethnicity, geography, and health outcomes (AACN, 2008). Examples of the lack of access have been supported by subjective evidence but not strongly supported by quantitative data. Low socioeconomic populations are generally required to work longer hours and more days (McGill &
Kennedy, 2009). Lack of extended hours for the working class and upfront costs have been cited as major, anecdotal reasons underserved populations do not have regular health assessments (Aronshon et al., 2013; IOM, 2004; Kumagai & Lypson, 2009).
Structural malfunctions have been described as a barrier to healthcare as well. Structural barriers to access include lack of interpreters for linguistics barriers, long wait times, and locations of clinics (Betancourt et al., 2005). Although access is a major factor in eliminating health care disruptions, it has been postulated patients with maximum access still have healthcare issues related to other disparities.
Quality of Care Multiple studies have concluded a lack of racial or ethnically diverse healthcare providers or culturally uneducated healthcare providers significantly impacts the quality of care delivered to patients (AACN, 2008; Betancourt, et.al, 2005; Trivedi et al., 2011).
41 Texas Tech University, Amanda Veesart, August 2016
The disparity lies when healthcare providers do not fully understand, appreciate, explore or except differences of reaction, opinion, or decisions based on assumptions of culture.
The differences of reaction and trust directly relates to a lack of compliance. For example, a Hispanic patient is more likely to remain compliant with physician orders if the physician is Hispanic as well. The IOM landmark report, Unequal Treatment, reported significant variations in the equality of healthcare treatment, procedures and prescriptions provided to patients of different race, or socioeconomic status (2004).
A patient who is cared for by a healthcare provider of another race, ethnicity, gender or sexual orientation is at higher risk for psychological damage, being involved in a preventable error or poor outcomes (Aronshon et al., 2013). However, enrollment in health science center (HSC) professions does not begin to fill the gap of minorities. In fact, in 2012, enrollment of minorities in the HSC professions had decreased 11% (HHS,
2010). The current lack of diverse cultures among healthcare supports increased intercultural knowledge among healthcare providers. Providers who do not discover ethnorelativism are at risk for making decisions based on stereotyping, cultural indifferences or discrimination. Thus, the aforementioned IOM study reveals a need to increase the number of healthcare professionals who are proficient in providing culturally competent care.
A significantly higher satisfaction was reported by physicians in underserved communities if the physician had access to trained interpreters. The need is supported by
Betancourt and team, stating, improved health outcomes result from mutually respected, trustworthy provider-patient communication (Betancourt et al., 2005). An additional barrier reported by minorities in underserved communities is a lack of referral to
42 Texas Tech University, Amanda Veesart, August 2016
specialists and continuation of care. The HHS (2010) conducted a survey revealing
Hispanics and African Americans reported an increased problem obtaining specialty care
when compared to White counterparts. The inability to continue care with specialists
decreases overall patient outcomes and impacts quality of care. The gap between racial
minority healthcare providers and minority patients is large, supporting the need for
increased cultural competence in healthcare curriculums.
Cultural Awareness in Nursing Education The realization for diverse education for the dominant culture did not occur until
late in the 20th century (Keating, 2011). The increased awareness at the national level of the importance of providing cultural competent care has fueled an investigation into the curriculum of healthcare providers. Improving CCC in the HSC professions education is
critical in eliminating health care disparities. The initial intervention for cultural care
was recruitment of underrepresented groups into nursing, in hopes they would return care
to underrepresented groups. Although the underrepresented graduates have increased
over the last 20 years, recruitment efforts do not guarantee the graduates will provide
healthcare in underrepresented populations (HHS, 2010). The solution is a combination
of recruiting more minorities and improving the implementation of cultural competence
into nursing education.
The lack of cultural competence in nursing care was identified through a series of
research projects. The use of patient satisfaction surveys started in the 1980s revealed
nurses across the nation were not offering CCC that once was believed to be natural to
nursing (Reyes et al., 2013; Soto et al., 2013). Other researchers have shown patients
refused to seek healthcare due to previously encountered cultural issues (Trimble, King,
LaFromboise, BigFoot, & Norman, 2014). In 2001, the Health Resources and Services
43 Texas Tech University, Amanda Veesart, August 2016
Administration (HRSA) released a standardized method for measuring cultural competence in health care settings. Organizations began utilizing the measurement methods and discovered the lack of nursing education regarding culture or the marginalization of cultures were present in nursing curricula (Keating, 2011; Kokko,
2011).
Call to nursing education reform In 2008, AACN recommended the cultural competency essentials become a part of the BSN curriculum. According to AACN (2008), cultural competency essentials include the following five components:
a. Apply knowledge of social and cultural factors that affect nursing and health
care across multiple curricula.
b. Use relevant data sources and best evidence in providing culturally competent
care.
c. Promote achievement of safe and quality outcomes of care for diverse
populations.
d. Advocate for social justice, including commitment to the health of vulnerable
populations.
e. The elimination of health disparities and participation in continuous cultural
competence development.
Traditional BSN universities aim to produce graduates who can provide safe and effective cultural competent care. Only after the aforementioned recommendations are effectively implemented, traditional BSN education graduates can begin to assist in the reduction of health disparities. Accredited BSN programs across the nation have been mandated to demonstrate graduates are able to provide cultural competent nursing care
44 Texas Tech University, Amanda Veesart, August 2016
(Kranovich-Miller et. al, 2008). The execution of the AACN (2008) essentials is one example being used to develop the curricula (Calvillo et al., 2009). Nonetheless, standardized cultural competence courses have not been identified, and investigation on the effectiveness of the courses offered are not evident (Lancellotti, 2007; Renzaho et al.,
2013) In fact, the use of a cultural awareness scale (CAS) instrument by multiple authors supported evidence of significant gaps in self-reported cultural competence among graduate nurses (Kokko, 2011; Kumagai & Lypson, 2009; Renzaho et.al, 2013).
The CAS instrument was developed and validated by a team of nursing educators investigating the effectiveness of a cultural curriculum in a nursing program in Texas
(Rew et. al, 2003). The CAS identifies four components of cultural competence: cultural awareness, cultural sensitivity, cultural knowledge, and cultural skills. Students should be exposed to strategies to address each component in order to learn the process of cultural competence. Some researchers stress competence is a process to aspire to achieve
(Campinha-Bacote, 2011; Lancellotti, 2007). There is also a consensus that a student must first develop cultural awareness to be on track to achieving cultural competence
(Kokko, 2011; Kumagai & Lypson, 2009; Renzaho et.al, 2013). In order to expose nursing students to each component necessary to learn the process, nursing programs must implement culturally sensitive content via assignments into undergraduate nursing curricula.
Nursing Education Reform The first forms of cultural education included charts about normal behavior in cultures other than the White dominant culture (Keating, 2011). Evidence of cultural education in nursing curricula dates back to 1977, when external factors were considered assessment data for curriculum development (Keating, 2011; Leininger, 2002). However,
45 Texas Tech University, Amanda Veesart, August 2016
as the demographics of the population changed overtime, the need for new cultural
content arose. The most recently published culturally based assignments (CBA) in
nursing education include unfolding case studies, debates on the impact of current health
issues, public policy review, conceptual mapping of cultural needs of patients, global
health travel, and service learning projects (AACN, 2008; Kokko, 2011; Spradlin, 2012).
Others have cited experiential gaming or journaling as a means to facilitate cultural
learning (Kumagai & Lypson, 2009; Renzaho, et.al, 2013). For the purpose of the current study the culturally based assignment, known as the Voice Project, was used to
evaluate the impact of CBAs on the level of cultural awareness in undergraduate nursing
students. The Voice Project was developed from a similar assignment designed by
Strange and Alston (1998). The assignment is based in multicultural learning theory and
was originally assigned to graduate students in the higher education programs (Strange &
Alston, 1998). The Voice Project is a teaching strategy designed to instill cultural
awareness through inquiry with patients. The original assignment intentions included
development of habits in empathy and human differences.
Theories in Cultural Care The research literature review identified several prevalent theories focused on cultural competence. The current research used two theories to complete the cultural competent care framework in nursing education: Cultural Care Theory (CCT) and a
Multicultural Learning Theory. The CCT attempts to eliminate the dehumanization caused by prejudice decisions. For example, a nurse who used the context of CCT would provide a patient individualized nursing care. A nurse who did not chose to utilize the
CCT in practice would generalize all nursing care for any patient, despite cultural differences. A Multicultural Learning Theory (MLT) embraces the education of
46 Texas Tech University, Amanda Veesart, August 2016 individualization based on the aspects different from others. For example, the implementation of MLT in education would provide students individualized instruction based on culturally driven preferences. The intention is to devise an approach to link an educational intervention to the ability of BSN graduates to provide CCT. CCT has been utilized in nursing for over 30 years (Lancellotti, 2007). Multicultural learning is broad and applied predominately in the educational settings or professions (Strange & Stewart,
2011). The simultaneous application of both theories formed a theoretical framework for evaluating the effectiveness of implementing a cultural awareness intervention with traditional BSN students.
Cultural Care Theory The cultural competent care theory was first introduced to nursing by Madeline
Leininger in 1976. Known in nursing as the founder of transcultural nursing, Leininger’s
Culture Care Theory (CCT) (2002) has been defined as a specific approach utilizing knowledge and understanding of the patient’s culture to enhance individualized nursing care. The CCT entails an understanding by the nurse of the importance of culture to a patient and the negative impact the lack of acknowledgement of culture could have on outcomes (Leininger, 2007). The CCT is an ongoing process of self-evaluation. When applied to nursing education, CCT is a series of cumulative educational processes providing awareness, knowledge, and skills to interact with patients of unlike cultures.
Desire is a major piece of the CCT. Desire is defined as the intrinsic motivations to self- evaluate and change how one responds to different cultures, traditions, or decisions
(Campina-Bacote, 2011). Each component of cultural competence is intimately related and impactful to the other.
47 Texas Tech University, Amanda Veesart, August 2016
The current research project focused on the first element of cultural competence which is cultural awareness. Cultural awareness is defined by Betancourt et al., (2005) as the ability for one to recognize personal uniqueness of a patients’ beliefs, values, preferences, and needs. Other authors define cultural awareness as a self-examination of beliefs, biases, and understandings of other cultures values, preferences or needs
(Campina-Bacote, 2011; Krainovich-Miller et al., 2008; Lancellotti, 2007). Self- examination includes the process of identifying one’s biases, prejudices, and assumptions involving a different culture. Cultural awareness questionnaires can be used to begin the cultural awareness process. An example of one cultural awareness question includes: Is the key to getting along in any culture is be yourself-authentic and honest (Rew et al.,
2014)?
In healthcare, the process of becoming aware of one’s personal reactions to a
patient’s culture decreases the harmful impositions a patient may incur. Cultural
imposition is identified as the tendency for an individual or nursing student to impose
his/her own beliefs or values onto the patient of a different culture (Leininger, 2002).
Therefore, the self-examination or cultural awareness step has been identified as the first
step in achieving cultural competent care. Cultural knowledge is defined as the process in
seeking or obtaining a fundamental understanding about cultures differing from one’s self
(Campinha-Bacote, 2011; Krainovich-Miller et al., 2008; Lancellotti, 2007). Cultural
knowledge is the cornerstone to implementing cultural awareness in nursing students.
Cultural knowledge can be perceived as the educational step in achieving CCC. The
process to overcome a lack of cultural knowledge is the implementation of multicultural
learning in the BSN curriculum.
48 Texas Tech University, Amanda Veesart, August 2016
Multicultural Learning Theory Today’s nursing classrooms are made up of an array of cultures. One might term a
‘melting pot’ of individuals with set beliefs, values, and behaviors. The increased diversity among nursing students facilitates a need for a multicultural learning environment and the examination of the traditional roles, values, and boundaries.
Multicultural learning is defined as teaching students how to explore, evaluate and expand perspectives beyond boundaries of age, gender, race, ethnicity socioeconomic class, or sexual orientation (Strange & Alston, 1998).
Until recently, the view among nursing education on multicultural education has been the integration of all cultures into one classroom (Beacham et al., 2009) with the expectation cultural identities will be relinquished or blended into a new culture. The process is viewed as disbanding a microculture into a macroculture, in this case, a nursing macroculture. Historically, nursing has been a caring profession with the idea that all should comply with a certain culture to become a nurse (Leininger, 2002). The reduction of microcultures in classrooms can lead to stereotyping and prejudice among faculty and students (Aronshon et. al, 2013). According to Kumagai and Lypson (2009), minimizing prejudices, stereotyping and social injustices goes beyond cultural competence to a more multicultural learning environment. The authors maintain multicultural education can increase problem-solving skills through the different perspectives applied to the same problems to reach solutions. The intent of embedding multicultural learning into BSN curricula is to ensure nursing students have the cultural knowledge and skills to provide cultural competent care.
Cultural skill is the ability of the healthcare provider to assess, evaluate and implement care based on culture preferences (Campinha-Bacote, 2011). The process
49 Texas Tech University, Amanda Veesart, August 2016
involves obtaining relevant information on the patient’s current condition as well as how
cultural beliefs, values or behaviors have or can impact the current condition. The process
of utilizing cultural skills begin at the basic BSN level but are not mastered until later
during professional experience, if ever (Leininger, 2002). However, the foundational
aspects of cultural skill must be introduced into a multicultural learning environment
during the first years of nursing education to begin the building of cultural competence.
Multicultural learning is an essential piece in teaching BSN students the process of
cultural competent care.
Culturally Based Assignments In order to answer the call of the AACN to increase cultural competence in
nursing education, a culturally based assignment (CBA) was created and implemented.
The CBA was designed using the CCT and multicultural learning theory and based in the
postmodernism paradigm. The CBA, named the Voice Project, was designed as a
semester-long assignment requiring students to submerse in a different cultural lens
through research, interviews, and self -reflection. The Voice Project was modified from a
similar project created in the education field by Dr. Carney Strange (1998). Strange used
his Voice Project to educate students who were education majors on the differences in
cultural learning. The CBA was modified for nursing students. The Voice Project used
in this study includes the nursing student’s completion of a pre-survey assessment of cultural awareness levels, identification of demographics and cultural traditions, a four-
hour interview with a patient during a clinical rotation, journaling during the interview,
refection after the interview, completion of a presentation with voiceover, and a post-
survey assessment of cultural awareness levels. Completion of all components are
required for completion of the CBA.
50 Texas Tech University, Amanda Veesart, August 2016
The pre-survey and post-survey are completed using a previously published assessment tool, the cultural awareness survey (CAS). The CAS was developed for use by nursing students currently enrolled in nursing programs (Rew, Becker,
Chontichachalalauk, & Lee, 2014) Originally published in 2003, the CAS was reanalyzed and validated in 2013 using the same population. In depth analysis of the instrument is located in Chapter three of this proposal. The second phase of the CBA was completed prior to the nursing student’s clinical day. This phase includes self-identification of demographical information, and cultural traditions. The demographical information was used as the basis for interviewee selection. Nursing students were required to interview a patient two degrees different from self, thus, identification of self-demographics was essential. The last section of the second phase was reflection. The pre-interview reflection included potential biases, conscious or unconscious, the nursing student may had towards other cultures. Unconscious biases are defined as a small amounts of information about others who create microagressions, preformed ideas, or implicit thoughts causing negative or positive responses (Bellack, 2015). Journaling about self-identified bias prior to the patient interview cues the nursing student about influences or behaviors they may have towards others.
The next two phases of the CBA are conducted simultaneously. The nursing student selected a patient two degrees separate from the identified demographics completed previously. The nursing student were then assigned to spend four hours with the patient in the hospital setting. The patient was approached by a clinical faculty prior to the interview to secure permission from the patient. All patient information was kept anonymous for the assignment completion. During the interview, the nursing student
51 Texas Tech University, Amanda Veesart, August 2016
would observe interactions with the healthcare providers, family members, and any team
member involved in the patient’s care. The nursing students was required to journal all
interactions, as well as the patient’s thoughts, responses, and nonverbal ques regarding
the interactions. Questions were given to students prior to the interview to prevent uncomfortable quiet time. The questions included topics such as, pre-hospital admission lifestyle, previous work assignments, family dynamics, and provoking thoughts about current healthcare quality. The questions were modified from the Voice Project (Strange
& Alston, 1998).
The fifth and sixth phase of the CBA included a post-interview reflection by the nursing student regarding bias observed, thoughts about healthcare provider interactions, identification of unconscious bias that surfaced during the interview, and ideas on changes to cultural awareness levels. The nursing student was required to complete a presentation using PowerPoint or Prezi software. The presentation was expected to include a voiceover component, or digital story, that tells the patient’s story, from the patient’s perspective. The presentation became the Voice of the patient. Digital storytelling highlights the importance of narrative and provokes long-term memories
(Lambert, 2010). The purpose of the digital storytelling for the CBA was to create a memory for the nursing student of the interviewee’s voice directly correlating to cultural differences. After completion of the digital storytelling component, the nursing student completed the aforementioned post survey via the CAS. The current research project hypothesized that self-reported levels of cultural awareness will change after completion of all components of the CBA.
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Summary Cultural competence has been identified as an essential piece of nursing education
and a large component of addressing health care disparities across the nation. However,
cultural competence requires an evolving evaluation of one’s self before addressing
others cultural needs (Betancourt et. al, 2005). In order to create a positive cultural
change towards others, transformation about other cultures must begin with self-
identification of cultural awareness levels. The current research project examines the
development of a CBA for nursing students who began the process of self-assessment of cultural awareness levels. The CBA was developed and implemented based on a postmodernism paradigm describing cultural behavior as fluid and ever changing
(Rodgers, 2005).
Using a combination of the CCC theory and multicultural learning theory, the project was completed during clinical assignments of a senior level nursing course.
53 Texas Tech University, Amanda Veesart, August 2016
CHAPTER III
METHODOLOGY
The purpose of the current research study was to examine the differences in the levels of self-reported, cultural awareness of senior nursing students who complete a semester-long culturally based assignment (CBA) while enrolled in a large, public university located in the southwest region of the United States. Additionally, the research study explored the perceptions of changes to levels of cultural awareness as reported by the students through written reflection. The research project used a mixed methods research design. The quantitative methodology utilized a retrospective, descriptive design. The objective of the quantitative, descriptive study was to identify variables, possible relationship among variables, and determine differences between or among existing groups (Creswell, 2014). The qualitative methodology used narrative inquiry to examine student reflections regarding the experience of interacting with a different culture. Narrative inquiry seeks to better understand the student’s experience through written reflection (Bruner, 1996). The aim of the research project was to examine any differences existing in self-reported cultural awareness levels within identified categories of senior nursing student who participated in a semester-long cultural assignment and exploration of student perceptions of the cultural assignment through reflection.
Paradigms The current study utilized a two paradigms, postmodernism for the quantitative aspect and constructivist paradigm for the qualitative aspect. Postmodernism is a belief that a single reality does not exist. Constructivist paradigm suggests that encounters within a person’s surroundings create memories. In turn, the person constructs a reality that is meaningful to self (Lincoln & Guba, 2013). Constructivist paradigms are not built
54 Texas Tech University, Amanda Veesart, August 2016
on proof, rather invite further investigation by the participant to allow situations,
experiences, or interactions to morph into an idea that makes sense to the participant.
Postmodernism Postmodernism rejects the metanarrative theory that one answer exists for each
interaction by upholding the philosophy of one’s beliefs, expectations, values, and/or
experiences which have a larger impact on one’s life. This belief challenges the bias of
assigned demographics such as race or gender dictating how one will respond to
situations or environment (Rodgers, 2005). Based in a postmodernism paradigm, cultural
competent care theory was first introduced in 1974 (Leininger, 2007). The CCC theory is
based on the idea that a person’s health and decisions are largely influenced by cultural
beliefs and failure to recognize, and uphold these beliefs could be detrimental to the
patient’s recovery. Individual attention to the influence of culture is necessary.
Constructivist The constructivist paradigm supports the postmodernism thoughts but adds to the
individualization of experiences. Constructivist believe people experience events but they
also create events by perception of the events or lack of events (Lincoln & Guba, 2013).
Constructions are the end product of person’s ability to make sense, and are heavily
influenced by ethnohistory, societal events, or cultural influences. Constructions can vary in differing settings. Although constructs are considered subjective, the importance of the construct must be considered imperative when investigating the impact of an educational assignment. Multicultural learning theory falls within the axiology of the constructivist paradigm; thus, it was used in the current research study.
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Application of Paradigms Paradigms provide a conceptual framework for interpreting the perceptions of
society which in this case is Cultural Care Theory (CCT). One of the major challenges
facing nursing educators is the development of effective, educational interventions or
assignments assisting in teaching cultural awareness (Reyes et al., 2013). The objective
of culturally competent nursing education is to teach a healthcare provider how to assess
patient behaviors within the context of identified culture instead of expected cultural
behaviors based on textbook definitions.
Historically, cultural competence education has been done with qualitative
assignments such as journaling, mentoring, or via service learning projects. Most of the
identified teaching strategies related to cultural education require reflection of one’s
thoughts but lack in self-analysis of levels of cultural awareness (Keating, 2011; Long,
2012). Studies have shown cultural competence assignments in nursing education
produce varying results. Several authors agreed multiple cultural assignments with
proven positive outcomes, including continuous evaluation of effectiveness, are key to
improving cultural competence in graduate nurses (Campinha-Bacote, 2011; Soto et al.,
2013). For the purpose of the current research project, the impact on self-reported levels of cultural awareness before and after the completion of a semester-long CBA was reported using both quantitative and qualitative data.
The semester-long CBA contains the following six components for completion: a self-identified culture demographics, a pre-completion reflection activity of expected results, identification of a patient to complete the interview, reflective journaling during the interview, a reflective journal after the interview, and completion of a PowerPoint presentation with audio. Each student completed a survey before completion of the
56 Texas Tech University, Amanda Veesart, August 2016
semester-long CBA and after the completion of the semester-long CBA and then reflected on the level of impact regarding cultural awareness the CBA created. The pre and post survey data were compared for significance in changes. The reflection on cultural awareness was coded for the qualitative data and is discussed further in following section of chapter three.
Theoretical Framework Nursing theorists have focused on culture as an essential piece of nursing education and practice. Cultural care theory (CCT) is an ongoing development of understanding that someone’s beliefs, desires, and choices related to education or healthcare will be greatly impacted by their life experiences (Leininger, 2007). Social interactions or events can impact a person’s beliefs or values and thus change the choices
made regarding educational majors, institutions attended, or even the choice to pursue
higher education (Spradlin, 2012). The aforementioned concept is the basis for
multicultural learning theory. Multicultural learning theory describes an ongoing
learning process developed from experiences throughout life.
Using the universal definition of cultural competence, the American Association
of College of Nursing (AACN) (2008) and the Institute of Medicine (IOM) (2004) have
defined cultural competent care (CCC) as providing quality care for a patient with
awareness, knowledge, respect and skills of the patient’s cultural back-ground and the
impact it has on health outcomes. The ability to provide CCC begins with the process of
developing cultural competence and applying it to the nursing care of the individual
patient. Furthermore, to be effective, CCC must begin at the first encounter of a
healthcare provider, usually a nurse (AACN, 2008). For this reason, nursing schools
should integrate CCC into the nursing curriculum. The AACN encouraged nursing
57 Texas Tech University, Amanda Veesart, August 2016 schools around the country to implement culture competent education into nursing curriculum, coining CCC as an essential piece of education in the BSN degree. AACN
(2008) developed five cultural competencies to prepare BSN students for CCC. The challenge is whether or not nursing programs are actually graduating culturally competent nursing students. Though five cultural competencies have been established by
AACN (2008) the concern of inadequate implementation of the competencies within nursing programs remains. Further research revealed the CCC essential was not being proficiently taught (Renzaho et al., 2013). A potential issue regarding culture competence is the challenges perceived by nurses. For example, it is not possible to have knowledge about all cultures in existence or the changes of specific culture beliefs
(Kokko, 2011). Nurses have reported frustration in relation to the lack of information provided by patients or the perceived stereotyping patients verbalize if nurses make decisions based on culture norms (Leininger, 2002). Thus, utilizing the CCT to create and evaluate a multicultural learning assignment will contribute to the body of knowledge regarding culture competent education among BSN students.
Research Questions The study was guided by six research questions:
1. How does the level of self-reported cognitive attitudes regarding cultural
awareness differ before and after the CBA?
2. How does the level of self-reported behaviors and comfort regarding cultural
awareness differ before and after the CBA?
3. How does the level of self-reported general education experience levels regarding
cultural awareness differ before and after the CBA?
58 Texas Tech University, Amanda Veesart, August 2016
4. How does the level of self-reported patient care and clinical issues regarding
cultural awareness differ before and after the CBA?
5. How do the levels of self-reported cultural awareness factors differ between
Cohort 1 and Cohort 2 before and after completion of the CBA?
6. What is the perception of the students on the change in levels of cultural
awareness they experienced by participating in the CBA?
Research Design The current study attempted to measure and comprehend the impact of a culturally based assignment (CBA) on self-reported cultural awareness levels in senior nursing students by using a mixed methods research design. Descriptive research explores real-life situations in natural settings (Burns & Grove, 2011). The quantitative, descriptive design allows the researcher to identify relationships between the concepts of cultural awareness and the CBA. Understanding the impact of culturally based assignments is essential in the attempt to close the gap of cultural education in nursing
(Calvillo, et. al, 2009). Using a survey design with numeric description, the researcher examined self-reported trends or attitudes of cultural awareness by BSN students. The study used a retrospective review of student’s surveys. Therefore, participation in this study did not impact the student’s grades for the course assignment. For the purpose of this section, the CAS is referred to as the identified survey.
Qualitative research attempts to develop a holistic, complex picture of the issue being studied (Creswell, 2014). For this study, the qualitative methodology was used to evaluate the emerging themes that students reported via written reflection that was completed throughout the Voice Project. For the qualitative portion of the study, a narrative analysis was conducted with student reflections. The last section of the CBA
59 Texas Tech University, Amanda Veesart, August 2016 includes a written reflection on the impact of the assignment on the student’s level of cultural awareness. The reflection was transcribed by the student and submitted electronically. The narrative inquiry methodology enhanced the understanding of the student’s perception of the influence of the CBA, thus strengthening the research study.
Pre-CBA Completion The survey was an instrument designed to examine self-reported cultural awareness in nursing students and was administered prior to the completion of the CBA.
The survey was distributed with instructions for completion to students. All students enrolled in the senior level course are required to complete the survey as part of the course assignment. The completion of the survey did not require any identifying information from the students. A numerical marker was assigned to each student for tracking purposes only. The numerical marker was placed at the right hand corner of the survey. The survey was administered with the intent to stimulate reflection journaling.
Information obtained regarding self-reported cultural awareness levels was not used for grading during the course assignment. The survey was completed in the first two weeks of the semester, during the allotted course period. The completion of the survey takes approximately thirty minutes. After the survey was completed the students were given detailed instructions with a comprehensive timeline for completing the CBA.
Instructions for the CBA included the objectives of the assignment which included defining cultural awareness, discussing aspects of different cultures and self- reflection of perceptions on cultures, and any achieved changes regarding different cultures. The instructions included the timeline for completion, each component of the assignment, the setting for the assignment, and the grading rubric, as well. The semester- long CBA required six components or phases for completion: a paragraph on self-
60 Texas Tech University, Amanda Veesart, August 2016 identified culture demographics, a pre-completion reflection activity of expected results, identification of a patient to complete the interview, reflective journaling during the interview, a reflective journal after the interview, and completion of a PowerPoint presentation with audio.
Phases of the CBA The first phase in the CBA was self-identification of cultural demographics. The student was required to complete one paragraph about his or her cultural demographics.
Self-identification of culture, includes self-identified race, ethnicity, age, and gender.
Additionally, students should identify behaviors, attitudes, thinking, and communication styles specific to the self-identified culture. The completion of the first component was important for identifying one’s own culture. Culture is defined by experiences in life that may not be specifically defined but impact the decisions made during individual situations (Sadler, 2012). Examples of such behaviors include, family meals, holistic medicine beliefs, or meditation rituals. Each student was instructed to spend one week reflecting on self-identified cultural behaviors and customs. The reflection required two separate journaling entries prior to completing the cultural demographic paragraph. After completion of the first section, the student was allowed to begin the second phase of the semester-long CBA.
The second phase of the CBA was the pre-reflection activities. The second phase required two weeks for completion. The pre-reflection was completed prior to selection of the patient used for the interview phase but included specific demographics the student sought in an interviewee. The student self-selected the cultural attributes of interest to further their cultural awareness levels. A list of potential attributes were created by the student and used by the faculty member in the clinical setting to identify a patient
61 Texas Tech University, Amanda Veesart, August 2016
interviewee. The patient interviewee was identified as the Voice for the student’s project.
The patient interviewee must possess at least two degrees difference in culture from the
student as identified from the completion of the first phase in the CBA. For example, if
the student identified as White female, the patient would be a Hispanic male. The student
was encouraged to select a Voice other than his or her own, for which the student
assumed responsibility as an advocate in letting the voice be heard. For example, as an
African American female a student might wish to consider the perspective of a Latino
male; as a heterosexual male, a gay male or lesbian female; or as a traditional age student,
a returning adult learner. Additionally, during the second phase of the CBA, the student
answered a set of questions via journal entries.
The reflection included the following instructions and questions:
a. Enter into your voice journal everything you currently presume and
understand about your voice.
b. Where and how did you develop such an understanding?
c. What difficulties do you perceive for your voice? How much do you know
about your voice?
d. How will your voice deal with the patient’s medical diagnosis, treatment, or
hospitalization?
e. The pre-reflection activity will aid the student in identification of biases prior
to choosing the patient interviewee (Spradlin, 2012).
Unconscious biases have recently been described as hidden blind spots which inadvertently influence one’s behaviors towards others (Bellack, 2015). Behavioral responses range from sadness to microagressions and can result in poor healthcare
62 Texas Tech University, Amanda Veesart, August 2016 delivery if exhibited by a healthcare professional. The ability to identify the unconscious biases through pre-reflection may decrease behavioral responses detrimental to patient care delivery.
The third phase of the CBA was conducted in the clinical rotation of the assigned course. The student was given a list of patients who have agreed to participate in the
CBA and have the culture characteristics identified by the student list during phase two.
All patients were approached by a clinical faculty member prior to the student’s selection to ensure the patient is comfortable and knowledgeable about the project. The student selected a patient to become the Voice for the project. The patient selected by the individual student using the guidelines of two degrees different previously completed.
Phase three occurred during the fourth week of the semester and during the student’s first clinical rotation for the course.
Phase four of the semester-long CBA included the interview portion and in-situ reflection. In-situ refers to on-site reflection or reflection occurring during an activity and is typically used in a simulation setting (Oguntoyinbo, 2013). The application of in-situ as a reflection required the student to reflect while interviewing the patient. After receiving a patient interviewee, or Voice, the student spent four hours with the patient.
The students were given a set of safety criteria for the interview process. The criteria includes:
a. Do not be judgmental, opinionated or harsh. You are a professional and have the
ability to see medical care through a patient’s perspective.
b. Do not intervene in a medical conversation unless you think the patient is at risk.
63 Texas Tech University, Amanda Veesart, August 2016
c. If at any time, you witness an error or safety issue, think you are in an ethical
dilemma or uncomfortable, report promptly to your course-faculty.
d. Do not lie about who you are to medical personnel. You may state you are a
nursing student conducting a project.
e. Engage the patient in conversation. If you just sit in the patient’s room, it will be
uncomfortable for both of you and you will not collect the data needed to
complete your project.
The students spent four hours at the patient’s bedside during the fourth week of the semester, observing interactions between the patient and medical personnel, family members, and/or auxiliary staff. Prior to starting the interview, the students discussed the
criteria or the interview and the process, including journaling with each assigned Voice.
The students were encouraged to speak with the patient about cultural beliefs, preferences
when receiving medical care, and any other culturally based discussion the patient is
willing to share. At no point should any student have made the patient feel compelled or
pressured the patient to share any personal information. The students journaled during the interview and were given instructions to share journal entries with the patient if the patient sought to review the entries. The journal entries were used by the students to
create the Voice. The patient identification or personal information was not revealed
during the project. The journal entries were not used for the current research project.
The fifth phase of the semester-long project included post-interview reflection. The
post-interview reflection was a form of reflection-on-action debriefing. Reflection-on- action is used as a debriefing model for students to reflect on behaviors (Oguntoyinbo,
2013). The students were given two weeks to complete the reflection journal. Journal
64 Texas Tech University, Amanda Veesart, August 2016 entries included reflection on predictions the student completed in phase two. The students answered questions such as: Were previous biases correct? Did the interview changed the pre-conceived ideas? If so, how? Additionally, the students answered the following questions:
a. Why is your patient in the hospital or setting you observed? Discuss the patient’s
journey before entering the hospital and during the hospital stay.
b. Brainstorm and list some key features of the healthcare environment most likely
to affect your voice. What are some barriers your voice faces?
c. Reflect on and list some of the gifts of your voice.
d. How do you think your voice has been impacted during their stay?
The questions were designed to assist the students in identifying cultural beliefs or attitudes impacting the patient’s healthcare. Multiple studies show culturally uneducated healthcare providers significantly impacts the quality of care delivered to patients
(AACN, 2008; Trivedi et al., 2011). After completion of the fifth phase of the assignment, students created the final Voice Project.
The Voice The last phase of the semester-long CBA was the completion of a PowerPoint with an audio component. The student was required to create a storyline using information from the previous five phases. The presentation required the student to use audio to tell the story of the Voice. Digital storytelling was a means for students to connect to the interviewee and create a memory of cultural interactions. The digital storytelling assisted the student in conveying the story from a different culture’s perspective. The digital storytelling allowed the student to form a deeper connection to the Voice by portraying the interviewee’s perspective through audio (Lambert, 2010).
65 Texas Tech University, Amanda Veesart, August 2016
Instructions were given to the student, including patient protection and cultural
sensitivity. Students were given technical instructions regarding PowerPoint or Prezi
creation and audio recording. The digital storytelling instructions were based on the
Digital Storytelling Book (Lambert, 2010). The Voice presentation was uploaded to the
course’s assignment section housed in the Electronic Management System (EMS). The
CBA content or grading was not used for the purpose of this study. The students were
given four weeks to complete the sixth phase of the CBA.
Post-CBA completion Following the completion of the Voice Project, the students were given the CAS
survey. The survey was administered after the students had submitted the assignment to the appropriate area in the electronic management system (EMS). The survey was collected by the faculty member and not associated with the assignment submission. The cultural awareness survey was identical to the survey completed prior to the CBA.
Study Setting and Population The study was conducted at a large university nursing school located in the
southwest region of the U.S. The university serves multiple disciplines of the medical
field. The study setting includes third and fourth-year nursing students who complete
each year over two semesters. The participants selected for the study were first-semester, fourth-year nursing students who were enrolled in an acute care, medical surgical nursing course. A convenience sample of 252 baccalaureate nursing students was used for the
evaluation of self-reported, cultural awareness before and after the completion of a
semester-long CBA. The sample was defined as Cohort A and Cohort B. Cohort A
completed the CBA in the fall semester of 2013. Cohort B completed the CBA in the fall
66 Texas Tech University, Amanda Veesart, August 2016
semester of 2014. The convenience sample was large and the return rate was 100%,
therefore, a power analysis was not needed for the research analysis.
There was no exclusion criteria, as all students completed the CBA as a course
assignment. The demographical statistics of each cohort were obtained from a secondary
data source. Demographics were used to describe the population of each cohort but was
not directly correlated to the surveys obtained during the assignment. The department of
student affairs provided the demographics of Cohort 1 and Cohort 2 following Internal
Review Board (IRB) approval. The data consisted of the aggregate data that is reported each year to the Board of Nursing, following commencement. The data included gender,
race/ethnicity, age, and socioeconomic status of each cohort.
Instrumentation The instrument used in the study supports the quantitative, survey research
design. The survey instrument used for the research project was the Cultural Awareness
Student (CAS) survey, created by a team at the University Of Texas School Of Nursing
(Rew et. al, 2003). The team completed a reanalysis of the tool in 2014 (Rew et. al, 2014)
with a similar population of nursing students. The tool has been used in multiple studies
across the nation (Krainovich -Miller et al., 2008; Long, 2012). Permission to use the
survey tool for classroom activities was secured by the researcher.
Although multiple tools related to the measurement of cultural competency exist,
the cultural assessment survey (CAS) has been validated within the population of nursing
students in similar institutional settings as the current research population. Therefore, the
CAS was selected for the current study (Campinha-Bacote, 2011; Rew, et.al, 2014). The initial study conducted on the CAS revealed an internal reliability of α=0.91 (Rew, et.al,
2003). Furthermore, a replication study was conducted in the northeastern region with a
67 Texas Tech University, Amanda Veesart, August 2016
similar convenience sample of 236 baccalaureate students in nursing that supports the
validity and reliability of the CAS (Krainovich-Miller et al., 2008). In 2014, Rew and
research team, did a reanalysis of the CAS and found the tool to be highly valid and
reliable within the nursing student population. The nursing students used for the
reanalysis included baccalaureate and graduate nursing students. For this reason, the CAS
was used for the self-reported level of cultural awareness in the current study. Thus,
utilizing this instrument on a similar population builds upon the Rew et al. (2014) study and the Krainovich-Miller’s (2008) study adding to the existing research on cultural awareness for nursing students. The current study was conducted in a different geographical region, demographic composition, and social contexts from the two aforementioned studies.
The original CAS consisted of 36 questions and used a 7-point Likert scale to rate statements from strongly disagree to strongly agree (1=strongly disagree to 7=strongly agree). Published in 2003, Rew et al. reported the results of a pilot phase of the CAS with a Cronbach’s alpha value of 0.91. The team consulted a panel of seven experts in the area of cultural awareness who assessed the content validity index to equal 0.88 (Rew et al.,
2003). A factor analysis was completed on the tool and five factors accounted for 51% of the variance. The five factors aligned with the concept of cultural awareness and were identified as the instruments subscales. The five categories consisted of general experiences at this school of nursing, general awareness and attitudes, nursing classes and clinical rotations, research issues, and clinical practice. All questions were placed within a subscale that aligns with the content of the question; therefore, the subscales are randomly listed throughout the survey. The 37 items are reflected in the following
68 Texas Tech University, Amanda Veesart, August 2016
categories: (a) awareness of attitudes (n=8), (b) clinical practice (n= 5), (c) research
issues (n=4), (d) general education experiences (n= 4), and clinical/classroom issues (n=
16). For the current study, the results of the questions were placed within the subscale
and paired t-test were conducted on the subscale totals.
The reanalysis of the CAS was published in 2014 (Rew, et al.). The team used a
confirmatory factor analysis to reevaluate the tool. One item of the original thirty-six did not test well and, therefore, was dropped from the survey. The resulting reliabilities for
General Attitudes and Research Attitudes were α = 0.80 and 0.89, respectively, and yet the reliability for Clinical Experiences was 0.70. However, after reanalysis in 2014, the survey was changed to 27-items (Rew et al., 2014). After the completion of a factor analysis the research team divided the survey into three factors or subscales: general attitudes, research attitudes, and clinical experiences. The general attitudes factor consist of 27 items, research attitudes consisted of four-items, and the clinical experiences consists of four items. The results encouraged the use of three subscales to obtain better statistical results. The surveys used for the current study included the 37-item survey and five subscales due to the timeline of the project. The current results were not released at the time of the classroom activity.
Discussion on Survey Content The general attitudes subscale items included subjects such as classroom activities that are considered culturally biased by the student, access to multicultural opportunities on campus, and perceived respect of peers or instructors. Patient care and clinical issues items were designated under the general attitudes subscale. The patient care/clinical issues section addressed questions such as respect of patient decisions, patient communication regarding culture, and the use of resources to expand knowledge
69 Texas Tech University, Amanda Veesart, August 2016
regarding patient decisions based on cultural beliefs (Rew et al., 2014). Additionally, the
general attitudes subscale included questions related to the student’s self-identified level of comfort when caring for a patient of differing cultural beliefs. Examples of questions categorized as cognitive awareness included items such as self-assessment of cultural beliefs or biases (Rew et al., 2014). The third subscale identified by the research team was research issues. The research issues subscale addressed items related to thesis or dissertation subjects, research analysis, and interpretation of study findings. The current study examined the research section of the survey, as it was not applicable to the objectives of the Voice Project.
Data Collection The data for the current study were collected from baccalaureate nursing students who were enrolled in nursing courses in a large, southwestern university. The research project was a retrospective review of information; thus, informed consent was not required. Following the approval of the Internal Review Board (IRB), data were collected from the archived files from the nursing course, Concepts of Acute Care, which was offered in the fall 2013 and fall 2014. As mandated in the proposal to the IRB, the data were retrieved by a faculty member other than the investigator, who was assigned to teach in the course in the fall semesters of 2013 and 2014. Therefore, the faculty member had access to the archived course files. Following the retrieval of the files, the assisting faculty member removed all student identifiers from the CBA and presented the anonymous assignments to the researcher for data collection and analysis. Data collection occurred over a one-month period.
70 Texas Tech University, Amanda Veesart, August 2016
Quantitative Collection Course files were retrieved in the aforementioned manner. Following retrieval, all surveys were separated from the CBA and compiled for data entry. Surveys were placed into pre-CBA categories or post-CBA categories. An excel document was created for
data entry. All surveys were reviewed for completion and found to be 100% completed.
Thus, all questions were used in the data entry stage. A numerical column was created for
identification of the survey question and directly correlated with questions 1-36 on the
cultural assessment survey (CAS).
The pre-CBA results were entered into the excel sheet and saved on an encrypted
universal serial bus (USB) device. A second column was created with correlating
numerical numbers. The post-CBA results were entered into the second column in the
excel spreadsheet. The data was entered exactly as answered by the student, using the 7-
point Likert scale. Only one number per question was entered into the spreadsheet. The
survey results were reviewed by the assisting faculty member for accuracy.
Qualitative Collection The first stage of the qualitative data collection was conducted in the same
manner as previously discussed. The student reflection assignments for all 252 students
were retrieved from the course files and de-identified. All reflections were reviewed for completion. Students were given two reflection questions to complete at the end of the
CBA. The two questions posed to students included:
How did this activity help you understand the differences in patients?
Reflect on how this project impacted you. Do you feel your culture awareness
improved?
71 Texas Tech University, Amanda Veesart, August 2016
Each completed reflection consisted of a one-to-two page reflection written by the participants. In qualitative data, the researcher serves as the instrument, therefore, a different collection sheet was not created (Creswell, 2014). However, the researcher used a memo style data collection when reviewing the student reflections to collect themes that were used for coding. A memo style collection is based on a grounded theory methodology (Creswell, 2014). The student reflections were numbered to reflect the correlating memos. Student reflections were randomly reviewed for common topics, groups, or emerging themes. Topics and themes that emerged are discussed in the data analysis section. A total of 12 reflections were reviewed before saturation of topics, groups, and themes occurred. The minimal amount of qualitative data required for qualitative research is three with the average number being 12 (Creswell, 2014). The data collection for the current study exceeds the average number of data and, therefore, is considered a valid sample.
Data Analysis Plan Quantitative Analysis Survey results were analyzed using SPSS PASW20 statistical package.
Descriptive statistics were computed for all background variables including ethnicity, race, gender, and age. Data analysis such as t tests were considered in order to answer five of the research questions. Additionally, measures of central tendency, and analysis of variance (ANOVAs) were computed to answer the research questions. The use of a
Pearson correlation test was considered for specified research questions. The p < 0.05 level was used as the criterion to determine statistical significance, and the assumption of homogeneity of variance was not tested due to the convenience sample size. The CAS used a 7-point Likert scale. Selecting 1 indicated a student strongly disagrees with the
72 Texas Tech University, Amanda Veesart, August 2016 question while selecting 7 indicates a student strongly agrees. Students who selected 4 indicate no opinion about the specific question. A t-test was completed for each question on the CAS, comparing the average of the pre-survey results and the average of the post- survey results. After the t-tests were completed, the results were categorized by subscales. An analysis of variance was completed for each subscale. A pretest result and a post-test result of the subscale were compared. In order to answer the research questions, a series of statistical analysis were completed. The result were used to determine the answers to the coordinating research questions.
Qualitative Analysis A narrative analysis was completed for the qualitative section of the research. The narrative analysis reviewed documents, specifically the student reflections presented in the CBA, to gather the student perceptions of the cultural project. All reflections are transcribed by the student at the end of the CBA and submitted electronically; therefore, interpretative analysis was not needed. After the reflections had been retrieved and de- identified by a faculty other than the investigator, the researcher reviewed the reflections to identify themes associated with the impact of the CBA on cultural awareness.
Common topics were grouped into themes which may include, but were not limited to feelings, awareness, gained knowledge, or confusion all related to cultural awareness and experiencing the CBA. Next, open coding was used to complete a line-by-line analysis of words used in the reflections. Themes that have emerged were reported once open-coding was completed. The themes involving personal or professional changes were investigated and transcribed by the researcher. The researcher reviewed the reflections to identify themes associated with the impact of the CBA on cultural awareness.
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Positionality I am a white, heterosexual female who has lived most of my life in the southwest region of the United States. Prior to conducting this research, I worked as a trauma nurse for 8 years and then taught undergraduate nursing students at the baccalaureate level, where I currently remain an Assistant Professor and program director. My experiences of working in healthcare with a diverse patient population and with a diverse nursing student population led me to the current research project. Through direct observation of nursing students during their clinical rotations, I noticed a lack of connection to patients of differing cultures than the students. The disconnection did not happen every time we were in clinical, but occurred often enough to raise concern about the educational experiences of nursing students. Through conversations and debriefing with the students,
I realized the students were lacking in education on cultural awareness that correlated into practice. I conducted a review of research and realized cultural awareness in nursing students was a common gap, although cultural awareness was identified as an essential piece of BSN education. The CBA was developed as a classroom assignment that would address the cultural awareness gap. The CBA received tremendous feedback from nursing students; thus, I thought a research project on the impact of the CBA should be conducted. According to Lincoln and Guba (2013), it is sensible to expect that a qualitative researcher’s background, culture, or beliefs are variables that may affect the research process. Qualitative research uses the researcher as the data collection instrument. For the current research, this may create a bias towards the effectiveness of the CBA, as well as the impact the CBA had on students. The researcher acknowledges the one’s views are not inevitable and that such bias could occur.
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Limitations Limitations of the current research study included location and population. The current research project was conducted in one nursing school located in the southwest region of the U.S. The single location may pose limitations to the rigor of the study.
After descriptive statistics were completed, the demographical make-up of the research population was explored to rule out limitations of the study. For the purpose of this study, external variables were not controlled, creating a limitation to research analysis.
Examples of uncontrolled, external variable include attendance in cultural events, interactions with cultures similar to the chosen Voice prior to completion of the CBA, availability of patients who met the criteria, or prior cultural interactions. Additional external variables that could impact the results of the CBA but were not controlled in the study, included other course assignments related to cultural awareness or previous attendance in a cultural course. The lack of a control group was a limitation of the study as well.
Summary The current quantitative research project was designed using a descriptive, survey model to examine the efficacy of a culturally based assignment on self-reported levels of cultural awareness in baccalaureate nursing students. The purpose of the research study was to examine differences in self-reported cultural awareness levels of the identified nursing students, before and after completion of a semester-long CBA. Although the need for increased cultural awareness education in nursing has been identified by multiple educational agencies across the nation (AACN, 2008), a gap in evaluation of cultural curricula remains. Thus, the research project adds to the current literature by providing an evaluation of a CBA in nursing curricula.
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CHAPTER IV
RESULTS
Chapter IV presents the findings of the study and included the following sections
(1) restatement of the research purpose, (2) restatement of the research questions, (3)
research design, (4) data collection, and (5) analysis of findings.
Restatement of the research purpose The United States population has erupted over the last twenty years, increasing by
47 million people (United States Census, 2015) with projection of continued growth. The
nation’s population growth naturally contributes to the evolution of a more diverse
population and changes to demographical disposition. The continued change in the
demographics of the population and the lack of a diverse nursing workforce creates a
cycle of cultural issues that may contribute to healthcare disparities (Munoz et. al, 2009;
Rosenbaum & Becker, 2011; Trivedi et. al, 2011; Wathington, 2013). According to the
AACN (2008), cultural competency should be included in all BSN programs, but recent
research questions the effectiveness of teaching cultural competency (AACN, 2008;
Long, 2012). The lack of dissemination from nursing education to nursing practice has
created a concern for nursing educators.
The purpose of the current research study was to evaluate how the completion of a
semester-long, cultural based assignment (CBA) impacted the self-reported levels of
cultural awareness or impacted nursing students in a positive manner. The research
project was completed by first-semester, fourth-year, nursing students who attended
nursing school at a southwest regional university. The study sought to identify a
difference between survey results for each subscale, before and after the completion of
the semester-long cultural based assignment (CBA). Additionally, the study sought to
76 Texas Tech University, Amanda Veesart, August 2016 identify any themes through student reflections regarding the impact of completing the
CBA or changes in feelings towards other cultures during the delivery of nursing care.
Restatement of the Research Questions The study was guided by six research questions:
1. How does the level of self-reported cognitive attitudes regarding cultural
awareness differ before and after the CBA?
2. How does the level of self-reported behaviors and comfort regarding cultural
awareness differ before and after the CBA?
3. How does the level of self-reported cognitive awareness levels regarding cultural
awareness differ before and after the CBA?
4. How does the level of self-reported patient care and clinical issues regarding
cultural awareness differ before and after the CBA?
5. How do the levels of self-reported cultural awareness factors differ between
Cohort A and Cohort B before and after completion of the CBA?
6. What is the perception of the students on the change in levels of cultural
awareness they experienced by participating in the CBA?
Research Design The current research study utilized a mixed methods research design. A mixed methods design included both quantitative and qualitative methodology (Creswell, 2014).
The study evaluated all assignments from the students who were enrolled in the fall semester of 2013 and fall semester of 2014; thus, a convenience sample of 252 students was examined. Only assignments that were fully completed were used for the research study. Full completion of assignments included a pre-CBA survey, a post-CBA survey, the CBA, and a narrative reflection. The quantitative research used a retrospective,
77 Texas Tech University, Amanda Veesart, August 2016 descriptive statistical design while the qualitative section utilized narrative analysis. All data were obtained from a secondary data source. The following section describes the participants’ data and data analysis results that were completed in order to answer all research questions.
Participants The convenience sample for the research project consisted of 252 baccalaureate nursing students who were enrolled in the first-semester, fourth-year, course that required completion of the semester-long CBA. The 252 students were from two separate cohorts,
Cohort A (116) and Cohort B (136). Demographics for each cohort varied and were reported to the researcher by the student affairs office. Gender was reported as male or female. Ethnicity/race definitions were defined by the university and self-reported upon enrollment to the nursing school. The nursing school reports age in ranges. The age range was collected upon admission into the program, which was fall 2012 and fall 2013 for each cohort. The average ages for the individual cohorts were 24 years of age and 23 years of age, respectively. The nursing school did not report individual socioeconomic status. However, students who are considered in need of financial assistance are reported as an aggregate group. Additionally, first-generation students are included in the demographic data for the nursing school.
Gender Consistent with the nation’s statistics regarding nursing students, the majority of nursing students are female (AACN, 2014). Females were the largest gender group for the entire participant sample. For Cohort A, the females accounted for 88.7% of the class. Cohort B was 88.9 % female. Males accounted for 11.3% for Cohort A and 11.1% for Cohort B, respectively.
78 Texas Tech University, Amanda Veesart, August 2016
The percentage of male nursing students closely aligns with the current national nursing population that reports less than 10% of a male nursing population (AACN, 2014).
Race/ethnicity Race and ethnicity were considered as one group for the nursing school and were, therefore, reported in the current research as one group. The only race/ethnicities that were reported were American Indian, Asian, Black, Hispanic, and White. The convenience sample consisted of predominately White nursing students. The convenience sample was 60% White, with Cohort A consisting of 56 % Whites and Cohort B reporting 64% White. The least represented race/ethnicity was American Indian, with only less than 1% of the convenience sample identifying as American Indian. Cohort A did not have any reported American Indian students. All other race/ethnicities were equally distributed across both cohorts. Table 4.1 represents all demographical data received from the Office of Student Affairs for Cohort A and Cohort B.
Table 4.1: Table for Gender and Race/Ethnicity Data for Cohort A and Cohort B
Demographic Variable Cohort A Cohort B
Female 103 121
Male 13 15
American Indian 0 2
Asian 11 6
Black 7 13
Hispanic 26 20
White 65 88
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Age The age range for the current research was in alignment with the average age of junior level, higher education students (Cohen & Kisker, 2010). The average age for
Cohort A was 24 years of age and for Cohort B was 23 years of age. The youngest participant in the research project was 19 years of age and the oldest was 51. Less than
1% of the participant population was above 39 years of age and 75% of the participants were less than 29 years of age. Although age could not be directly tied to individual surveys, the researcher can assume that the age of the participants may have impacted some of the results. For example, questions regarding previous interactions with cultures or clinical experiences could have been influenced by age. Participants who were younger may not have the life experiences of the older participants involving different cultures other than self. This assumption is explored further in Chapter 5. For the purpose of the study, standard age ranges were used for reporting (Creswell, 2014). All results for age ranges are listed below in Table 4.2(Cohort A) and Table 4.3 (Cohort B).
Table 4.2: Table Showing Cohort A Age Ranges
Age Range Cohort A Results
19 9
20-29 85
30-39 21
40- 49 1
50-59 0
80 Texas Tech University, Amanda Veesart, August 2016
Table 4.2: Table Showing Cohort B Age Ranges
Age Range Cohort B Results
19 4
20-29 91
30-39 39
40- 49 1
50-59 1
Socioeconomic Status Socioeconomic status was not reported individually by nursing students who attended
the university during the research timeframe. However, the nursing school provides a
yearly report to the scholarship office regarding financial need of the nursing students by
cohort. This report assisted the Associate Dean’s with distribution of scholarship funds.
The financial need of students was not disclosed to the investigator. However, the student
affairs office provided the researcher with an aggregate report of financial need of each
cohort. Less than 10% of the students in Cohort A reported the need for financial
assistance or scholarships funds. Cohort B reported a higher financial need with an
aggregate need of 22%. Although Cohort A and B reported low financial needs, a
significant difference was reported between cohorts. Cohort B had more than double the
amount of participants who requested financial assistance. Self-reported financial need cannot be directly correlated to socioeconomic status so one can assume students who seek additional financial compensation would be categorized in a middle income or lower socioeconomic category (Bellack, 2015).
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Data Analysis Results The next section discusses the analysis of the data for each research question.
Inferential procedures were used to examine the differences in CAS rsults pre and post
CBA. All data results were placed into individual tables (Tables 4.3-4.11) according to the identified subscale and presented later in this chapter. In order to execute the data analysis, questions from the CAS were regrouped into subscales in the excel document.
The subscales were identified by the original authors of the CAS and directly correlate with proposed research questions (Rew et. al, 2015). For the qualitative data, a narrative analysis was conducted and memo style methodology was used to identify emerging themes from student reflections that were submitted after the completion of the CBA.
Quantitative Data Analysis A quantitative data analysis was completed with a Pearson correlation, coefficient of determination, a paired t-test and Cohen’s d. A Pearson correlation tests measure the degree of relationship between two variables, in this case, the relationship between pre-
CBA results and post-CBA results (Creswell, 2014). The Pearson correlation cannot determine cause and effect relationships, rather, the closer to 1.00 the stronger the degree of relationship is between the variables. A paired t-test was used to examine if a statistical
significance existed in pre-CBA results and post-CBA results.
The p < 0.05 level was used as the criterion to determine statistical significance
(Creswell, 2014). To determine the effect size of the paired t-test results, a Cohen’s d was
calculated for each subscale result. Cohen’s d has widely accepted suggestions about
what constitutes a large or small effect: r = 0.10 (small effect), r = 0.30 (medium effect), r
= 0.50 (large effect) (Creswell, 2014). For the purpose of this research study, these effect standards were used to determine the size of the effect for each paired t-test. Even if the
82 Texas Tech University, Amanda Veesart, August 2016 population is not normally distributed, the Central Limit Theorem allows us to infer normality as the sample sizes increase. Due to the size of the convenience sample (252), and the multiple questions examined (36), it can be assumed that homogeneity existed within the data (Creswell, 2014). Further comparison was completed between Cohort A and Cohort B. A one-way analysis of variance (ANOVA) was conducted for each subscale of the CAS. The pre-CBA results and post-CBA results for each cohort were compared to examine any differences in reported levels.
Cognitive Attitudes Results The first subscale examined was cognitive attitudes which refer directly to general attitude towards the student’s educational experience. An example of topics related to cognitive attitudes included questions regarding feelings of respect for differences, sensitivity of multicultural issues, and understanding different cultural groups. The subscale refers directly to general experiences at the nursing institution. The cognitive attitudes subscale included fourteen items from the CAS. The fourteen questions included questions 1-4, 14, 16, 18-19, 21-22, 24-27 (Rew et al., 2014). The questions are randomly placed on the CAS to increase the reliability. The 14 items were regrouped within the excel spreadsheet for Cohort A and Cohort B. The average of the 14 items for
Cohort A and Cohort B were calculated. A total of 252 entries were averaged. The results were placed in a corresponding column. Using the data analysis function in excel, the following data were calculated and will be reported in the following summary section
(Table 4.4).
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Summary for Cognitive Attitudes The results for subscale one supported the hypothesis that a significant impact in
cognitive attitudes regarding cultural education would occur pre-CBA and post-CBA.
The cognitive attitudes subscales asked questions such as classroom discussions regarding culture, clinical course interactions, and overall general education experiences for cultural awareness. The Pearson correlation result supported a strong, positive relationship between the pre-CBA and post-CBA results for cognitive attitudes meaning that all participants’ post-CBA increased in the same manner. The result provides significant correlation to the impact of the CBA on the entire sample, which means that
all participants were positively influenced.
The difference between the pre-CBA mean and post-CBA mean was calculated.
The difference supported further testing to evaluate the significance in the change. A t- test was conducted to determine the significance of change in the pre-CBA results and post-CBA results. The t statistic obtained (t=3.19) was in the critical region; therefore, the researcher concluded there was a significant difference in the participant’s self-reported level of cognitive attitudes towards cultural awareness between the pre-CBA and post-
CBA. The results supported that participants who completed the CBA experienced a change in attitudes towards their general educational experiences regarding cultural awareness.
A Cohen’s d test was conducted to examine how large the change was for the participants. The Cohen’s d result supported the change was in fact a large effect change between the participants’ self-reported cognitive attitude levels pre-CBA and the post
CBA completion. Although still controversial in the literature, the positive, significant
84 Texas Tech University, Amanda Veesart, August 2016
changes support the idea that educational interventions may have significant impacts on
cultural awareness (Long, 2012; Reyes et al., 2013; Soto et al., 2013).
Table 4.4: Comparison of Participant’s Cognitive Attitude Levels Pre and Post-CBA
Cognitive Attitudes Results Pre-CBA Post-CBA Mean 4.50907 4.874716553 Variance 0.514878 0.333009717 Observations 252 252 Pearson Correlation 0.846311 df 251 t Stat -15.1385 P(T<=t) two-tail 3.19E-37 t Critical two-tail 1.96946
Mean difference 0.36565 Standard deviation 0.441374 Results for Cohen's d 0.82843
Behavior and comfort levels The second subscale represents nursing student’s behaviors and comfort levels
while interacting with patients of differing cultures or with instructors (Rew et al., 2014).
The behaviors and comfort subscale includes six items on the CAS. As previously mentioned, the questions were regrouped within the excel spreadsheet to calculate the data analysis. The six questions included questions 8-10, 12-13, and 36. A total of 252 entries were averaged for the second subscale. The results were placed in a correlating column for completion of the following data analysis. The data results are listed in table
4.5 presented in the summary section below.
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Summary for behaviors and comfort The behaviors and comfort subscale examined participants’ level of comfort when interacting with a patient from a different culture, avoidance of different cultures, and interactions of instructors with students of different cultures (Rew et al., 2014). Although the Pearson correlation for subscale two revealed a positive correlation between pre-CBA
results and post-CBA results, the correlation was 37% which is considered a weak
correlation. The results showed that minimal changes occurred in the variables, but the
variables that changed did so in a positive manner (Burns & Grove, 2011). The
differences in the mean values for the pre-CBA results and post-CBA results for the second subscale were minimal. A t-test was conducted to examine if a significance existed. The t statistic was not in the critical region; therefore, it was concluded that a significant difference did not occur between the pre-CBA and post-CBA for behaviors and comfort. Due to the t-test results, a Cohen’s d was not conducted.
The non-significant finding between pre-CBA and post-CBA was not a surprise finding and in fact, supports current curricular nursing designs. Nursing education historically educates students on cultural interactions at the start of a nursing program
(Keating, 2011). The CAS asked the participants to disclose the frequency in which they avoided patients of a different culture (Rew, et al., 2014). The participants’ pre-CBA results showed a strong disagreement, meaning the participants felt that culturally different patients were not treated differently. If the results would have produced a significant change, it would have indicated that participants became more biased towards culturally different individuals. The non-significance was unexpected but reveals a feeling of unbiased, cultural education for the participants and will be further explored in the discussion section.
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Table 4.5: Comparison of Participant’s Behaviors/Comfort Levels Pre and Post-CBA
Behaviors-Comfort Final Pre-CBA Post-CBA Mean 2.44709 2.391534 Variance 0.5056 0.473359 Observations 252 252 Pearson Correlation 0.379125 Hypothesized Mean Difference 0 df 251 t Stat 1.131023 P(T<=t) two-tail 0.259125 t Critical two-tail 1.96946 Mean difference 0.055556 Standard deviation 0.039284
Cognitive Awareness The third subscale examined was cognitive awareness which refers to the nursing
student’s ability to identify behaviors, attitudes, and influences of one’s own beliefs on
nursing care decisions (Rew et al., 2014). The cognitive attitudes subscale includes seven
items from the CAS. The seven questions included questions 5-7, 11, 15, 17, and 20
(Rew et al., 2014). The questions were randomly placed on the CAS to increase the
reliability. The seven items were regrouped within the excel spreadsheet for Cohort A and Cohort B. The average of the seven items for Cohort A and Cohort B were calculated. A total of 252 entries were averaged. The results were placed in a corresponding column. Using the data analysis function in excel, the following data were calculated and placed into Table 4.6 presented in the summary section below.
Summary for Cognitive Awareness The researcher hypothesized that cognitive awareness would have a significant change after completion of the CBA. Cognitive awareness questions refer to the
participant’s beliefs and attitudes regarding cultural. The prediction was the CBA would
87 Texas Tech University, Amanda Veesart, August 2016
increase the participant’s comfort level, therefore, decreasing how much the participant’s
attitude and beliefs impacted interactions with patients of differing cultures. The Pearson
correlation revealed a 44% correlation, which is considered a weak relationship between
the two variables but a positive change. The results for the Pearson were expected
because the variables shifted in opposite directions. Pre-CBA results were closer to the
section of strongly agree, while the post-CBA results moved closer to the strongly
disagree section of the CAS. The difference in the mean values of the pre-CBA and post-
CBA was significant and indicated further need for testing.
A paired t-test was conducted to evaluate the significance of the difference. The t
statistic was within the critical region; and, therefore, statistical significant differences occurred in the levels of cognitive awareness between the pre-CBA and post-CBA. The result for Cohen’s d (0.82) shows a large effect for the difference and supports a significant change.
The results showed that participants allowed personal culture to have less impact on interactions with patients of different cultures. The results also exposed a lack of reflection for the participants. Two questions asked the frequency of reflection on cultural beliefs, actions, and attitudes. The participants reported strong agreement prior to the completion of the CBA but discovered a significant gap in reflection after completion of the CBA, which was also revealed in the narrative analysis of the participant’s reflections
and discussed in depth in Chapter 5.
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Table 4.6: Comparison of Participants Cognitive Awareness Levels Pre and Post-CBA
Cognitive Awareness-Final Pre-CBA Post-CBA Mean 6.037981859 5.255102041 Variance 0.478997196 0.548859954 Observations 252 252 Pearson Correlation 0.449139194 df 251 t Stat 16.50057183 P(T<=t) two-tail 6.32474E-42 t Critical two-tail 1.969460227 Mean difference 0.782879819 Standard deviation 0.945019538 Results for Cohen's d 0.828427125
Patient Care and Clinical Issues The last subscale examined was the patient care and clinical issues subscale. The patient care and clinical issues subscale consisted of five items on the CAS. The five questions included question 23 and 32-35. The subscale measured the self-reported ability of students to assess cultural needs, resources, or influences during nursing practice. As previously discussed, the subscale questions were regrouped in the excel spreadsheet in order to calculate the effectiveness between pre-CBA and post-CBA results. The data analysis is presented in the following section in Table 4.7
Summary for Patient Care and Clinical Issues Patient care and clinical issues was represented on the CAS by questions such as respect of healthcare decisions influenced by culture, comfort with seeking resources, and pursuing further information from a patient or family member if needed (Rew et al.,
2014). The Pearson correlation for the fourth subscale resulted in a 55% correlation between the patient care and clinical issues pre-CBA and post-CBA data. The correlation was considered positive. The differences between the mean of the pre-CBA results and
89 Texas Tech University, Amanda Veesart, August 2016
post-CBA results showed a 15% difference. Therefore, a t-test was conducted to examine
the significance. The t statistic (t=-3.25) was in the critical region thus, statistically significant. The results supported a difference in self-reported cultural awareness levels in relation to patient care and clinical issues involving culture. The Cohen’s d (.82) supported a large effect of change occurred between the pre-CBA and post-CBA. The significance in change supported the need for a CBA to educate nursing students on the process of seeking additional resources and comfort with patient questioning.
Table 4.7: Comparison of Participant’s Patient Care/Clinical Issue Levels Pre and Post-CBA Patient Care/Clinical Issues Pre-CBA Post-CBA Mean 4.973016 5.12619 Variance 0.492974 0.741463 Observations 252 252 Pearson Correlation 0.558667 Hypothesized Mean Difference 0 Df 251 t Stat -3.25248 P(T<=t) two-tail 0.001301 t Critical two-tail 1.96946 Mean difference 0.15317 Standard deviation 0.184898 Cohen's d 0.82843
Comparison of Cohort A and Cohort B In order to address research question five, a single factor ANOVA was conducted
for each of the four subscales to determine any significant differences between the two
cohorts. The ANOVA compared the results of Cohort A and Cohort B pre-CBA and post-
CBA. The data analysis is presented in the following sections within Tables 4.8-4.11.
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Cohort A vs Cohort B cognitive attitudes As previously mentioned, cognitive attitudes were measured by examining the participants’ response to questions regarding sensitivity to cultural differences, respect of different cultures, and positive interactions with patients of different cultures. The data analysis in Table 4.8 revealed a P-value of 0.053. The P value was not less than 0.05; therefore, there was no statistical difference between Cohort A and Cohort B. A small variation was shown between the Cohort A’s pre-CBA results and Cohort B’s pre-CBA results.
The results show that Cohort A and Cohort B did not have any differences in self- reported levels of cultural awareness in regards to general attitudes, for the pre-CBA survey or the post-CBA survey. The finding was expected, as Cohort A and Cohort B had similar demographics, age ranges, and both were predominately female. The CBA had the same requirements for each portion; thus, a similar change in cognitive attitude was desired for both cohorts. Though the results were not statistically significant, the differences in means indicated that Cohort A felt more confident in their respect, and sensitivity regarding cultural differences prior to completing the CBA. Furthermore, the differences in means in the post-CBA results indicated Cohort B had a larger change between pre-CBA to post-CBA.
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Table 4.8: Comparison of Cohort A and B Cognitive Attitude Levels Pre-CBA and
Post-CBA
Anova: Single Factor SUMMARY Groups Count Sum Average Variance 544.609 4.69491 0.33816 Pre-CBA (A) 116 9 3 2 540.118 4.65619 0.32252 Post-CBA (A) 116 3 3 6 621.122 4.56707 0.29377 Pre-CBA (B) 136 5 7 9 646.336 4.75247 0.31970 Post-CBA (B) 136 2 2 2 ANOVA Source of Variation SS Df MS F P-value F crit 2.45538 0.81846 2.57703 0.05311 2.62273 Between Groups 4 3 1 3 9 5 158.799 0.31759 Within Groups 1 500 8
161.254 Total 5 503
Cohort A vs Cohort B Behaviors and Comfort Issues The behaviors and comfort issues subscale was examined for differences between
Cohort A and Cohort B. The complete analysis follows in Table 4.9. The data analysis
indicated a P-value greater than 0.05. Thus, a statistical significance did not exist between
Cohort A’s level of comfort regarding cultural awareness and Cohort B’s level of comfort
regarding cultural awareness for the pre-CBA survey or the post-CBA survey.
The nonsignificant results for behaviors and comfort issues between the cohorts was an expected result as well. The behaviors and results section of the CAS examined the participant’s comfort and patience when interacting with a patient of a different
92 Texas Tech University, Amanda Veesart, August 2016 culture. Both cohorts reported strong disagreement about the impact of these topics during the pre-CBA survey. Thus, a significant change was not expected.
Table 4.9: Comparison of Cohort A and B Behavior/Comfort Levels Pre-CBA and
Post-CBA
SUMMARY Groups Count Sum Average Variance Pre-CBA (A) 116 288.8333 2.489943 0.508835 Post-CBA (A) 116 277.8333 2.395115 0.524894 Pre-CBA (B) 136 327.8333 2.410539 0.503666 Post-CBA (B) 136 324.8333 2.38848 0.432945 ANOVA Source of Variation SS df MS F P-value F crit Between Groups 0.78635 3 0.262117 0.534232 0.658997 2.622735 Within Groups 245.3212 500 0.490642
Total 246.1076 503
Cohort A vs Cohort B Cognitive Awareness Data analysis was completed for the cognitive awareness subscale and is presented in Table 4.10. A one-way ANOVA revealed the F-ratio of 32.6. The critical region for the data set was 2.62; thus, a statistically significant difference occurred between Cohort A and Cohort B. Cohort A had a larger shift in cognitive awareness levels between pre-CBA and post-CBA in comparison to the shift that occurred for
Cohort B between pre-CBA and post-CBA. The differences can be impacted by a number of variables.
The cognitive awareness subscale referred to the impact of the participant’s culture on their beliefs, attitudes, and behaviors. The subscale additionally examined the perceptions of participants regarding the impact of culture on classroom participation.
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The differences in results between Cohort A and Cohort B might be attributed to
demographics, including age, race/ethnicity, and socioeconomic status. Cohort B had a larger White population, was younger in age, and had a larger need for financial assistance. According to Spradlin (2012), individuals who have cultural beliefs different from the dominant population are more aware of the impact of culture on attitudes and decisions. The literature supported the belief that Cohort A would have less of an understanding about the impacts of culture on beliefs and attitudes in comparison to
Cohort B. This presumption will be further discussed in Chapter 5.
Table 4.10: Comparison of Cohort A and B Cognitive Awareness Levels Pre-CBA and
Post-CBA
SUMMARY Groups Count Sum Average Variance Pre-CBA (A) 116 609.8571 5.257389 0.547727 Post-CBA (A) 116 696 6 0.451464 Pre-CBA (B) 136 714.4286 5.253151 0.553883 Post-CBA (B) 136 744.381 5.473389 0.26041 ANOVA Source of P- Variation SS df MS F value F crit Between 2.61E- Groups 44.10443 3 14.70148 32.69371 19 2.622735 Within Groups 224.8365 500 0.449673
Total 268.9409 503
Cohort A vs Cohort B Patient Care and Clinical Issues A final data set was completed in order to compare Cohort A and Cohort B’s
results for patient care and clinical issues. Table 4.11 shows the P-value was not less
than 0.05. Thus, Cohort A and Cohort B comparison is not significantly different. For the
same reasons previously mentioned, the results were expected for the subscale on patient
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care and clinical issues. The research supports the non-significant results, citing similar
backgrounds, age ranges, and environmental factors as key components to cultural
awareness (Campinha-Bacote, 2011). Additionally, a review of the participant’s
previous courses revealed previous training in cultural assessments which may have
impacted the comparison results between the cohorts.
Table 4.11: Comparison of Cohort A and B Patient Care/Clinical Levels Pre-CBA and
Post-CBA
SUMMARY Groups Count Sum Average Variance Pre-CBA (A) 116 576.2 4.967241 0.509178 Post-CBA (A) 116 595.2 5.131034 0.420942 Pre-CBA (B) 136 677 4.977941 0.482769 Post-CBA (B) 136 696.6 5.122059 1.019954 ANOVA Source of Variation SS df MS F P-value F crit Between Groups 2.96848 3 0.989493 1.596826 0.18924 2.622735 Within Groups 309.8314 500 0.619663
Total 312.7999 503
Qualitative Data Analysis This narrative analysis focused on the reflective experiences of participants during completion of the CBA. Participants were required to keep a personal journal and provide a detailed reflection at the completion of the CBA. The qualitative data was retrieved from the archived course files that included student reflections regarding the impact of the CBA. The reflective narratives were submitted by the students; therefore, transcription of the narrative was not needed. The researcher used narrative analysis to derive the themes and extract the experience of the participants during completion of the
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CBA. Open coding was conducted to evaluate for emerging themes, common topics, feelings, personal, or professional changes. Saturation of themes occurred after reviewing
12 random participant reflections. After unitizing, coding, and categorizing the participant’s reflections, themes were identified.
The qualitative analysis yielded four emergent themes. The first theme that emerged was the discovery of unconscious biases. Unconscious biases are defined by
Bellack (2015) as small amounts of information about others which create microaggressions, preformed ideas, or implicit thoughts causing negative or positive responses. Participants reported unknown biases, unconscious biases, and changes to previously felt biases. The second theme that emerged was the impact felt by participants on their personal levels of cultural awareness. Cultural awareness is defined as the ability for one to recognize personal uniqueness of a patients’ beliefs, values, preferences, and needs (Betancourt et. al, 2005) or a self-examination of beliefs, biases, and understandings of other cultures’ values, preferences, or needs (Campina-Bacote, 2011;
Krainovich-Miller et al., 2008; Lancellotti, 2007).
The third theme included the impact of cultural awareness on nursing practice.
Multiple participants reflected on observed, negative impacts created by healthcare providers who lacked cultural awareness. Although this is considered a relatively known issue (Long, 2012), participants had not previously observed the impacts first hand and were taken aback. The last theme to surface was participant’s interaction with different cultures and the differences between pre-CBA and post-CBA. Although other topics were present in the student reflections, these themes were the most prevalent. Reflections were de-identified prior to the researcher securing possession, thus the narrative
96 Texas Tech University, Amanda Veesart, August 2016 reflections are referred to as participants 1-12. . Participants responses included below have not been altered or edited to correct grammatical mistakes. Their narrative reflections are presented in the original format submitted in the course.
Theme 1-Discovery of Unconscious Biases A common approach in identifying unconscious biases is journaling about self- identified bias (Bellack, 2015). In relation to healthcare, journaling should occur prior to patient interactions to cue the healthcare professional about influences or behaviors they may have towards others. Participants were prompted to reflect on biases prior to interviewing their voice selection and following the completion of the CBA. Common reflections on biases included topics such as intolerance for addiction, possible communication issues, religious concerns, or ideas on changing outlooks prior to caring for patients. Participant 1 chose an alcoholic patient to interview and stated,
This activity allowed me to gain so much insight and knowledge about someone I
would usually cast judgment on, or have a certain mind-set before taking care of
them… It allowed me to see past what I used to think of as bad and open up to an
individual first, so that he could open up to me… It helped me understand how
hard having an addiction is, especially given the current situation that was
presented to him at this time in his life.
Participant 3 discussed potential biases prior to meeting the selected patient. The participant selected a Hispanic male to interview, since that was two degrees different.
Participant 3 stated,
The voice I envision is a 79-year-old Hispanic male. I think the difficulties will
include communication. I think he will mainly speak and understand Spanish, so
I’m worried he may not be able to answer my questions. Also, because he is
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elderly, I’m worried he may not hear very well. I also wonder how open he will
be with me since I am a young white female student... I think my voice as a
Hispanic male will be frustrated by his medical diagnosis because typically men
do not like to be dependent on other people for help. I anticipate a day of
challenges, yet rewarding experience as I see him interact with the medical
personnel in the hospital and his family… many Hispanics are catholic, so I am
interested to learn about his belief system.
The participants were anticipating stereotypical responses from their patients, thus supporting the need for journaling about biases prior and after interactions with different cultures. Participant 6 discussed the unconscious bias and how it impacted the interaction: “My encounter with this patient made me more aware of my own biases and my view of people of other cultures other than myself. It made realize that differences are a result of their upbringing.”
Furthermore, biases impacted who some of the participants chose to interview.
For example, during the pre-reflection narrative, Participant 11 discussed multiple patients who were two degrees separate from self, but chose the most comfortable situation to pursue the voice interview. Below is the quote from Participant 11 regarding the choice of patients available to interview,
18-year-old patient, she was very needy and OCD about her care. She made a
notecard of what she expected, requested vitals every hour, and would not accept
care from another race than hers. I avoided this room. Had a 32-year-old
transgendered patient that I could have chosen... Nurses told us beforehand that
the patient goes by Miss, even though she still looks very masculine. She was
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very nice and friendly but I was uncomfortable... Nurses treated her with respect,
and nobody accidently called her the wrong name. I chose this voice because it
was someone who was different then me…but only 2 degrees….she is my age but
a different culture.
The unconscious biases were evident in the reflection, as well as the completed project for Participant 11. Participant 12 had a slightly different experience with unconscious biases. The narrative reflection revealed biases that were received from the healthcare team for Participant 12.
I had no idea what my patient would be like or their problems they were facing…
when I went to clinical, I randomly selected my voice patient. However after
selecting this particular patient all I received were “good lucks” and “I hope you
don’t hurt yourself” remarks. I didn’t understand why these comments were being
made to me, but as I read the patients chart I soon found out why. My patient
weighed 700 pounds, and was in the hospital for being septic after having an
abscess on her tooth. Not only was this her only problem, but in fact also had
numerous skin tears underneath her skin folds and horrible pain…. My patient
clearly suffered from the pain that was caused by her skin tears but also the
somewhat abuse she would receive from other staff members when concerning
her weight. As the day went on I kept noticing every time this patient needed
something comments were made about her weight even when it didn’t even play a
factor in the situation. Then I realized not only was this happening to her behind
her back but as well as right in front of her. As I sat in the nurse station, I
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reflected on what I had just witnessed…I was horrified at the actions of my fellow
team
Theme 1, was very prominent throughout all 12 participant narratives. A common response by the participants was shock or disbelief, particularly when nurses were unkind or biased towards patients. Many expressed how their own reaction towards different cultures were shocking to self. The experience to explore these biases left most participants eager to develop their cultural awareness skills to avoid future uncomfortable interactions. The narratives also revealed a personal insight to rethink personal biases as evident by Participant 4’s final quote, “This project truly opened up my eyes and mind and I hope that I can impact someone else the way that this man impacted me… This project helped me get outside of myself.”
Theme 2-Impacts on Cultural Awareness The second theme that emerged from the narrative analysis was the impact on the participant’s cultural awareness. One of the final reflection questions of the CBA was
“Reflect on how this project impacted you. Do you feel your culture awareness improved?” The narrative reflections were consistent in all 15 participant submissions.
The level of impact varied. Participant 9 discussed in-depth changes to self that occurred over one day in the clinical setting while completing the CBA:
After talking to him, I realized that culture awareness was something that I was
definitely going to work on and I will never judge anyone else without knowing
their background. Even though the nurse I worked with, treated him well and with
respect, she still judged him too when she was not in his room.
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The impact that was presented by Participant 9 was a common theme in all 12 narratives.
Participant 7 discussed interviewing a patient who was predominately Spanish speaking and the participant did not speak Spanish.
I got to step in a 61 year old Hispanic males shoes that day…My culture
awareness has increased. . I know that when it comes to my actions there won’t be
any hatred or judgment when it comes to dealing with mental illness and I hope
others can learn by my example.
Other participants mentioned cultural awareness as an evolving skill. The idea of evolving skill was presented by Participant 5: “Cultural awareness is the foundation of communication and it involves the ability of standing back from ourselves and becoming aware of our values, beliefs, and perceptions.” Furthermore, Participant 8 presented similar insight stating, “We tend to assume, instead of finding out what a behavior means to a person involved.” Although addressed in the assignment, cultural awareness appeared to be a new concept for most of the participants.
Cultural awareness was mentioned in all 12 narratives and with very similar insight. Participant 10 selected a mentally ill patient to interview, although the mental illness was not obvious at first assessment. However, the voice interview and project ultimately impacted Participant 10 in a major way:
Just by looking at my voice and conversing with her, you wouldn’t think that she
had any type of ailments or issues understanding any information given to her.
Nonetheless, she did have a mental illness… I have learned to be much more
aware of cultural differences in patients and that each patient …It is a sad truth
that, for Americans, the quality of health care received varies greatly depending
101 Texas Tech University, Amanda Veesart, August 2016
on race, ethnicity, ability to speak English, socioeconomic group, or place of
residence…It is my duty to value each patient’s uniqueness and more importantly
their worth.
The sense that cultural awareness was lacking prior to competing of the CBA was common among Theme 2 as well. Sentences such as “I did not realize” emerged in 11 of
12 narratives. Additional, reflections such as “Lessons that I will forever live by” or “I will always remember my voice.” were prevalent in the narratives.
The last topic that emerged under cultural awareness was the ability to truly see an individual, instead of a medical diagnosis. For example, reflections such as
“Sometimes we get lost in the whole physiological part of health care, that we forget that theirs an emotional side to it” (Participant 12), “It helped me become that powerless patient that could not understand my English-speaking doctor” (Participant 3), or “I actually gained some insight into what it meant to be have a life-long addiction”
(Participant 6) were commonly used. Participant 2 went further to explain the connection between understanding a patient and the impact the understanding can have on cultural awareness,
I think the assignment shines light onto who your patient truly is. It is very easy
to consider each person just another sick individual who needs your help but very
hard to remember that each one has a story and a purpose…While completing this
project, there was a lot of time to reflect on my experience. Although there are
times we get to converse with our patients, we never get to hear a life story…I
was able to understand his culture and background much better knowing how
important he placed other individuals and priorities above his own.
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Theme 3- Impact on Nursing Practice The third emergent theme revolved around impacts to healthcare and nursing
practice. There were several topics identified within this theme. Topics included how the
lack of cultural awareness negatively impacted the patient and how the completion of the
CBA would impact the participant’s future nursing. Multiple studies have shown
culturally uneducated healthcare providers significantly impact the quality of care
delivered to patients (AACN, 2008; Soto, Martin, & Gong, 2013; Trivedi et al., 2011).
The lack of cultural awareness among healthcare professionals was evident in the
narrative reflections. Participant 5 commented on the healthcare workers insensitive
approach with the assigned interviewee. The interviewee was a patient who had
attempted suicide and Participant 5 chose the patient: “because I am African, suicide is
viewed as a shame and most of the time people do not want to assist at the funeral.”
Participant 5 explained how the healthcare team approached this patient,
My nurse would personally avoid the room, unless she absolutely had to go in
there. All the nurses were talking negatively about this patient as well… not only
did I feel horrible for my patient and her feelings she must of dealt with, but the
fact that these issues were happening to her every time someone walked into her
room or wouldn’t go to her room.. Some people desperately need help, and most
of the time you cannot really understand what people live unless you step in their
shoes.
Another negative interaction occurred for Participant 7,
I also saw how the staff, nurses and doctors, treated this alcoholic patient inside
and outside of his room. I saw that in his room they were very pleasant, but
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outside some snickered about how much he drank. Experiencing that, only made
me want to be more aware of mental health and how alcoholism is a disease.
This observation of healthcare providers occurred in more than one narrative reflection.
Participant 6 voiced similar interactions,
Outside of his room, some of the medical personnel did make comments about his
possible level of education and his ability to understand the severity of his
disease. They made this assumption after talking to him for no more than 3
minutes. It is very sad how cruel some professionals can be just based off of an
individual’s diagnosis and/or their appearance.
Participant 9 commented on the negative impact as well, “That’s where healthcare, I feel, fails at times. It fails to listen to patients when they need it the most and when simply listening will do the most good for them.” Participant 1 stated, “As I got to step in to this man’s life today, it showed me how cruel some nurses and healthcare workers can be during treatment of an addict.”
Participants continued to express life-long impacts of the CBA. Participant 11 commented on their Voice Project, “As professionals in the healthcare industry, it is our responsibility to see each patient as their own and treat each one with the equal amount of respect because we may truly never understand how they feel in their current state.”
Additionally, Participant 1 stated,
To improve cultural competence in healthcare as a whole we must “improve the
accessibility and effectiveness for people by increasing awareness… It taught me
the true meaning of culture awareness and what it means to put that into my
nursing practice.
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Participant 4 stated,
My sense of culture awareness and the need to differentiate patients has definitely
improved and will continue to do so. This project has made a lasting impact, and I
am eager to carry out the lessons learned during my nursing career.
Participant 8 echoed the impact of the CBA and how it would be carried forward in his or her nursing career: “Every patient is going to present with their own challenges that nurses have to address.” Participant 10 added, “By doing this project and raising our awareness, I feel we can have a major impact on how healthcare where we work can be improved for those patients with different cultures and languages.” The theme emerged as a life-long lesson for each participant.
Theme 4- Cultural Interactions beyond the Classroom The fourth theme that emerged during the narrative analysis was the differences in cultural interactions beyond the classroom before and after the completion of the CBA.
Participants were required to predict how they would feel when interacting with their voice selection, prior to completing the interview section. Examples of pre-CBA entries include Participant 11’s thoughts,
I envision that my voice won’t understand her medical diagnosis due to her past
drug use and because her health might not matter to her. Everything that
encompasses a hospital stay will be overwhelming for her and stressful to deal
with.
Similar narratives to Participant 11 emerged during coding. Participant 8 wrote “Because of his diagnosis I predicted that my voice was an alcoholic. My patient had a diagnosis of hepatitis C and cirrhosis of the liver.” However, after completion of the CBA,
Participant’s 8 thoughts were changed “I made an assumption based on his history of
105 Texas Tech University, Amanda Veesart, August 2016 hepatitis C that my patient would also be a drug abuser. This did not prove to be the case, he had no history with drug abuse.”
The changes between pre-CBA reflections and post-CBA reflections were echoed by Participant 1
It helped me understand how hard having an addiction is, especially given the
current situation that was presented to him at this time in his life. Once I began
asking him questions about his life, it was like I was talking to a completely
different person than the image I engrained in my head before starting this project.
This man was much more than the label ‘addict’, he was a loving father, a caring
husband, and being more culturally appropriate and aware has immensely
impacted my care in the future for my nursing career.
Participant 5 discussed the impact of suicide and how it resonated with the participant before and after the CBA,
Before I first met my patient, I am not going to lie, I used to think no one can help
you if you do not want to be helped. After this project, I apprehend that way of
thinking as too easy and loose. Some people desperately need help, and most of
the time you cannot really understand what people live unless you step in their
shoes.
Although most of the 12 participants found this degree of change, some did not. For example, Participant 9 discussed pre-CBA and post-CBA encounter in this manner,
I went into this project knowing that mental health wasn’t given enough attention,
but hearing my voices’ story makes me want to do something to raise even more
awareness to the severity of mental illnesses because they are indeed, neglected.
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Qualitative Summary Overall, the pre-CBA and post-CBA encounters were different. The impacts of the project completion were significant, as evident by the qualitative narratives. All 12 participants revealed a personal change in cultural awareness and the intent to carry forward the lessons learned when interacting with people of different cultures. The completion of the CBA showed a positive impact for all participants.
Summary The complexity of cultural awareness requires both quantitative and qualitative data analysis. The quantitative results of the current study showed statistical significance in two of the four areas of the CAS. Although not all data analysis was statistically significant, the preceding data analysis supports the hypothesis that completion of the
CBA impacts level of cultural awareness for participants. There are some other trends worth noting.
The quantitative data (see Table 4.3) for general attitudes towards cultural awareness showed significant impact for participants. The narrative analysis supported the same shift towards general attitudes for all participants. Although the quantitative and qualitative data analysis were not linked, the findings strengthen the impact of differences that occurred for general attitudes toward cultural awareness. The Cohen’s d results show a large effect of change. Thus, it is clear that nursing students who participated in a semester-long CBA had significant shifts to their general attitudes towards differing cultures.
For the subscale of cognitive awareness, both quantitative and qualitative analysis indicated significant impact. The quantitative data (see Table 4.5) indicated a statistical significant difference in cognitive awareness for students who completed a semester-long
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CBA. The preceding qualitative narrative analysis shows a similar trend. The Cohen’s d
results supported a large effect change for the convenience sample. The results of both data analysis revealed that nursing students who participated in a semester-long CBA had significant changes to their cognitive awareness levels in regards to cultural awareness.
The quantitative and qualitative data for subscale’s two and four had varied results. Subscale two, behaviors and comfort with differing cultures, did not have a statistical change within the quantitative data. However, the qualitative analysis revealed that participants were more comfortable with caring for patients from different cultures following the completion of the CBA. Patient care and clinical issues subscale showed the opposite results. The quantitative data for this subscale indicated a statistically significant change pre-CBA and post-CBA regarding patient care and clinical issues.
However, the qualitative data did not support this type of change among participants.
Cohort A and Cohort B did not show significant differences between the two groups in any subscale except cognitive awareness. The cohort comparison revealed a large difference between groups in regards to changes in levels of cognitive awareness. The participant reflections were de-identified prior to the researcher taking possession; therefore, cohort differences could not be determined for the qualitative data. The summary of data analysis presents a positive impact for completion of a semester-long
CBA. Although all subscales did not show statistically significant levels of change, the combination of the quantitative and qualitative results support some change among participants.
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CHAPTER V
DISCUSSION AND CONCLUSION
The purpose of this study was to examine how completing a CBA impacted levels of cultural awareness in nursing students. The major themes and findings that emerged in the previous chapter clearly demonstrated the relationship between cultural education and cultural awareness, although accrediting bodies have mandated the inclusion in BSN education (AACN, 2014; Keating, 2011; NLN, 2013). The call for cultural education cannot go unanswered. In fact, continuing to minimize cultural education will be detrimental to the health of the United States. As the population expands, the diversity will continue to grow, thus, changing the culture of the population and increasing the demand for cultural education. Nursing programs must educate future nurses to provide individualized, cultural care to avoid contributing to the ever growing healthcare disparities. As Spradlin (2012) states,
The cumulative effect of our life experiences creates in each of us a lens
through which we observe our environment. This cultural lens focuses our
attention on particular aspects of what we see. Cultural heritage and
background influence our lives in many ways. In fact, all aspects of human
life are touched and altered by culture. (p. 5)
Nursing leaders of the past were familiar with this concept, asserting the need for cultural nursing care as early as the 1930s (Leininger, 2007; Wald, 1934). Only in the last 10 years has the nursing profession realized the gap in cultural understanding stemmed from the lack of inclusion in nursing education (Keating, 2011). Creating educational assignments that teach cultural assessment at an individual level will not only benefit
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nursing practice, it will reduce healthcare disparities related to culture. The final chapter
will present the summary of the study findings including a discussion regarding the issues
related to the study findings. Recommendations for nursing education will be reviewed.
Finally, direction for future research utilizing the CBA and other cultural assignments
will be discussed.
Summary of Study The research study was based on six research questions. The first research
question examined how the level of self-reported cognitive attitudes changed for all participants after completion of the CBA. The results revealed a statistically significant change in the levels of cultural awareness regarding cognitive attitudes between pre-CBA results and post-CBA results. Multiple variables may attribute to the large change and will be further discussed in the following section. A major finding was the nonsignificant change observed for the second research question regarding behaviors and comfort. The nonsignificant finding was unexpected but provided a new perspective on the CBA. The next section discusses this finding in detail. The third research question assessed how impactful the CBA was on the levels of cognitive awareness. The results revealed a significant impact, which was an expected finding as well. The patient care and clinical issue subscale results were statistically significant different between the pre-CBA results and the post-CBA results. Again, the intent of the CBA was to impact the participants’ perspectives on cultural care, so this finding was an expected finding.
The subscales did not have significant differences in cultural awareness levels between the cohorts with the exception of one subscale. Although nonsignificant differences were an expected finding, the results are worth exploring further as a major finding. The one subscale that resulted in a significant difference was cognitive
110 Texas Tech University, Amanda Veesart, August 2016 awareness. Cognitive awareness differences between cohorts was an unexpected result and will be discussed in the following section as well. The last research question for the study was examining the perceptions of the participants through narrative reflection. The narratives indicated a major impact in participants’ perceptions regarding cultural awareness. Furthermore, the narrative analysis revealed many participants identified biases about themselves that were unexpected. An unexpected finding for the final research question was the unveiling of the behaviors of healthcare professionals. Many of the narratives included references to healthcare professionals treating patients in a culturally biased manner. The following section will discuss these aforementioned issues and major findings.
Positionality Influence on Qualitative Analysis and Reflection According to Bourke (2014), a researcher’s bias impacts the research process and point of view of a research study. Assumptions about research outcomes are made based on the researcher’s positionality. As a Caucasian female, nursing instructor the researcher’s positionality impacts the interpretation of each data result. The researcher is a first generation graduate of higher education who grew up in a lower socioeconomic household. After obtaining a nursing degree, the researcher began her nursing practice in an emergency medicine facility located in a rural area of Texas. The majority of the patients who were seen were from poverty stricken homes and had poor nutrition, obesity, and violence as common ailments. Although the researcher identifies with the
Caucasian race per U.S. Bureau Census definitions, the researcher was raised in a predominately Mexican culture. The term Hispanic was viewed as derogatory or a catch all phrase that many members of the researcher’s community did not choose to use. The researcher’s nursing journey expanded leading to different jobs across different areas.
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Exposure to different healthcare facilities revealed a common problem in nursing, discrimination. For example, interacting with healthcare providers who refused to care for Black or gay patients was common place. Judgmental comments about Hispanic or obese patients could be heard daily. Additionally, the researcher became involved in nursing education. The underserved students were still underserved. This prompted the researcher to reach out to the students who identified as underserved. The response was overwhelming and created a further need to investigate the researcher’s personal delivery of nursing curricula.
The work history coupled with the intense desire to help underserved nursing students, similar to the researcher, becomes the researcher’s positionality. The identified positionality could create a position in which the researcher becomes an oppressor
(Bourke, 2014). Thus, the researcher approached each section of the research without expectations. It is the duty of the researcher to present the result of the current study from the voice of the participants, not that of the researchers. The researcher attempted to approach each narrative reflection with an intentional investigation to find the participant’s voice. Each participant reflected on the completion of the CBA from their perspective which comes from an individual, cultural background. Failure to use the aforementioned approach could have led to a biased or White dominant interpretation, which would have been counterintuitive to the investigation of impacts on cultural awareness levels for participants (Bourke, 2014). The following sections include inferences made by the researcher that are grounded in the researcher’s positionality.
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Major Quantitative and Qualitative Findings The following section discusses the major findings of the data analysis. The focus
of the discussion will be nonsignificant statistical conclusions. The large effect changes
that occurred in subscales one and two will be reviewed, as well as the differences
between Cohort A and Cohort B for research question five. Key factors related to the
unexpected qualitative findings are presented. Finally, the researcher’s analysis of the
evaluated disconnection between quantitative data results and qualitative data results is
offered.
Discussion of Nonsignificant Results from Quantitative Analysis One of the major findings for the quantitative data was the nonsignificant change in self-reported behaviors and comfort between pre-CBA and post-CBA completion.
When the entire convenience sample was calculated there was not a statistically significant change. The subscale included questions such as “when I have an opportunity to help someone, I offer assistance less frequently to individuals of certain cultural backgrounds” (Rew, et. al, 2015). The subscale examines patience of the participants when caring for a patient with differing cultures, as well.
The results from the data analysis revealed that participants strongly disagreed with the questions prior to the completion of the CBA. A number of assumptions can be made for the reasoning of the results. The first assumption is based on a similar study conducted by Campinha-Bacote (2011) that showed healthcare providers have difficulty or hesitation when approached about cultural conflict with patients. Using the same premise, one can expect nursing students with less experience to feel uncomfortable when their reactions to different cultures are being examined. Questions such as these can make participants feel defensive towards cultural biases, especially nursing students.
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The core of nursing is to care for those who cannot care for themselves (Ward, 1934).
Nursing students may not have the ability to distinguish questions such as these as helpful
in self-development, rather, a challenge to their ability to care for patients holistically.
After further investigation into the participant’s curricular offerings, a second assumption was developed for the nonsignificant results. Participants were educated on cultural differences in multiple courses prior to the course which offered the CBA. The curricula specifics were not investigated but assessments of cultural needs was identified as an objective in more than one nursing course prior to the course with the CBA completion. Thus, the nonsignificant findings were unexpected for the researcher because the participants’ reported feelings of comfort and nonbiased when caring for patients with different cultures than themselves. Additionally, the participant’s completion of any social sciences classes prior to entering the institution were not investigated and could have impacted the responses to this subscale.
The ANOVA’s conducted for subscales one, two and four revealed nonsignificant results as well. These analyses were conducted to examine the difference between Cohort
A and Cohort B’s results for each subscale. Although the results were nonsignificant, the results were expected following the examination of the demographics for each cohort.
Cohort A and Cohort B do not have significant demographical differences. The researcher assumed the reason for the nonsignificant results for the three subscales was related to the same demographic make-up between the cohorts. However, one subscale did result in a significant difference between Cohort A and Cohort B. Which will be discussed in the next section.
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Discussion of Significant Results from Quantitative Analysis Subscale three, cognitive attitudes, had statistically significant differences between Cohort A and Cohort B’s results. The results were unexpected considering the cohorts had similar demographic composites. However, similar demographics did not appear to impact the questions for subscale three. Subscale three examined topics such as personal reflection on the participants’ culture and the influence it may have on beliefs and attitudes. Other questions examined the participants’ assessment of the instructor’s culture and the influence it has on the delivery of education.
One can surmise that the significant difference occurred due to the instructor’s relationship the instructor had with Cohort A. The instructor had previously taught
Cohort A in the preceding semester, setting a foundation of trust and understanding regarding the instructor’s beliefs, attitudes, and educational decisions. Cohort B did not have previous interactions with the instructor, therefore, the level of trust and understanding may be a factor that influenced the differences found between Cohort A and Cohort B. The pre-CBA results for Cohort B pertaining to the instructor’s attitudes were different than Cohort A’s pre-CBA results. After a semester of interactions with the instructor, Cohort B’s post-CBA results aligned more closely with Cohort A’s post-CBA results. Another factor that could possibly explain the significant differences was the socioeconomic status of Cohort B. Socioeconomic status was the only demographic that was drastically different. Cohort B reported a financial need that was more than double the financial need reported by Cohort A. Financial need can impact one’s cultural assessment. According to Andersson (2015), people who identify with specific categories such as low socioeconomic status (SES) tend to have an exaggerated perception of biases or discriminations. The research results support the differences in
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Cohort A’s response and Cohort B’s response. Another consideration for the differences
in Cohort A and Cohort B for the third subscale was preceding curricular changes. Cohort
B had less reflective assignments prior to the semester in which the CBA was completed.
The subscale discussed self-reflection and thinking about behaviors that are impacted by
culture. Cohort A may have completed more reflections in previous courses, allowing
them to report a stronger agreement regarding self-reflection.
The cognitive awareness and cognitive attitudes subscales revealed a significant change between pre-CBA and post-CBA as well. With the understanding and consideration of the purpose of the CBA, the differences in the two subscales were congruent with the researcher’s expectations. The intention of the CBA was to influence the participants’ viewpoint on multicultural issues. The pre-CBA survey results versus the post-CBA results showed the CBA impacted the participants’ perspective for both general experiences regarding cultures and experiences with multicultural patients. The cohorts were not controlled groups, therefore, the researcher cannot attribut the differences solely to the CBA, however, the result supported the CBA impacted the participants in a positive manner.
Summary of Quantitative Results Culturally competent care requires a continuous, evolving knowledge of self, others, and environmental influences (Campinha-Bacote, 2011). Completion of one project during attendance in nursing school will not develop cultural competence. In fact, cultural competence should be an ongoing task and may never be achieved. However, the overall data revealed a statistically significant difference in cultural awareness levels pre-CBA and post-CBA.
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Although all subscales did not produce statistically significant differences, a
difference was noted for all subscales between the pre-CBA and post-CBA results. The differences support the literature findings regarding the need for cultural assignments or courses in nursing education (Loftin, Hartin, Branson, & Reyes, 2013; Keating, 2011).
Analysis showed a significantly positive impact by the CBA with respect to cultural awareness levels. The individualization of the CBA allowed for a greater chance of impact on participants’ self-reported cultural awareness levels. Although participants had to complete the CBA as part of the course, the characteristics of the voice selection permitted the participants freedom to explore a cultural difference of their choice. The ability to choose is supported by the multicultural learning theory that was presented in
Chapter 2.
Discussion of Participants Perceptions and Themes from Qualitative Analysis The qualitative sections of the research project included a narrative analysis of
participant reflections. Four themes were identified from the narrative analysis, as well
as, some emotions about completing the Voice Project. Participants expressed a range of
feelings including a hesitation about completing the project to excited anticipation. A few
participants voiced concerns about being uncomfortable created while completing the
project or the perception of hospital staff while completing the project. One participant
reported a feeling of discomfort about completing the interview process over a four hour
period, stating “I am not sure what I am going to talk about for four hours, this will be
very uncomfortable.” These reported feelings emerged from the pre-CBA reflection
questions.
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Additionally, participants were given two reflection questions that were completed at the end of the CBA:
How did this activity help you understand the differences in patients?
Reflect on how this project impacted you. Do you feel your culture awareness
improved?
Common themes were extracted from both pre-CBA reflections and post-CBA reflections. Following coding of the participants reflections, four themes emerged from the data. The themes were (a) the discovery of unconscious biases, (b) the impact felt by participants on their personal level of cultural awareness, (c) the impact of cultural awareness on nursing practice, and (d) participants’ interactions with different cultures pre and post CBA completion. Participants selected a variety of different cultures for their Voice Projects. The most commonly selected patients included patients who were identified by the term Hispanic or a patient who was admitted with a form of drug or alcohol addiction. Voice selections were supposed to be two degrees different from the participants. The voice selections for Hispanic or addiction follows the two degrees separation, as the participants were predominantly White without claimed addiction issues. A process for selection of voice interviews was noted in the reflective analysis.
The participants provided a variety reasons for selection of their voices, including previous experiences with the particular culture, curiosity about a certain group, or personal connections to the cultural group. Participants typically sought a certain, preconceived voice interviewee but had to change selection due to availability. The patient population dictated the availability of voice interviewees. The majority of participants used their second choice for their voice projects. After selecting their voice
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interviewee, participants spent time gathering information from the patients’ medical
chart, including medical diagnosis and demographics. The pre-investigation provided the
participants with the ability to familiarize themselves with the voice. This process
allowed the participants the opportunity to gain a simple understanding of characteristics
and influences of the selected voice interviewee (Strange & Alston, 1998). The next step
enhanced the participants’ understanding of the voice, furthering the connection between
the two. The participants’ expressed a stronger connection to their voice and the need to
advocate for their selected voices. The deeper connection allowed for personalization of
the assignment and ultimately, a better understanding regarding the impact of culture on
healthcare.
Theme 1- The Discovery of Unconscious Biases The results presented in Chapter IV paint a clear picture that unrecognized biases
were present in the majority of participants. The first theme that emerged from the
narrative analysis was the discovery on unconscious biases when delivering nursing care
to a patient from a different culture. Biases ranged from preconceived biases towards a
culture to discovered biases while interacting with a different culture. The development
of cultural awareness includes a self-examination of one’s own beliefs, biases, and attitudes towards different cultures (Campina-Bacote, 2011; Krainovich-Miller et al.,
2008; Lancellotti, 2007). The CBA was developed in a manner in which an opportunity was created for participants to begin the self-examination process.
The pre and post-reflection activities prompted the participants to explore their own biases. The majority of the biases that were expressed were geared towards the selection of the voice. Many participants voiced hesitation about the interview process.
Statements such as “I was unsure what I could talk about for hours with someone who
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was not like me” or “I have nothing in common with my selection, I don’t know how this
will go” were found in many of the narrative reflections. The hesitation to interview
people of certain cultures was prevalent as well. For example, one participant stated “I
avoided that patient at all cost” referring to a transgender patient. However, the
participant had a different response in the post-CBA reflection. The participant realized the statement was a biased response and expressed how the CBA awoken this bias and
the need to work through it. This response is directly related to the completion of a
culturally driven assignment and supports the need for more cultural education in the
nursing curricula (AACN, 2014; Keating, 2011).
Using a culturally based assignment allows a participant a live experience with a
person who identifies as a different culture. The Voice Project, although an assignment, is
a live experience which allows a participant the chance to advance their knowledge.
Advancing student knowledge beyond informational allows for a more personalized
encounter and deeper level of cultural understanding (Strange & Stewart, 2011). The
completion of the CBA also prompted the participants to seek new insights on cultural
awareness. Providing nursing students a tool to view a patient’s perspective regarding
healthcare should translate into a culturally competent workforce and ultimately, a
healthier society who seeks care without hesitation.
Another bias that was revealed were the assumptions that were made after the
participants received initial information on their voices. After participants received their
voice assignment, they were required to complete a pre-reflection journal entry about
possible characteristics of their voice. All narrative reflections included these
assumptions, thoughts, or ideas regrading expectations of the patients who were being
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interviewed. This portion of the CBA was conducted to encourage the discovery of the
participant’s cultural lens. A cultural lens is defined as the way a person views situations
or people based on life experiences (Spradlin, 2012). Understanding that a person’s
perspective is influenced by their cultural lens is the basic foundation of the Voice
Project. The participants were encouraged to examine their cultural lenses by the pre-
reflection activity. Many did not realize how their life experiences impacted how they
viewed their patients or fellow healthcare providers. The pre-reflection activity allowed the discovery of their cultural lens and eventually, their unearthing of unconscious biases.
Many participants assumed their voices were in the healthcare facility due to bad choices they had made in life. One participant explained “I assumed my patient chose drugs over her family and that is why she did not have custody of her children.” The majority of the participants were wrong, further supporting the need for cultural awareness training during nursing education. The reason for the assumptions is usually attributed to cultural bias phenomenon. Cultural bias phenomenon occurs when someone uses one’s own culture as the basis for normal behavior and therefore, judges a person of differing cultures because actions or decisions are not the same (Spradlin, 2012). This phenomenon is what occurred during the pre-CBA reflections. Participants had preconceived ideas about the decisions of their voice prior to meeting them. The research project also showed that all participants possess a cultural lens and completion of the
CBA allowed them to be more aware of the impact their personal cultural lens can create.
Theme 2-Impact on Cultural Awareness The second theme that emerged from the reflections was the impact of the CBA on the participant’s level of cultural awareness. The majority of the participants stated,
“My level of cultural awareness has increased.” Another common statement was “My
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cultural awareness was greatly impacted.” These brief comments have great meaning in
reference to the CBA. A few participants gave examples of cultural awareness growth,
referring directly to comfort levels, the increase in ability to answer questions, and
noticing interactions between other healthcare providers and the interviewee. The impact
of completing the CBA was prevalent in all the narrative reflections. Recollection of the
event allows the participants to revisit the feelings that were present while the
interviewee received care.
According to Lincoln and Guba (2013), a person will construct an idea about
someone based on the person’s own culture or understanding and the circumstances
surrounding the event. This is exactly what happened when participants began the CBA.
Participants started the assignment with a pre-reflection that revealed preconceived biases
as discussed in the previous section. The environment was a healthcare facility, which
made the participants revert to prior knowledge. For example, if a participant had
previously cared for a patient of the same culture or same medical diagnosis, the
participant immediately assumed their voice would be the exactly the same. This was
most commonly observed with participants who selected voice interviewees who were
diagnosed with a disease that could be related to addiction. One example was “I assumed
he was an alcoholic because he was Hispanic and admitted for liver failure.” Instead of preparing to interview for liver failure, the participant prepared to interview an alcoholic.
The participant was surprised to find the patient had liver failure secondary to long-term
medication consumption for seizures. These types of interactions saturated the narrative reflections. In fact, all entries had some preconceived thought that was not true but changed after the participants completed the CBA.
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Theme 3-Impact on Nursing Practice One of the most exciting themes emerging from the narrative analysis was the student’s belief regarding the impact on nursing practice. The key to an effective cultural assignment is the cumulative effect the assignment will have on nursing practice
(Lancellotti, 2008). Multiple narratives expressed the continuation of cultural awareness as the participants move into nursing practice. One example was the participant’s willingness to “always revisit how my biases could have impacted that person’s day.”
Unfortunately, many nurses who currently practice lack culturally sensitive habits and may have not developed culturally competences prior to entering the workforce and the participants witnessed the insensitive behaviors. One participant stated “it is so sad that she chose to be a nurse if she is going to avoid patients.” Many participants included comments such as these in their narratives. The observed biases added to the pre- conceived discrimination.
There are a few assumptions as to why the participants felt healthcare workers were being discriminatory or insensitive. Nurse burnout may be one reason for the behaviors observed by the participant. Nursing burnout is defined as emotional exhaustion that leads to depersonalization and reduced personal accomplishments (Wang,
Liu, & Wang, 2015). The nurse burnout phenomenon is caused by increased workloads, stressful workplaces, and nursing shortages. The behavior is not condoned but must be understood to dissect the reasons for insensitive nursing care. Participants may have been in direct contact with nursing staff who are near the end of their careers or who were experiencing a phase of nurse burnout. Further, participants for each cohort are somewhat young in their careers and life experiences: the average age was 23 and 24 years of age respectively. Many of the participants stated this was their first time in the acute care
123 Texas Tech University, Amanda Veesart, August 2016
setting of a healthcare facility. The reaction of healthcare workers may have appeared
abrupt or crude. This is another common misconception of nurses. The unsurmountable workload or stress experienced by nursing staff results in brief interactions with fellow nursing staff and patients leading to decreased staff and patient satisfaction levels (Wang, et al., 2015).
Regardless of the reason for the participant’s reaction, a positive outcome was achieved. Participants observed the poor behaviors and vowed to personally change their own behaviors. Narrative such as “I will always remember how uncomfortable I felt for the patient in the room and try to never make someone feel that way” or “I never want to see my patients hurt emotionally like my voice did” are examples of this self-declaration.
The CBA stimulated those thoughts for each participant which will hopefully translate
into nursing practice. Thus, the goal for culturally based assignments or cultural nursing
education is to graduate nursing students who provide culturally competent care.
Increasing the number of culturally competent healthcare workers can inevitably decrease
the number of healthcare disparities related to culture and in essence reframe the culture
of the nursing profession (Renzaho, et al., 2013).
Theme 4-Cultural Interactions beyond the Classroom The final theme emerging from the narrative analysis was the differences
expressed about cultural interactions outside of the classroom before and after the
completion of the CBA. Participants were asked to predict how they would feel
interacting with a patient from a different culture. Many participants expressed
judgmental thoughts or predictions about the patient prior to conducting the interview.
Each participant had a different perspective after completion of the CBA. This discovery
is similar to the quantitative data and the first 3 themes. In the end, the participants
124 Texas Tech University, Amanda Veesart, August 2016
changed their perspective after the interview section of the CBA. The anticipated changes
on cultural perspectives are the first steps in cultural knowledge (Campinha-Bacote,
2011). Entries in the post-CBA reflection revealed a “change of heart” as described by one participant. Participants made statements such as, “I look at people who are standing at the bus stop differently” or “I sat in a different section of church Sunday.” The CBA made a large impact outside of healthcare by examining all cultural interactions and the participant’s feelings toward cultural interaction in a holistic manner. The significant difference in results were unexpected and heavily discussed in the narrative reflections of the post-CBA.
The researcher assumed the analysis is a direct result of the discovery of self-
biases and cultural lenses. Historically, educational courses do not include a means for
students to self-evaluate nor do courses define cultural lenses. This lack of explanation
leaves a nation full of educated graduates without the ability to define their cultural lens.
The gap is detrimental to achieving cultural understanding, knowledge, or awareness and
may contribute to the increasing healthcare and health disparities.
Discussion on Irregularities between Quantitative and Qualitative Results An inconsistency between the quantitative results and qualitative results was
identified. The resulting differences cannot be triangulated nor does one necessarily have
to reflect the other, however, a difference in the results was noted. The quantitative data
produced statistically significant differences in three of the four subscales. The one
subscale that did not have statistically significant results was the comfort and behaviors
subscale. This particular subscale examined the participants’ levels of comfort when
caring for patients from a different culture. Additionally, the subscale identified the
perceived behaviors of the course instructors towards cultural differences.
125 Texas Tech University, Amanda Veesart, August 2016
The qualitative data revealed themes of change in comfort levels for the participants. Participants expressed reflections such as “I feel more comfortable entering a room of a patient who is different from me.” Another statement involving comfort was
“I will not think twice about taking care of someone who is Hispanic.” Two different approaches were used and two different forms of questioning, so as mentioned, this cannot be triangulated. However, one must question why the quantitative and qualitative data had opposing results. A few speculations were deduced. The questions for the quantitative data were not open-ended, limiting the answers for the participants. The participants were required to answer the survey questions before completing the reflection section of the CBA. This could have potentially impacted the results between the quantitative section and qualitative section. The Voice Project reminds participants of the difficulty of viewing the world through someone else’s eyes (Strange & Alston,
1998). In the research, the voice was a patient in a healthcare setting. The completion of the post-CBA survey was done prior to the due date for the reflection section of the CBA.
Therefore, the reflection may have stimulated feelings of increased comfort or changes to the participants comfort level after the participant had already filled out the survey. This time lag could have resulted in different answers to similar topics.
Other Outcomes Although the current research study focused on how students were impacted after completing a culturally based assignments, a few informal outcomes were discovered.
Faculty who were involved in evaluation of the CBA during the course of the semester mentioned the impact of the project multiple times. Discussion regarding how the CBA refreshed their nursing drive or brought back a desire to reduce discrimination towards
126 Texas Tech University, Amanda Veesart, August 2016
patients. These were informal comments, not researched in the current project and
should be evaluated for future research.
Implications for Nursing Education Nursing education should take steps to ensure that cultural education is present in
the nursing curricula. The American Nurses Association (ANA) (2010) defines the
profession of nursing as a practice committed to providing individualized care with
attention to the patient’s dignity, and uniqueness. Nursing professionals are considered
the most trusted profession in the U.S. which reflects the ANA’s definition (Aronshon, et.
al, 2013). Providing education on how to provide cultural competent care is the first step
in continuing this trustworthiness. As discussed in Chapter 2, the gap lies in the
effectiveness of the cultural education that is being provided (Fealy et al., 2015). The
results of the current study showed that participants at a senior level did not feel
comfortable caring for a patient who was culturally different. The results aligned with the
literature review that revealed baccalaureate of science in nursing (BSN) students
reported feelings of unpreparedness or discomfort when caring for culturally diverse
populations (Kardong-Edgren & Campinha-Bacote 2008; Rew, et. al, 2015; Reyes,
Hadley, & Davenport, 2013). It is important for faculty to seek student feedback regarding the effectiveness of culturally based assignments. The call for mandated reform was made in 2008 by the AACN. However, the results of the current research imply nursing curricula are not as advanced as once thought in regards to cultural education. Culturally sensitive content is often overlooked or dismissed entirely, leaving nursing students at a disadvantage when attempting to provide culturally competent care
(Calvillo, et al., 2009). The lack of cultural education means nursing programs are graduating nurses who are not prepared to care for a culturally diverse population.
127 Texas Tech University, Amanda Veesart, August 2016
Healthcare Disparities An additional implication for nursing education is how culturally insensitive care effect health and healthcare disparities. Continuing to provide nursing students with a nursing curricula that does not education on cultural sensitive throughout the entire curricula will eventually increase healthcare disparities. Culturally insensitive healthcare providers have been directly linked to healthcare disparities and the health of the US
(Aronshon, et al., 2013; Campinha-Bacote, 2011). Health and healthcare disparities are one of the leading causes of death in the United States (Betancourt et al., 2005). The inability to change and evaluate nursing curricula will result in furthering this epidemic.
Therefore, nursing curricula must thread cultural education throughout the curriculum, immediately.
Recommendations for Nursing Education The current study revealed an effective means to educate nursing students about cultural awareness and cultural competent care. Nursing educators across the nation should examine the use of culturally based assignments and the effectiveness each assignment has on students (Keating, 2011). It should be stated, the CBA cannot be solely responsible for the participants change in cultural awareness levels when reviewing the quantitative data. However, the qualitative narratives showed that participants felt the CBA had major impacts on their cultural awareness levels. The results support the need for cultural education in nursing curricula. In order to achieve the same results, nursing educators across the nation must first assess their current curricula. The assessment should include an in-depth analysis of any cultural assignments. The nursing curricula should be analyzed for cultural objectives and content and a review of the extent of which each is covered. Research studies have
128 Texas Tech University, Amanda Veesart, August 2016 shown cultural curricula exists in nursing education, but not to the degree needed to be effective (Kumagai & Lypson, 2009; Renzaho, et.al, 2013). Therefore, the next step for nursing education is a comprehensive examination of the effectiveness of each cultural assignment. This research will provide nursing educators with the appropriate appraisal of the curricula effectiveness. A tool such as the CAS should be utilized to evaluate the cultural awareness level of each nursing student. The tool is most effective if used at the beginning of the nursing program and the end of the nursing program (Rew, et al., 2015).
Only then, will nursing educators begin to understand the implications of their cultural assignments.
Recommendations for Future Research Several areas should be researched in the future regarding the CBA and other culturally based assignments. The impact of the CBA could be further researched by following nursing school alumni in the first year in the workforce. A survey could be sent out to alumni. Identification of the use of culturally competent care could be assessed. The future research should investigate the perceptions of alumni regrading previously disclosed biases. For example, does the participant still recognize and address personal biases every day before providing patient care? Many participants included the phrase “I will always remember…” Future research should investigate if the participants carried this personal assessment into nursing practice or if the CBA actually impacted their approach with patients. An assessment of alumni who participated in the CBA would determine if the impact of the CBA translated into nursing practice.
A second area for future research for the CBA would include a demographic connection to the cultural awareness survey results. For example, the current research study did not collect individual data for participants. Therefore, ethnicity, race, gender,
129 Texas Tech University, Amanda Veesart, August 2016
age, nor socioeconomic status could be connected levels of cultural awareness. A future
research study would include the impact or changes of the CBA on participants of
different demographical compositions.
Lastly, future research should be completed on all culturally based assignments that are completed in nursing curricula. Nursing students should be evaluated for cultural awareness levels prior to beginning a nursing program to provide a basis for cultural education. This would provide nursing educators a starting point to further development cultural education. Additionally, all culturally based assignments should be evaluated for effectiveness.
Geographic Proximity It should be discussed that all culturally based assignments for the current
research study occurred in one geographical location, the southwest region. The
geographical proximity contributes to the similarities identified in the demographics of
both cohorts. Furthermore, the geographical proximity may have limited the selection of
voice interviewees. Future research should be conducted using multi-site nursing schools located in different parts of the nation. The extension of this research project would provide a more global perspective on CBA’s, and specifically the Voice Project.
Additionally, surveying other nursing school’s implementation of the Voice Project would contribute to validity of CBA’s in nursing education.
Conclusion The preceding chapters provide a mixed methods review on the impact of completing a semester-long CBA while attending a nursing program in the southwest.
The research was based on six questions:
130 Texas Tech University, Amanda Veesart, August 2016
1. How does the level of self-reported cognitive attitudes regarding cultural
awareness differ before and after the CBA?
2. How does the level of self-reported behaviors and comfort regarding cultural
awareness differ before and after the CBA?
3. How does the level of self-reported cognitive awareness levels regarding cultural
awareness differ before and after the CBA?
4. How does the level of self-reported patient care and clinical issues regarding
cultural awareness differ before and after the CBA?
5. How do the levels of self-reported cultural awareness factors differ between
Cohort 1 and Cohort 2 before and after completion of the CBA?
6. What is the perception of the students on the change in levels of cultural
awareness they experienced by participating in the CBA?
Using a mixed methods approach, the data revealed significant differences in 3 of the 4 subscales and a significant difference between Cohort A and B on 1 subscale. The results were supported by the prior literature review that connected cultural education to changes in cultural awareness levels (Campina-Bacote, 2011; Krainovich-Miller et al., 2008).
The aggregated data for demographics showed a similar population among cohorts, which aligned with the current nursing workforce demographics (HHS, 2010). Thus, the present research project confirmed the need to implement more cultural education in nursing curricula to increase cultural understanding between healthcare workers and patients.
131 Texas Tech University, Amanda Veesart, August 2016
This study is one of the first studies completed on culturally based projects assigned during nursing school. The current research evaluated the implementation of the
Voice Project. This study is the first known study which implemented an adapted version of the Voice Project outside of the education area of higher education. In the future, any cultural based assignment implemented in nursing curricula should be examined for the effectiveness or impact on students’ cultural awareness levels. All nursing schools should evaluate the nursing curricula for cultural education and ensure nursing instructors have adequate training to teach cultural competent care. The evidence of the impact of cultural education is not lacking. In fact, the connection to healthcare disparities and culturally insensitive healthcare providers was overwhelming. Nursing educators must answer the call for cultural education in their curricula. The results of the present research study support the use of the Voice Project at the intermediate level of nursing school to educate nursing students on their personal cultural awareness. Indeed, the Voice
Project provides one tool for nurse educators to move forward in the demand to bridge the gap in delivering culturally competent care and supports the need for nurse educators to seek additional tools for cultural education. However, the core of the study reveals the need for the nursing curriculum to actively engage in reform utilizing cultural awareness exercises. Cultural awareness, or the lack of cultural awareness, is the root cause for many healthcare disparities across the nation. The current study adds to the discourse regarding the importance of cultural awareness at the most basic level in healthcare, nursing education.
132 Texas Tech University, Amanda Veesart, August 2016
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Appendix Cultural Awareness Scale Use the scale of 1 to 7 (1=Strongly Disagree, 4=No Opinion, 7=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.
Apply Not Does Disagree Strongly Opinion No Agree Strongly
General Experiences at this School of
Nursing
1 1. The instructors at this nursing school 1 2 3 4 5 6 7 adequately address multicultural issues in nursing
1 2. This nursing school provides 1 2 3 4 5 6 7 opportunities for activities related to multicultural issues.
1 3. Since entering this school of nursing my 1 2 3 4 5 6 7 understanding of multicultural issues has increased.
1 4. My experiences at this nursing school 1 2 3 4 5 6 7 have helped me become knowledgeable about the health problems associated with various racial and cultural groups.
General Awareness and Attitudes
2 5. I think my beliefs and attitudes are 1 2 3 4 5 6 7 influenced by my culture.
2 6. I think my behaviors are influenced by 1 2 3 4 5 6 7 my culture.
2 7. I often reflect on how culture affects 1 2 3 4 5 6 7 beliefs, attitudes, and behaviors.
4 8. When I have an opportunity to help 1 2 3 4 5 6 7 RC someone, I offer assistance less frequently to individuals of certain cultural backgrounds.
142 Texas Tech University, Amanda Veesart, August 2016
4 9. I am less patient with individuals of 1 2 3 4 5 6 7 RC certain cultural backgrounds.
4 10. I feel comfortable working with patients 1 2 3 4 5 6 7 of all ethnic groups.
2 11. I believe nurses’ own cultural beliefs 1 2 3 4 5 6 7 influence their nursing care decisions.
4 12. I typically feel somewhat uncomfortable 1 2 3 4 5 6 7 RC when I am in the company of people from cultural or ethnic backgrounds different from my own.
Nursing Classes/Clinicals
4 13. I have noticed that the instructors at 1 2 3 4 5 6 7 RC this nursing school call on students from minority cultural groups when issues related to their group come up in class.
1 14. During group discussions or exercises, I 1 2 3 4 5 6 7 have noticed the nursing instructors make efforts to ensure that no student is excluded.
2 15. I think that students’ cultural values 1 2 3 4 5 6 7 influence their classroom behaviors (for example, asking questions, participating in groups, or offering comments.)
1 16. In my nursing classes, my instructors 1 2 3 4 5 6 7 RC have engaged in behaviors that may have made students from certain cultural backgrounds feel excluded.
2 17. I think it is the nursing instructor’s 1 2 3 4 5 6 7 responsibility to accommodate the diverse learning needs of students.
1 18. My instructors at this nursing school 1 2 3 4 5 6 7 seem comfortable discussing cultural issues in the classroom.
1 19. My nursing instructors seem interested 1 2 3 4 5 6 7 in learning how their classroom
143 Texas Tech University, Amanda Veesart, August 2016
behaviors may discourage students from certain cultural or ethnic groups.
2 20. I think the cultural values of the nursing 1 2 3 4 5 6 7 instructors influence their behaviors in the clinical setting.
1 21. I believe the classroom experiences at 1 2 3 4 5 6 7 this nursing school help our students become more comfortable interacting with people from different cultures.
1 22. I believe that some aspects of the 1 2 3 4 5 6 7 RC classroom environment at this nursing school may alienate students from some cultural backgrounds.
5 23. I feel comfortable discussing cultural 1 2 3 4 5 6 7 issues in the classroom
1 24. My clinical courses at this nursing school 1 2 3 4 5 6 7 have helped me become more comfortable interacting with people from different cultures.
1 25. I feel that this nursing school’s 1 2 3 4 5 6 7 instructors respect differences in individuals from diverse cultural backgrounds.
1 26. The instructors at this nursing school 1 2 3 4 5 6 7 model behaviors that are sensitive to multicultural issues.
1 27. The instructors at this nursing school 1 2 3 4 5 6 7 use examples and/or case studies that incorporate information from various cultural and ethnic groups.
Research Issues
3 28. The faculty at this school of nursing 1 2 3 4 5 6 7 conducts research that considers multicultural aspects of health-related issues.
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3 29. The students at this school of nursing 1 2 3 4 5 6 7 have completed theses and dissertation studies that considered cultural differences related to health issues.
3 30. The researchers at this school of nursing 1 2 3 4 5 6 7 consider relevance of data collection measures for the cultural groups they are studying.
3 31. The researchers at this school of nursing 1 2 3 4 5 6 7 consider cultural issues when interpreting findings in their studies.
Clinical Practice
5 32. I respect the decisions of my patients 1 2 3 4 5 6 7 when they are influenced by their culture, even if I disagree.
5 33. If I need more information about a 1 2 3 4 5 6 7 patient’s culture, I would use resources available on site (for example, books, videos, etc.).
5 34. If I need more information about a 1 2 3 4 5 6 7 patient’s culture, I would feel comfortable asking people I work with.
5 35. If I need more information about a 1 2 3 4 5 6 7 patient’s culture, I would feel comfortable asking the patient or a family member.
4 36. I feel somewhat uncomfortable working 1 2 3 4 5 6 7 RC with the families of patients from cultural backgrounds different than my own.
2003
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IRB Letter
INSTITUTIONAL REVIEW BOARD FOR THE PROTECTION OF HUMAN SUBJECTS FWA # 00006767 LUBBOCK/ODESSA IRB #00000096
EXEMPT FROM FORMAL IRB REVIEW
March 28, 2016
IRB #: L16-105 STUDY: Examining the change in cultural awareness of senior nursing students who participate in a semester-long culturally based assignment at a large public university
PRINCIPAL INVESTIGATOR: Sharon Cannon SUBMISSION REFERENCE #: 059544
TYPE OF REVIEW: ADMINISTRATIVE DATE CLASSIFIED AS EXEMPT: 03/28/2016 APPLICABLE FEDERAL REGULATION: 45 CFR 46.101 categories 1, 2 & 4
Summary: The differing beliefs demand a more culturally competent population, especially in the fields of education and healthcare. According to Leininger (2002), cultural dimensions influencing how a person responds to situations include religious beliefs, social structures, political/legal concerns, economics, educational trends, technologies, cultural values, and ethnohistory. The failure to recognize cultural influences as a driving force for patient decisions in healthcare or student decisions in education could be detrimental to overall success or health of the individual (Long, 2012). Despite the research supporting the importance of cultural competency in healthcare, multiple studies have shown BSN students reported feeling unprepared or uncomfortable when caring for culturally diverse populations (Kardong-Edgren & Campinha-Bacote 2008; Rew, Becker, & Chontichachalalauk, 2014; Reyes, Hadley, & Davenport, 2013).
146 Texas Tech University, Amanda Veesart, August 2016
The purpose of this study is to retrospectively review a cultural-based assignment to examine the differences in the levels of self-reported, cultural awareness of senior nursing students who completed a semester-long culturally based assignment (CBA) while enrolled in a large, public university located in the southwest region of the United States. Additionally, the research study will explore the perceptions of changes to levels of cultural awareness as reported by the students through written reflection.
There will be two groups of data reviewed. Individuals in cohort 1 completed pre- and post- surveys and reflection pieces in fall of 2013; while cohort 2 individuals completed the same surveys and reflection pieces in fall of 2014. According to the investigators, all assignments have been de-identified.
Student assignments were completed without requiring identifying information. The CAS was completed during a classroom activity and turned in at the end of class. The surveys contained no identifying information. Reflections were submitted to the course files via the electronic management system as part of the CBA. To protect student anonymity, all reflections will be retracted from the course files and names removed by a course faculty member different from the researcher. The researcher will be given the de-identified reflections to complete the narrative analysis. Additionally, the students have separated from the university, therefore, grades cannot be impacted by the research project. Study data will be stored in a secure, password protected computer belonging to one of the investigators.
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L16-105 Recommendation: As presented, this research meets the criteria for exemption from formal IRB review in accordance with 45 CFR 46.101(1), (2), and (4). All data are in existence at the time of this application but will contain no-identifying information. HIPAA regulations do not apply to the research.
This application was screened for exempt status according to TTUHSC policies and the provisions of applicable federal regulations. The study was found not to require formal IRB review because the research falls into one of the categories specifically designated as exempt per 45 CFR 46.101.
Do not use any subject names or identifiers when presenting or publishing the study results.
There is no expiration date for studies which have been classified as Exempt from formal IRB review.
Study Personnel Currently Approved to Conduct the Research: Amanda Veesart, RN, MSN, Catherine Lovett, RN, MSN, CCRC, CCRP, Josephine Rene Resendez, MA
Reporting: Modifications to this research proposal must be submitted to and approved by the IRB prior to the implementation of the modification. You must report to the IRB any serious problem, adverse effect, or outcome that occurs in conjunction with this project. You are also required to notify the IRB when this study is completed.
The Texas Tech University Health Sciences Center Institutional Review Board is duly constituted (fulfilling FDA requirements for diversity) allows only those IRB members who are independent of the investigator and sponsor of the study to vote/provide opinion on the study, has written procedures for initial and continuing review, prepared written minutes of convened meetings, and retains records pertaining to the review and approval process; all in compliance with requirement defined in 21 CFR (Code of Federal Regulations) Parts 50 and 56 and ICH (International Conference on Harmonization) guidance relating to good clinical practice.
Please retain this letter with your research records. Research records include all Institutional Review Board submissions and responses and must be kept in the principal investigator’s file for a minimum of three (3) years after completion of the study.
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The Texas Tech University Health Sciences Center (TTUHSC) IRB Policies and Procedures are available for reference on the TTUHSC Human Research Protection Program Website (http://www.ttuhsc.edu/research/hrpo/irb/).
TTUHSC Lubbock/Odessa Institutional Review Board 3601 4th Street STOP 8146 Lubbock, TX 79430 806-743-4753
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