524790

research-article2014

TCNXXX10.1177/1043659614524790Journal of Transcultural NursingShen

Research Department: Literature Review

Cultural Competence Models and Cultural Competence Assessment Instruments in Nursing: A Literature Review

Journal of Transcultural Nursing 2015, Vol. 26(3) 308­–321 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524790 tcn.sagepub.com

Zuwang Shen1

Abstract The author reviewed cultural competence models and cultural competence assessment instruments developed and published by nurse researchers since 1982. Both models and instruments were examined in terms of their components, theoretical backgrounds, empirical validation, and psychometric evaluation. Most models were not empirically tested; only a few models developed model-based instruments. About half of the instruments were tested with varying levels of psychometric properties. Other related issues were discussed, including the definition of cultural competence and its significance in model and instrument development, limitations of existing models and instruments, impact of cultural competence on health disparities, and further work in cultural competence research and practice. Keywords cultural competence, cultural competence definitions, nursing models, transcultural nursing, cultural competence assessment, instrument construction, instrument validation, psychometric properties, health disparities, healthcare disparities

Introduction Cultural competence is viewed as a critical factor and essential component in providing relevant, effective, and culturally responsive healthcare services to the increasingly more diverse U.S. population (Campinha-Bacote, 2002b; Health Resources and Services Administration [HRSA], 2001b; Purnell, 2008), reducing racial and ethnic disparities in health and healthcare, and improving healthcare quality, patient satisfaction, and health outcomes (Brach & Fraserirector, 2000; Capell, Veenstra, & Dean, 2007; National Center for Cultural Competence, 2003). Over the past three decades, research on cultural competence and transcultural care has been undertaken in the nursing field with a proliferation in the literature. A recent literature search in the Cumulative Index of Nursing and Allied Health Literature database revealed that about one third of the published articles on the subject since 1980 had been authored by nurse researchers and about 17% of them dealt with cultural competence models and frameworks in nursing. The decades of conceptualization have developed more than a dozen cultural competence models (Shen, 2004), including the six comprehensively reviewed by Sagar (2012) and much more. Over the years, application of several major cultural competence models in nursing practice, education, research, and administration has been cited by numerous researchers (for

example, Brathwaite, 2003; Campinha-Bacote, 2002b; Giger & Davidhizar, 2002; HRSA, 2001a; Jeffreys, 2010a; Leininger, 2002b, 2002c; Lipson & DeSantis, 2007; Purnell, 2008; Willis, 1999). Sagar (2012) conducted a comprehensive review of the six best-known transcultural or cultural competence nursing models and concluded, however, that “there is paucity of literature applying those models” (p. xvii). The inapplication of the models may be attributable to the fact that, compared with theories, models are more abstract with a broader focus but less specific and precise with clearly defined concepts (Fawcett, 2005) and that there are very few tested or validated instruments or measures in the literature available to evaluate cultural competence (Balcazar, SuarezBalcazar, & Taylor-Ritzler 2009; HRSA, 2001b; HRSA, 2002; Sagar, 2012). These two factors, among others, make it more difficult for the models to be applied in practice. Nevertheless, a good many assessment instruments including tools, scales, and questionnaires exist in the nursing literature designed to measure cultural competence. 1

The City University of New York/Bronx Community College, Bronx, NY, USA Corresponding Author: Zuwang Shen, MA, MLIS, Assistant Professor, The City University of New York/Bronx Community College, Bronx, NY 10453, USA. Email: [email protected]

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Shen Although very few of the existing instruments in the literature have been tested for psychometric evaluation (Brathwaite, 2003; Balcazar et al., 2009; Gozu et al., 2007), most were poorly constructed, lacking acceptable psychometric properties (Jeffreys, 2010b). Overall, despite decades of research and development, major concerns about the reliability, utility, and validity of existing instruments remain and health professionals have yet to establish valid measures to assess cultural competence (Kumas-Tan, Beagan, Loppie, MacLeod, & Frank, 2007). In the nursing field, a significant number of instruments have been developed and reported to have been empirically tested with varying levels of validity and/or reliability. This study was intended to review cultural competence models and assessment instruments developed and published by nurse researchers since 1982. The models and instruments were examined and analyzed in terms of their components (domains, constructs, or subscales), conceptual or theoretical backgrounds, empirical testing or validation, and psychometric evaluation. As cultural competence is the key concept, its various definitions were explored. Other related issues were also discussed, including the impact of cultural competence on health disparities and limitations of existing models and instruments.

Method Two separate literature searches were performed primarily in the Cumulative Index of Nursing and Allied Health Literature, using such terms as cultural competence, nursing, transcultural nursing, theoretical nursing model, and conceptual framework to find English language journal articles and book chapters on the conceptualization of models; and using terms such as cultural competence assessment, tools and scales, instrument construction, instrument validation, and psychometric properties to retrieve studies on the instrumentation of assessment measures. The search terms were properly combined with Boolean operators to obtain optimal results. Additional database searches were conducted in MEDLINE/PubMed, and in Google Scholar for potential leads to previously missed scholarly articles and in Google for U.S. government documents pertinent to the subjects. Moreover, reference citations in the reviewed articles and books were carefully examined for additional pertinent sources. All articles to be included for review had to be authored by nurse researchers who reported studies on the development, refinement, adaptation, testing and/or retesting of cultural competence models and assessment instruments for empirical validation or psychometric evaluation. As this study aimed to review models and instruments designed to apply to individual healthcare providers, those developed for use by organizations were excluded, as well as unpublished theses and dissertations. As a result, a total of 18 cultural competence or transcultural care models and 15 instruments were identified that met the inclusion criteria. In order to

obtain an interdisciplinary perspective on the concept of cultural competence in medicine, counseling psychology, physical therapy, and social work, additional database searches were conducted in PsycINFO, Social Sciences, and Medline/ PubMed. The model for cultural competence developed by Burchum (2002) was used as an organizing framework for analyzing the elements essential for formulating the definition of cultural competence and the domains comprising the models of cultural competence.

Discussion Cultural Competence Definitions There are as many varying definitions for the term cultural competence as there are for the term culture (Giger & Davidhizar, 1999). It is no surprising that there is ongoing dispute about the very meaning of and components of cultural competence (Kumas-Tan et al., 2007), concern about the “lack of a unified definition of cultural competence (Suarez-Balcazar et al., 2011), and a call for the clarification of the concept by the American Academy of Nursing (AAN, Giger, Davidhizar, Purnell, Harden, Phillips, & Strickland, 2007). Table 1 presents a brief summary of definitions for cultural competence provided primarily by nurse researchers. According to Leininger (1993b, 1999, 2002b), the term cultural competence was first coined by her in the 1960s as part of her theory of cultural care diversity and universality. In the published literature, however, the term was used first by Cross, Bazron, Dennis, and Isaacs in 1989 (Burchum, 2002; Gallegos, Tindall, & Gallegos, 2008). In fact, the very term cultural competence was initiated and defined 1 year earlier by Cross (1988) in the social work profession. A similar term, cross-cultural competency, was introduced in counseling psychology by D. W. Sue and colleagues in 1982. Cross et al. (1989) defined cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.” The authors went on to emphasize that cultural competence implies “having the capacity to function effectively” among people with “the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group” (p. 28). In the nursing literature, the term cultural competence was first brought up by DeSantis (1990). According to Burchum (2002), the most closely related term to cultural competence is cultural congruence or culturally congruent care defined by Leininger as “care that is meaningful and fits with cultural beliefs and lifeway” (Leininger, 1999, p. 9). Earlier on, Leininger (1991) defined the term as the “use of culturally based care knowledge that is used in assistive, facilitative, sensitive, creative, safe, and

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Table 1.  Definitions for Cultural Competence (in chronological order). Author

Term

Orque, 1983

Ethnic nursing care

AAN Expert Panel on Culturally Competent Nursing Care, 1992 Andrews & Boyle, 1997

Culturally competent nursing care Cultural competence

Smith, 1998a

Cultural competence

Kim-Godwin, Clarke, & Barton, 2001 Burchum, 2002

Cultural competence Cultural competence

Leininger, 2002b

Culturally competent nursing care

Campinha-Bacote, 2002b

Cultural competence

Purnell & Paulanka, 2003

Cultural competence

Giger & Davidhizar, 2004

Cultural competence

Suh, 2004

Cultural competence

Papadopoulos, 2006

Cultural competence

Zander, 2007 Jirwe, Gerrish, Keeney, & Emami, 2009

Cultural competence Cultural competence

Jeffreys, 2010a

Cultural competence

Definition Nurse’s effective integration of the patient’s ethnic cultural background into her nursing process-based patient care Care that is sensitive to issues related to culture, race, gender, and sexual orientation A process in which the nurse continuously strives to work effectively within the cultural context of an individual, family, or community from a diverse cultural background A continuous process of cultural awareness, knowledge, skill, interaction, and sensitivity among caregivers and the services they provide (attributes by concept analysis) Caring, cultural sensitivity, cultural knowledge, and cultural skill (attributes by concept analysis) A process of development that is built on the ongoing increase in knowledge and skill development related to the attributes of cultural awareness, knowledge, understanding, sensitivity, interaction, and skill (attributes via concept analysis) The explicit use of culturally based care and health knowledge that is used in sensitive, creative, and meaningful ways to fit the general lifeways and needs of individuals or groups for beneficial and meaningful health and well-being or to face illness, disabilities, or death “The ongoing process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community). …This process involves the integration of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire” (p. 181). Self-cultural awareness, knowledge, and understanding of the client’s culture, acceptance of, and respect for cultural differences, openness to cultural encounter, and adaptation of care to be congruent with the client’s culture A dynamic, fluid, continuous process whereby an individual, system, or health care agency finds meaningful and useful care delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care An ongoing process with a goal of achieving ability to work effectively with culturally diverse groups and communities with a detailed awareness, specific knowledge, refined skills, and personal and professional respect for cultural attributes, both differences and similarities (antecedents via concept analysis) The process one goes through to continuously develop and refine one’s capacity to provide effective health and social care, taking into consideration people’s cultural beliefs, behaviors, and needs, as well as the effects that societal and organizational structures may have on them. Having three elements: cultural awareness, cultural knowledge, and cultural skills Five core components common to cultural competence models: cultural awareness, knowledge, skill, encounter, and sensitivity (p. 2638, via concept analysis) A multidimensional learning process that integrates transcultural nursing skills in all three dimensions (cognitive, practical, and affective), involves transcultural self-efficacy (TSE; confidence) as a major influencing factor, and aims to achieve culturally congruent care (p. 46)

meaningful ways to individuals or groups for beneficial and satisfying health and well-being or to face death, disabilities, or difficult human life conditions.” Leininger defined culturally competent nursing care as “the explicit use of culturally based care and health knowledge that is used in sensitive, creative, and meaningful ways

to fit the general lifeways and needs of individuals or groups for beneficial and meaningful health and well-being or to face illness, disabilities, or death” (2002b). As Andrews and Boyle (2003) noted, Leininger has used cultural congruence, culturally congruent care, culturally competent care, and culturally competent and congruent

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Shen Table 2.  Cultural Competence: Domains and Dimensions in Nursing and Other Caring Professions. Nursing

Affective Dimension

Authors

Cultural Sensitivity

Awareness

Knowledge

Understanding

Skill

Interaction/Encounter

Total

Burchum, 2002 Campinha-Bacote, 2002b Jirwe et al., 2009 Smith, 1998a Purnell & Paulanka, 2003 Papadopoulos, Tilki, & Taylor., 1998 Perng & Watson, 2012 Suh, 2004 Kim-Godwin, Clarke, & Barton, 2001 Leininger, 2002b, 2002c Schim & Doorenbos, 2010 Wells, 2000 Zander, 2007 Bernal & Froman, 1993 Willis, 1999 Total

√ √ [cultural desire] √ √

√ √ √ √ √ √ √ √

√ √ √ √ √ √ √ √ √ √

√

√ √ √ √ √ √ √ √ √ √ √[diversity]

√ √ √ √ √

6 5 5 5 5 4 4 4 3 3 3 3 3 2 2  

Counseling Psychology D. W. Sue et al., 1982, 1992, 1996

√ √ √ √ √ √ √

11

Cognitive Dimension

√ √ √

11

Beliefs/Attitudes Sensitivity

Social Work

Attitudes

NASW, 2001 Orlandi, 1992 Physical Therapy: APTA, 2008 Medicine: Beach et al., 2005; Gozu et al., 2007

Attitudes Attitudes Attitudes Attitudes

√ √ √ √ 14

Skill/Practical/Behavioral Dimension

√

2

Knowledge Awareness

Knowledge

Awareness Awareness

Knowledge Knowledge Knowledge Knowledge

Knowledge

care interchangeably. Indeed, Leininger has defined cultural congruence, culture care, and cultural competence virtually with little distinction. Many researchers used the method of concept analysis to explore the meaning of cultural competence. In the evolutionary view of concepts, a particular set of attributes that become associated with a concept through socialization and repeated public interaction constitute the definition of the concept (Rodgers, 1989), and a concept can be defined by analyzing the ways it and its associated terms are used (Rodgers, 2000). Using Rodgers’s evolutionary concept analysis method, Burchum (2002) identified a total of six attributes of cultural competence that are identified in the literature most consistently, namely, cultural awareness, cultural knowledge, cultural skill, cultural sensitivity, cultural interaction, and cultural understanding. Moreover, most of these attributes were also identified by other researchers in their separate concept analysis studies (Jirwe et al., 2009; Smith, 1998a; Suh, 2004). Most importantly, however, four of the six attributes, namely, sensitivity, awareness, knowledge, and skill, constitute the domains or subscales among 13 of the 15 cultural competence models or assessment instruments, as presented in Table 2. Accordingly, these four attributes can be incorporated into the definition of cultural competence as key elements. Cultural competence has been viewed as a developing, learning process in affective, cognitive, and skill/practical/behavioral dimensions (Jeffreys,

Understanding

√ √ √ 14

5 Skills

 

Culturally appropriate intervention skills, strategies, and techniques

 

Skills Cross-cultural skills Culturally appropriate intervention strategies Skills Skills

         

2010a; Orlandi, 1992; D. W. Sue, Arredondo, & McDavis, 1992; Suh, 2004; Wells, 2000), and each dimension may be characterized by distinct attributes or domains in different caring professions. While the three domains of attitudes/ beliefs, knowledge, and skills in three dimensions are adopted in the fields of medicine, counseling psychology, social work, and physical therapy, the aforementioned four domains in three dimensions are shared by most researchers in the nursing field, as shown in Table 2. As cultural competence consists of two subconcepts, culture and competence, its definitions may vary depending on which component is in focus for intended utility on the part of researchers. With competence in focus, the characteristics of competence may be manifested explicitly as sensitivity, knowledge, and skill; with culture in focus, the domains of culture may be presented specifically as cultural values, religion, and health beliefs, among others. This perspective may help further explain why cultural competence models in this study can be categorized into two groups, namely, theoretical models and methodological models, as discussed in the next section. Furthermore, cultural competence has been consistently recognized as a continuous, developmental, evolutionary, evolving, and dynamic process by most researchers (e.g., Andrews & Boyle, 1997; Burchum, 2002; Campinha-Bacote, 2002b; Giger & Davidhizar, 2004; Jeffreys, 2010a; KimGodwin et al., 2001; Papadopoulos & Lees, 2001; Purnell &

312 Paulanka, 2003; Schim & Doorenbos, 2010; Smith, 1998a). This perspective is compatible with Rodgers’s (2000) evolutionary view of concepts as dynamic, nonfinite, contextdependent, and subject to change with time, purpose, and utility. Accordingly, what constitutes the definition or meaning of cultural competence, including such domains as cultural knowledge and skills, are not static or finite and will change in response to the needs in the changing demographic and cultural context. As discussed above, a definition of cultural competence in nursing need to include manifestations of the culture and competence components by domains or characteristics in affective, cognitive, and practical/skill dimensions and description of cultural competence as a dynamic, continuous, and developing process in providing culturally congruent and competent health care for culturally diverse populations.

Cultural Competence Models Theoretical and Methodological Models A 2001 HRSA study identified two approaches, theoretical and methodological, adopted to conceptualizing cultural competence in the literature. Cross et al. (1989) and Campinha-Bacote (1999) took a theoretical approach in which cultural competence is seen as a process or continuum. On the other hand, Leininger (1993a), and Davidhizar, Bechtel, and Giger (1998), among others, “offer a more methodological approach that focuses on the methods that a professional might use in order to become culturally competent and provide culturally competent care” (HRSA, 2001b, Section II, A). Using this grouping-by-approach method, 12 of the 18 models covered in this review can be classified as theoretical models, and the remaining six as methodological models, as summarized in Table 3 and Table 4, respectively. As previously discussed in defining cultural competence, the emphasis on either culture or competence component is apparently reflected in the construction of the domains of the models. While the theoretical models appear to have the competence component in focus, manifesting the competencies of awareness, knowledge, sensitivity, and skill as the domains, the methodological models are likewise focused on the culture component, manifesting the aspects of religion, ethnicity, healing beliefs and practices, and value orientations as the domains. In other words, domains of a model, whether theoretical or methodological, can be derived from the attributes of cultural competence if clearly defined with one component or the other in focus. In this sense, a clearly defined concept may well determine what constitutes the domains of a cultural competence model.

Theoretical Backgrounds of the Models Several approaches are attributable to the development of cultural competence models in nursing, as described below.

Journal of Transcultural Nursing 26(3) Pioneer researchers drew on theories from nursing and some other disciplines, predominantly anthropology and sociology. For example, Orque (1983) conceptualized the Ethnic/Cultural System Framework from theory in sociology while Leininger developed the culture component from anthropological theory and the care component from nursing theory. As Leininger (2002a) stated, it was anthropological insights, along with her extensive and diverse nursing experiences, life experiences, values, and creative thinking, that helped create the Sunrise Model with the culture care theory. According to Leininger (2002c), the Sunrise Model was developed to depict the Theory of Cultural Care Diversity and Universality: The Model shows different factors or components that need to be systematically studied with the theory. It serves as a cognitive guide to tease out culture care phenomena from a holistic perspective of multiple factors that can potentially influence care and the well-being of people. (p. 79)

The Sunrise Model, as Giger and Davidhizar (1999) noted, “has served as the prototype for the development of other culture-specific models and tools.” Indeed, both Campinha-Bacote (2002b) and Giger and Davidhizar (2002) attributed the development of their models partially to Leininger’s transcultural nursing theory and her seminal work, respectively. Moreover, Leininger’s transcultural nursing concept and theory are reflected profoundly in a number of major models authored by Andrews and Boyle (2008), Jeffreys (2010a), Pacquiao (2012), and Schim and Doorenbos (2010). Some models are developed based on theories from multiple disciplines. The Purnell model, for example, was conceptualized on theories in biology, anthropology, sociology, economics, geography, political science, pharmacology, nutrition, as well as theories from communication, family development, and social support (Purnell, 2003). Finally, concept analysis over literature review provides an effective method for several researchers (Burchum, 2002; Jirwe et al., 2009; Kim-Godwin et al., 2001; Suh, 2004) in developing their theoretical models which derived their composite domains directly from the attributes, or definition, of cultural competence. Among the methodological models in Table 4, there are at least five domains (phenomena, or constructs) in common, namely, biological variations, communication, social organization, religion, and health beliefs and practices. These five domains also align well with Spector’s (2004a) model components, the body, mind, and spirituality. As both types of models place an emphasis on only one component of cultural competence with its domains presented explicitly, the characteristics of the other component remain abstract. For example, most theoretical cultural competence models in Tables 2 and 3 share the domains of cultural sensitivity, cultural knowledge, and cultural skills; however, the meaning of culture is anything but explicit.

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Shen Table 3.  Theoretical Models of Cultural Competence (Arranged by validation, instrument linkage, year). Authors, year

Model Name

Components or Constructs or Domains

Sources Leininger’s (1991) transcultural nursing theory; Pedersen’s (1988) multicultural development theory (as cited in CampinhaBacote, 2002b)

Campinha-Bacote, 2002b

Culturally competent model of care

Five constructs within the cultural context of individual, family, and community (cultural awareness, knowledge, skill, encounters and desire [cultural desire added in 1998])

Papadopoulos et al., 1998

Model for the development of culturally competent health practitioners

Four components (cultural awareness, cultural knowledge, cultural sensitivity, cultural competence)

Kim-Godwin, et al., 2001  

Culturally competent community care model

Three constructs (cultural competence, health care system, and health outcomes) with four dimensions (caring, cultural sensitivity, cultural knowledge, and cultural skills)

concept analysis

Jeffreys, 2010a

Cultural competence and confidence model

Transcultural nursing skills in cognitive, practical, and affective dimensions, transcultural self-efficacy, and culturally congruent care

Schim & Doorenbos, 2010; Schim, Doorenbos, Benkert, & Miller, 2007; Schim, Doorenbos, Miller, &, Benkert, 2003 Campinha-Bacote, 2005

3–D model of culturally congruent care

Three dimensions of provider level (cultural diversity, cultural awareness, cultural sensitivity, and cultural competence behaviors), client level (patient, family, and community attitudes, beliefs, and behaviors) and culturally congruent care as outcome layer (when provider and client levels fit well together)

Leininger’s transcultural nursing theory; Bandura’s (1986) self-efficacy theory in psychology Leininger’s transcultural nursing theory

Biblically based cultural competence model

Eighteen intellectual and moral virtues (love, caring, humility, love of truth, teachableness, intellectual honesty, inquisitiveness, wisdom, discernment, judgment, prudence, attentiveness, studiousness, practical wisdom, understanding, temperance, patience and compassion) integrated into the five constructs (cultural awareness, cultural knowledge, cultural desire, cultural skill and cultural encounters) Four components (cultural awareness, cultural knowledge, cultural sensitivity, cultural competence) with culture-generic and culturespecific competence as the two layers of cultural competence Seven-step progression (knowledge of one’s own culture, knowledge of others’ culture, cultural interaction, cultural tolerance, cultural inclusion, cultural appreciation/acceptance, cultural competence) A continuum of six stages in two phases (cultural incompetence, cultural knowledge, and cultural awareness as the cognitive phase; cultural sensitivity, cultural competence, and cultural proficiency as the affective phase) Six attributes (cultural awareness, knowledge, understanding, sensitivity, interaction, and skill): a nonlinear, expansive process of becoming culturally competent Three components: cultural context; compassionate advocacy for social justice and human rights protection for culturally congruent healthcare for vulnerable populations; and culturally competent healthcare by realization of cultural preservation, cultural accommodation, and cultural patterning Four domains as antecedents: cognitive (cultural awareness, knowledge), affective (sensitivity), behavior (skills), and environmental (encounters); three attributes of cultural competence (ability, openness, flexibility); and three variables (receiverbased, provider-based, and health outcome)

Papadopoulos & Lees, 2001

Model for the development of culturally competent researchers

Willis, 1999

Framework for cultural competence

Wells, 2000

Cultural development model (for individual and institutional cultural competence development) Model for cultural competence

Burchum, 2002

Pacquiao, 2012

Culturally competent model of ethical decisions

Suh, 2004

Model of cultural competence

Assessment Instrument Linkage

Validation

Inventory for assessing the process of cultural competence among healthcare professionals, revised (IAPCC–R)

Yes

Cultural competence assessment tool (CCATool), 2004 (40 items) based on Papadopoulos et al.’s 1998 model Cultural competence scale to test the 3 dimensions of cultural sensitivity, knowledge, and skills Transcultural self-efficacy tool (TSET)

Yes

Cultural competence assessment (CCA)

Inventory for assessing a biblical worldview of cultural competence (IABWCC) among healthcare professionals

Yes  

Yes

Yes

 

 

 

Cross et al., 1989; Orlandi, 1992

 

Concept analysis

 

Leininger’s transcultural nursing theory and principles of culturally congruent healthcare as a basic human right

 

Concept analysis

 

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Table 4.  Methodological Models of Cultural Competence (Arranged by validation, instrument linkage, year). Authors

Model Name

Components/Constructs/Domains

Sources

Assessment Instrument Linkage

Validation

Tested by Smith (1998b) with three scales: CAS by Bonaparte [1977, 1979]; CSES by Bernal & Froman [1987, 1993]; and Rooda’s [1990, 1992] knowledge-based questions on cultural competence); also as cited in Giger & Davidhizar, 2002 Heritage assessment tool with 29 questions, Spector (2004b)

Yes

Bloch’s (1983) assessment guide for ethnic/cultural variations

 

Giger & Davidhizar, 2004, 2008

Transcultural assessment model

Six cultural phenomena (communication, space, social organization, time, environmental control, and biological variations)

Leininger (1991); Spector (1996); Orque, Bloch, & Monrroy (1983); as cited in Giger & Davidhizar (2004, 2008)

Spector, 2004a, 2009

Health traditions model

Giger & Davidhizar’s (1999, 2002, 2004, 2008) model; Ester & Zitzow’s theory (as cited in Spector, 2013)

Orque, 1983

Ethnic/cultural system framework

Leininger, 1991

Sunrise model

Purnell, 2003, 2008

Purnell model for cultural competence

Andrews & Boyle, 2008

Transcultural nursing assessment guide for individuals and families

Five aspects of heritage consistency (culture, ethnicity, religion, [acculturation and socialization, 2009]) interrelated with six cultural phenomena (communication, space, social organization, time, environmental control, and biological variations) to maintain, protect, and restore the health of the body, mind, and spirit Eight components applicable to nurses and clients (diet, family life processes, healing beliefs and practices, language and communication process, social groups’ interactive patterns, value orientations, religion, art and history) along with two models (intercultural communication model and model of biological, sociological and psychological systems) Six domains (culture values and lifeways; religious, philosophical, and spiritual beliefs; economic factors; educational facors; technological factors; kinship and social ties; and political and legal factors) and three modalities (cultural care preservation and maintenance; cultural care accommodation and negotiation; and cultural care repatterning and restructuring) Twelve cultural domains (overview, inhabited localities, and topography; communication; family roles and organization; workforce issues; biocultural ecology; high-risk health behaviors; nutrition; pregnancy and childbearing practices; death rituals; spirituality; healthcare practices; and healthcare practitioners) Twelve categories of cultural knowledge (cultural affiliations, values orientation, communication, healthrelated beliefs and practices, nutrition, socioeconomic considerations, organizations providing cultural support, education, religion, cultural aspects of disease incidence, biocultural variations, and developmental considerations across the life span, p. 35)

Likewise, most methodological models in Table 4 have specific cultural domains (Leininger, 1991; Purnell, 2008), cultural phenomena (Geiger & Davidhizar, 2008; Spector, 2009) or 12 categories of cultural knowledge (Andrews & Boyle, 2012), but the aspects of competence are implicit. Several authors have provided frequently updated profiles of various U.S. ethnic or cultural groups in detail (e.g., Geiger, 2013; Purnell, 2008; Spector, 2009) as useful guides or references for healthcare practitioners. Although there is not a cookbook approach to delivering care to clients by virtue of race, ethnicity, or culture, when the informed nurse considers the significance of culture, clients are approached with a more informed perspective (Giger, 2013). Perhaps, more importantly, “cultural assessment skills, combined with the nurse’s critical thinking ability, will provide necessary knowledge on which to base transcultural nursing care” whereby “nurses will be able to provide culturally competent and contextually meaningful care for clients from a wide

Nursing, sociology

 

Nursing, anthropology

 

Organizational, administrative, communication, and family development theories

 

Leininger’s transcultural nursing theory

 

variety of cultural backgrounds, rather than simply memorizing the esoteric health beliefs and practices of any specific cultural group” (Andrews & Boyle, 2012, p. xi).

Limitations of Cultural Competence Models The existing models have some noted limitations. First of all, most models evaluate only healthcare providers’ cultural competence, and patient and health outcomes are not addressed (Balcazar et al., 2009; Capell et al., 2007). As exceptions, only three models in this review include patient/ client outcomes and health/healthcare outcomes (KimGodwin et al., 2001; Schim & Doorenbos, 2010; Suh, 2004) as model components or constructs. Without consideration or measurement of the behavior of the healthcare professional and the patient outcomes (patient satisfaction and clinical outcomes), the cultural competence of the care provided cannot be validated (Capell et al., 2007).

315

Shen Second, few models are empirically tested (Brathwaite, 2003); few validated measures and even fewer conceptual frameworks are available to assess cultural competence (Balcazar et al., 2009). Although the literature review identified a total of six validated models (Papadopoulos, Tilke and Taylor, 1998; Jeffreys, 2010a; Schim and Doorenbos, 2010; KimGodwin et al., 2001; Giger and Davidhizar, 2008) and twelve validated assessment instruments as shown in Table 5, they nevertheless account for a mere minority as a whole in comparison with the totals of the models and instruments currently available in the nursing literature. In addition, even with those few validated models, little guidance is provided as related to the validation process adopted and the relevancy of validation to the application of the models in nursing practice. Both theoretical and methodological models by nature are very abstract and therefore difficult to apply in practice. In order to be put into practical use, quantitative instruments need to be developed using the associated model domains as theoretical or conceptual underpinnings to derive the subscales for data collection and psychometric evaluation.

Cultural Competence Assessment Instruments For the purpose of this review, cultural competence assessment instruments refer to self-reported, or self-administered, quantitative instruments, including tools, scales, or measures in the form of Likert-type questionnaires with varying numbers of items categorized under preset subdomains or subscales. All the assessment instruments identified for this review are used to measure or evaluate the cultural competence of nursing professionals, educators, and students.

Theoretical Backgrounds of Assessment Instruments The first six assessment instruments as presented in Table 5 were developed by authors who used their own cultural competence model as a framework under which subdomains or subscales of an instrument were derived directly from the components of the underlying model. For example, Campinha-Bacote’s two assessment instruments (2003, 2005) and Papadopoulos et al.’s assessment tool (CCATool, 2004) drew all the domains (five for the former and four for the latter) from their respective cultural competence models. Doorenbos et al. (2005) derived the three subdomains of the assessment instrument from the corresponding providerlevel component of their 3-D Model of Culturally Congruent Care (Schim & Doorenbos, 2010; Schim et al., 2007). In Jeffreys’s (2010b) two assessment tools, the three (cognitive, practical, and affective) subscales were derived from the three namesake dimensions of transcultural nursing skills. Some assessment instruments are grounded partially in Bandura’s (1986) self-efficacy theory in psychology. The

prominent examples are Transcultural Self-Efficacy Tool (TSET) and its adapted evaluation tool (Jeffreys, 2010b), Cultural Self-Efficacy Scale (Bernal and Froman, 1987, 1993) and Eldercare Cultural Self-Efficacy Scale (Shellman, 2006). Adaptation or modification of existing assessment instruments is another method with which to develop new assessment tools to meet the need for nursing practice and research. The instruments developed by Escallier et al. (2011), and Shellman (2006) fall into this category. As for qualitative data obtained from a theory, for example, Leininger’s cultural care theory, which is “not easily translated into a practical assessment tool for researchers or clinicians” (as quoted in Capell et al., 2007, p. 31), Canales and Rakowski (2006) offered an example of translating such qualitative data derived from a culturally competent nursing framework into quantitative questionnaire items. Their study provided a practical approach to developing new assessment tools to suit special needs. To develop a first cultural assessment instrument in a specified field of study or practice where no such instruments can be found, Suarez-Balcazar et al. (2011) proposed a five-phase process of literature review, factor analysis, question development under each factor, expert panel’s items preview with feedback, and pilot testing with clinical practitioners working with clients from various ethnic backgrounds.

Limitations of Assessment Instruments There are limitations of the existing assessment instruments. First, few assessment instruments survey patient or recipient outcomes (Kumas-Tan et al., 2007; Perng & Watson, 2012). “The lack of assessment of patient outcomes in the current measures may limit comprehensive analysis of the cultural competence of healthcare professionals when managing patients from other cultures” (Capell et al., 2007, p. 35). Second, most instruments are not tested for psychometric evaluation (Gozu et al., 2007; Kumas-Tan et al., 2007). As for those tested, their validity or reliability may remain questionable, because most of them lack “methodological rigor” (Price et al., 2005), are “poorly constructed,” “have not been rigorously evaluated,” and lacking “acceptable psychometric properties” (Gozu et al., 2007). Third, the very few instruments that are tested and/or retested with high validity and/or reliability may still have limitations or drawbacks. For example, Campinha-Bacote’s IAPCC (1999) was not suited “for interdisciplinary teams or groups with mixed educational levels” (Doorenbos, Schim, Berkert, & Borse, 2005). Bernal and Froman’s (1987) Cultural Self-efficacy Scale (CSES) was quite long with 58 items and not linked to an “overarching cultural competence model” (Doorenbos et al., 2005). Despite its robust psychometric properties, Jeffreys’s TSET (2010b), with more than 80 items and a 10-point rating scale, was “a complicated and time-consuming instrument to complete” (Fitzgerald, Cronin, & Campinha-Bacote, 2009).

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Table 5.  Cultural Competence Assessment Instruments (Ranking by model linkage, validation, year). Authors Campinha-Bacote, 2003, 2007

Doorenbos, Schim, Benkert, & Borse, 2005; Schim et al., 2004 Papadopoulos, Tilki, & Lees, 2003 Jeffreys, 2010b

Items

Inventory for assessing the process of cultural competence among healthcare professionals— revised/student version (IAPCC–R, 2002a)/ (IAPCC–SV, 2007) Cultural competence assessment (CCA)

25 (IAPCC–R); 20 (IAPCC–SV)

Five domains (cultural awareness, knowledge, skill, encounters and desire)

RV

Campinha-Bacote’s cultural competence model

25

Assessing healthcare providers and staff members’ cultural awareness and sensitivity and cultural behaviors

RV

40

Four sections (awareness, knowledge, sensitivity, and competent practice) each with 10 questions Three subscales: cognitive, practical and affective to measure and evaluate students’ confidence for performing general transcultural nursing skills among diverse populations Three subscales (extent of culturally specific care; cultural assessment; cultural sensitivity, etc.) to measure different dimensions of clinical cultural competence behaviors To measure one’s level of cultural competence with cultural desire, awareness, knowledge, skill, and encounters

RV

Based on the provider level of 3–D model of culturally congruent care by Schim et al. (2003, 2010) Papadopoulos & Lee’s (2001) cultural competence model

Cultural competence assessment tool (CCATool) Transcultural self-efficacy tool (TSET)

83

Jeffreys, 2010b

Cultural competence clinical evaluation tool (CCCET) [Adapted from her TSET]

83

Campinha-Bacote, 2005

Inventory for assessing a biblical worldview of cultural competence (IABWCC) among healthcare professionals Heritage assessment tool (HAT)

25

Spector, 2004b

Escallier, Fullerton, & Messina, 2011

Bernal & Froman, 1987, 1993

Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals— Revised (IAPCC–R, 2002a); Student Version (IAPCC–SV, 2007) Cultural self-efficacy scale (CSES)

29

25 (IAPCC–R); 20 (IAPCC–SV)

58

Shellman, 2006

Eldercare Cultural SelfEfficacy Scale (ECSES)

38

Meretoja, Isoaho, & Leino-Kilpi, 2004

Nurse competence scale (NCS)

73

Rew, Becker. Cookston, Khosropour, & Martinez 2003

Cultural awareness scale (CAS)

36

Perng & Watson, 2012

Nurse cultural competence scale (NCCS)

41

Kim-Godwin et al., 2001 Tulman & Watts, 2008

Cultural competence scale

24

Blueprint for integration of cultural competence in the curriculum questionnaire (BICCCQ)

31

a

R = reliability; V = validity.

Subscales/Domains

R/Va

Instrument

To assess the degree to which a given person/ family/community adheres to traditional ethno-religious-cultural health and healing beliefs and practices in culture, ethnicity, religion, socialization, acculturation, and assimilation Five components: faculty self-assessment (25 items); student self-assessment (20); student view of curriculum (31); expert review of, and client perceptions of, the curriculum

Three domains (knowledge of cultural concepts, knowledge of cultural patterns, skills in performing transcultural nursing functions) to determine nurses’ level of confidence in caring for diverse cultural groups To measure nursing students’ level of selfefficacy towards caring for older adults of four distinct ethnic groups (White, African American, Hispanic, and Asian American) Seven categories (helping role, teachingcoaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality, and work role) To measure nursing students’ multicultural awareness in five categories (general educational experience, cognitive awareness, research issues, behaviors/comfort with interactions, and patient care/clinical issues) To measure 4 domains (cultural awareness, cultural knowledge, cultural sensitivity and cultural skill) with Mokken scaling analysis to investigate the scale’s unidimensionality and hierarchical nature To measure three dimensions of cultural sensitivity, knowledge, and skills To measure student reports of components of content on cultural competence taught in undergraduate and graduate nursing programs

Model Linkage

RV

Guided by Jeffreys’s cultural competence and confidence model (CCC)

RV

Jeffreys’s cultural competence and confidence model (CCC) Campinha-Bacote’s cultural competence model

Spector’s Health traditions model, 2004a, 2009

R V (for IAPCC–SV)

RV

RV

Adapted from Goode’s Cultural competence self-test for health care providers, CampinhaBacote’s (2007) IAPCC–SV, Tulman & Watts’s (2008) BICCCQ Bandura’s (1986) self-efficacy theory

RV

Bandura’s (1986) self-efficacy theory; modified version of Bernal & Froman’s (1987, 1993) CSES Derived from Benner’s competency framework (as cited in Meretoja, Isoaho, & Leino-Kilpi, 2004)  

RV

 

RV

   

317

Shen Fourth, as a relatively small convenience pool of respondents is usually selected in a limited sampling area, the generalizability of findings is limited (Fitzgerald et al., 2009). Finally, as assessment instruments are self-reported or self-administered, they are susceptible to social desirability effects (Jeffreys, 2010a; Kumas-Tan et al., 2007). The key to the usefulness of a cultural competence assessment instrument is its proven high reliability and validity through repeated rigorous tests and retests at appropriate intervals on a carefully selected, rather than convenience, sampling population. As the “significance of construct validity is in its linkage with theory and theoretical conceptualizations” (Polit & Hungler, 1978, as cited in Campinha-Bacote, 1999, p. 206), the assessment instruments should be based on a well-constructed model. Jeffreys (2010b) provided a useful example for validating her TSET through such rigorous tests and retests. In a series of five studies conducted between 1996 and 2010, high psychometric properties were consistently reported, including various types of validity and reliability.

Cultural Competence and Health/ Healthcare Disparities As clearly demonstrated in the literature, most, if not all, cultural competence models in nursing were developed in an effort to provide culturally congruent and competent health care for patients from all racial, ethnic, and cultural backgrounds. For example, Leininger (1993b) has consistently emphasized that transcultural nursing care she founded in the 1960s “focuses on all cultures and subcultures” (p. 282). For Andrews and Boyle (2012), the primary goal “has been to advance the use of transcultural knowledge in nursing practice and to develop cultural competence in the care of individuals and groups” (p. xi). Purnell (2008) developed his model initially for use as a framework for clinical assessment. Giger and Davidhizar’s model was developed “in response to the need for a practical assessment tool for evaluating cultural variables and their effects on health and illness behaviors” in an effort to provide cultural competent care” (Giger, 2013, p. 5). Cultural competence models have been promoted primarily in response to the rapidly growing racial, ethnic, and cultural diversity of U.S. population in the past two decades. Since the releases of several major documents on health and healthcare disparities among the four major racial, ethnic minority groups (e.g., Institute of Medicine, 2003; Nickens, 1985; U.S. Department of Health and Human Services [USDHHS], 1990, 2000), cultural competence models have also been viewed by a good many researchers to have the potential to help address the disparities issue. However, studies on the health outcomes of cultural competence interventions are lacking in the literature (Brach & Fraserirector, 2000; Schim & Doorenbos, 2010; S. Sue, 2003). As an AAN report noted, “interventions in health care alone, especially those focused on cultural competence, may

not necessarily reduce or eliminate health disparities (2007, p. 96). This is because the “sources of these disparities are complex, are rooted in historic and contemporary inequities” (Institute of Medicine, 2003, p. 1) but also because these disparities are linked to socioeconomic status (Giger et al., 2007; Agency for Healthcare Research and Quality [AHRQ], 2004; Daniels, Kennedy, & Karachi, 1999; Kawachi, Daniels, & Robinson, 2005). In fact, according to AHRQ’s annual National Healthcare Disparities Report, the disparities have been described as “pervasive” (2003, 2004), “prevalent” (2006), “have not been reduced” (2007), persistent (2008), “not improving” (2010-2011) and “not changing” but access getting worse (2012). In a word, healthcare disparities in the U.S. have not been reduced since 2003 despite the USDHHS’ efforts to “reduce health disparities among Americans” by 2000 (1990) and “to eliminate health disparities among different segments of the population” by 2010 (2000). Although cultural competence alone is not sufficient to reduce health and healthcare disparities, it “remains one of the significant aspects for addressing health disparities” and changes in health policies at the national and state levels, in society and in the healthcare system (Giger et al., 2007) along with culturally competent care are import steps toward that end.

Conclusions The significant contribution that nurse researchers have made over the past three decades through the continuous development and refinement of so many models and assessment instruments in advancing the body of knowledge in the cultural competence literature for the benefit of nursing and other caring professions cannot be overestimated. These models and instruments have raised the awareness, understanding and sensitivity among nurses and other healthcare professionals of importance in providing cultural competent care and improving quality of care for clients from various cultural backgrounds. There is ample evidence in the nursing literature. In the endeavor to further advance the application of the models and instruments, education and training of nursing students and professionals are critical. Issues as raised in a study by Lipson and DeSantis (2007) merit particular attention to strategic planning for resolution, including lack of standards on curricula and coursework and lack of faculty and institutional commitments, among others. Much to the contrary, this study shows that key elements in the definition of cultural competence and major domains of cultural competence models in all three dimensions are actually shared by the majority of nurse researchers. This could provide a common ground for further refinement of the existing models which, in turn, can serve as conceptual or theoretical underpinnings for the refinement or development of assessment instruments to evaluate cultural competence. Rigorous psychometric tests and retests on the instruments

318 are needed to obtain high levels of reliability and validity. More outcomes studies are needed to test the usefulness or effectiveness of clinical or educational cultural competence interventions. Ultimately, all this may facilitate the application of cultural competence models and instruments in practice. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author received no financial support for the research, authorship, and/or publication of this article.

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