Which nursing activity shows an understanding of the process of culturally competent nursing practice?

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Cultural competence is an essential skill for nurses, nurse educators, and administrators of nursing education programs. Unfortunately, not all nursing educational practices are culturally competent; some diverse nursing students may believe that they're negatively affected by nurse educators and student peers. Culturally competent nursing care is linked to a culturally diverse pool of nursing students and graduates that reflects the diverse attributes of the patient population. Successful nursing students need culturally competent nurse educators who reflect, value, and celebrate the diverse attributes of the student groups they teach.

This article focuses on the importance of culturally competent nursing education (CCNE) and how it can be applied in the classroom. Diversity can refer to many different characteristics, but this article deals with cultural diversity; a discussion of age and gender diversity is beyond its scope. Although this article is written with a focus on nurse educators who teach nursing students, the concepts presented apply to nursing education in virtually all clinical settings.

Increasingly diverse

The U.S. population is growing increasingly diverse. As of 2016, the ethnic breakdown was 61.3% White American (non-Hispanic/Latino), 17.8% Hispanic/Latino, 13.3% Black American/African-American, 5.7% Asian, 1.3% Native American/Alaskan Native, and 2.6% self-reporting two or more races.

Although efforts to increase diversity (gender, racial, ethnic, and age) have yielded small gains, faculty diversity levels don't resemble diversity levels of students and communities.

Within baccalaureate nursing programs, about 32% of students are from non-White minority groups. In 19 states, the percentage of minority nursing students more than doubles the percentage of minority faculty.

Learning is contextual; besides teaching and modeling culturally competent nursing care, faculty members demonstrate CCNE by modifying style, presentation, and evaluation strategies to accommodate student diversity. (See Key terms.) This sensitivity is essential to the success of recruitment and retention strategies designed to create a more representative nursing workforce. Because student learning outcomes depend on CCNE skills, nurse educators need to deliver CCNE to each nursing student.

Self-assessment

CCNE begins with the educator's self-assessment of skills, practices, and attitudes that transform teaching and learning practices into positive learning experiences for diverse nursing students. Here are a few questions culturally competent nurse educators may ask themselves:

• What's my cultural identity and how's it similar/different from my students'? What assumptions do I have regarding other cultural identities?
• Are diverse nursing students given equal opportunities to express themselves (written, verbal, online)? What do I do when students self-isolate?
• Do I respect, appreciate, and embrace diverse points of view during and outside of class?
• What's my comfort level and how do I behave when I'm with students who have cultural characteristics that are different from mine?
• Do I inappropriately ask students possessing diverse characteristics to become the class expert regarding that culture?
• What are my assumptions regarding students' diverse characteristics, and do I challenge these personal biases and assumptions?
• How do I respond to conflict and high-emotion situations? Do I use culturally competent techniques to challenge intolerance (in and out of class) and incivility that demeans others and myself?
• What are my teaching style preferences and what alternative methods do I use that help diverse students (for example, multimedia or psychomotor approaches)?

Class assessment

Understanding diverse students requires educators to understand various culturally influenced factors, including:

• how students may perceive the learning environment and learning challenges
• what students think and do related to their own learning goals based on their social and cultural networks
• the type of education that students consider useful and appropriate
• each student's own cultural identity and cultural awareness
• each student's level of comfort with and commitment to the learning environment and the student-faculty roles within that environment.

Nursing students find meaning in their studies by applying learning to knowledge already acquired within a cultural framework. Educators can conduct a basic assessment of each class of students for group composition to help direct CCNE efforts. Understanding student demographics improves the teaching-learning process.

When student learning needs are assessed early and promptly addressed with CCNE interventions, frustration and confusion decrease and time spent remediating is minimized. For example, faculty members can begin understanding their classes by performing a learning needs assessment on each student and including a confidential “Who am I?” survey early in the term.

Helpful student survey questions may include the following:

• In addition to being a student, what roles are you now experiencing (spouse, parent, employee) and what's your estimated time commitment to each?
• What are your cultural identities?
• What are your short- and long-term academic and personal goals?
• What's your ideal learning experience?
• What are your learning strengths and challenges?

Using transcultural nursing assessment and intervention techniques within education settings will improve student-faculty relationships, communication, and experiences. In doing so, educators must avoid stereotyping and remember that the beliefs and behaviors of individual students can't be predicted based on any demographic or diversity characteristic.

Skills and techniques

Nurse educators can employ the following skills and techniques when implementing CCNE in the classroom.

Feedback. Culturally competent nurse educators provide prompt, personalized, confidential, culturally sensitive, and constructive feedback during class, on written assignments, and during clinical rotations. Because comfort levels with seeking help vary among students, faculty members should post and keep office hours, and schedule face-to-face meetings with each student as part of course requirements. Avoid words such as “must,” “should,” or “ought,” which can be intimidating.

Culturally competent nurse educators share their feedback style with students early in the term. They also measure comprehension at specific targeted intervals using various assessment techniques, such as exams/quizzes, journaling, written papers, group and individual projects, case studies, role playing, and demonstrations. Educators should grade exams as soon as possible and conduct postexam discussions that highlight problem areas.

During class, educators assess student engagement and understanding with specific open-ended questions, and use attentive prosocial nonverbal behaviors (open posture, lean toward questioner, eye contact) when students respond or seek clarification.

Faculty peer relationships. CCNE requires faculty peers to cultivate culturally competent relationships. When relationships are culturally incongruent—for example, when incivility, bullying, or microaggressions are present—faculty members become less productive, experience self-efficacy and self-esteem issues, feel isolated and alone, and are more likely to resign their positions.

Mutual respect is essential for a healthy, cooperative work environment. Faculty members who feel respected and valued by their peers and administration believe that peer relationships are enhanced and students experience a more culture-friendly educational environment. This mutual respect needs to be evident when diverse nurse educators serve on committees, establish research trajectories, and meet with administrators.

Mentoring and support. Although culturally competent faculty members model cultural competence for students and patients, they also need mentoring and supportive leadership to prevent feelings of isolation and improve their effectiveness as educators. Culturally diverse mentors are extremely helpful for new faculty because these mentors share a similar set of experiences and help mentees navigate within the system, plan research trajectories, and dispel emotional turmoil.

Curriculum development and implementation. Nurse educators can create a culturally sensitive curriculum by diversifying teaching strategies. Examples include:

• creating culturally diverse student groups
• assuring students that multimedia, such as texts, reading assignments, slide presentations, podcasts, and videos, include equal representation of culturally diverse nurses
• role-playing case studies and simulations to present issues of health disparities and access to care in a diverse patient population
• modeling, encouraging, and teaching mutual respect, cultural competence, and culturally sensitive interactions
• calling on students by name
• using an end-of-class and clinical 1-minute paper to evaluate potential student difficulties (A 1-minute student-generated paper may include a brief description of how and why the class or clinical experience met [or didn't meet] the students' learning goals for that activity.)
• checking attendance and early departures to help identify students who may be experiencing learning or other problems
• implementing structured journaling in a way that helps diverse students connect new and former learning experiences
• anticipating controversy and planning ahead for discussions about “hot-button” topics, such as racial prejudice, bias, stereotyping, and health disparities among culturally diverse patient groups
• evaluating all course materials for fair and respectful treatment of all culturally diverse groups
• recording class lectures and posting online whenever possible to reinforce learning
• accommodating religious holidays and practices, such as special days for worship or festivals, religious garments, and more.

Student disruption. Ideally, student disruption and conflict present teachable-moment opportunities for faculty to help all students learn professional, culturally competent behaviors and interactions. A calm, measured response is essential. Here are some ways culturally competent faculty members respond to culturally incompetent behaviors, such as incivility, bullying, and ethnocentric put-downs:

• Stop, pause, remain composed, take a deep breath, and ask for a break if necessary. Rhetorically address the class and remind students of the importance of a safe and effective teaching-learning environment for all. Repeat rules of conduct as published in handbooks, syllabi, and other sources.
• Avoid embarrassing the student by singling out cultural incompetence with public shaming.
• If incivility behavior is directed toward faculty, privately ask students how they'd approach the behavior if they were teaching the class. Publicly refer students to program and school handbooks regarding chain of command processes that guide students to take their issue to the next level.
• Ask to meet privately with the disruptive student(s) to explore and clarify their point of view. While maintaining confidentiality and with the student's knowledge, keep notes and/or record these meetings. Listen especially for discord between student beliefs about the teaching-learning process and those cultural norms and expectations of the school and faculty. If you can make modifications, do so. If not, explain the rationale behind the expectations to students and the class.
• Explore with students potential etiologies for class or clinical cultural incompetence, such as knowledge deficit, physical or mental problems (including medications, fatigue, and hearing or vision problems), and transferred anger or stress.
• Routinely discourage ethnocentrism, especially during discussions of prejudice and health disparities. Encourage assertive, open communication among students within the teaching-learning environment and use friendly in-class reminders of culturally competent nursing interactions.
• Don't ignore cultural incompetence. Carefully and specifically document all culturally incompetent behaviors. This documentation includes faculty behaviors pre- and postincident along with the date, time, individuals involved, and context.

Clinical considerations

Culturally diverse students may need additional considerations when clinical assignments are made. For example, as clinical locations are established, faculty members need to be aware of transportation problems that may affect students from certain neighborhoods, such as lack of access to mass transit. Faculty members should avoid clinical assignments that accentuate a student's difference, such as assigning older students to older patients or hearing-impaired students to unconscious patients.

Cultural emersion experiences facilitate greater transcultural nursing understanding for all students. Faculty may frontload didactic learning, moving all clinical hours into the latter portion of the course, to expand clinical learning opportunities into nontraditional settings, such as rural or inner-city health centers, or international locales.

Clinical considerations also include monitoring for and intervening as needed when student-to-student or student-to-patient/family cultural incompetence is identified.

Empowerment for all

A culturally competent learning environment is one that respects, values, and empowers all members of the instructional team, including students and faculty peers. CCNE commitments create excellent learning environments for all students and superior working environments for nurse educators. Ultimately, culturally competent learning environments translate into a more successful fulfillment of the educator's promise to future generations of nurses who'll perform skilled nursing care within a diverse world.

Key terms

• Culture dynamically represents learned language, values, beliefs, behaviors, and practices. It guides how we think, what we do, and who we believe we are. Culture influences our decisions, perceptions, attitudes, and how we interpret our environment.
• Cultural competence is a continuous process of cultural awareness, knowledge, interaction, and sensitivity among caregivers. It's the continuous acquisition of skills, practices, and attitudes that enables nurses to transform interventions into positive health outcomes.
• Culturally competent nursing education is the process of adapting teaching and learning techniques in a way that values, empowers, and accommodates nursing student diversity. It begins with an assessment of the learner's needs and includes student interactions, curricula and policy development, in-class and online considerations, culturally competent policies and procedures, and nurse educators committed to lifelong learning.

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