THREE
A Model to Guide Cultural Competence Education
The Cultural Competence and Confidence (CCC) model presents an organizing framework for examining the multidimensional factors involved in the process of learning and developing optimal cultural competence in order to identify at-risk individuals, develop diagnostic-prescriptive strategies to facilitate learning, guide innovations in teaching and educational research, and evaluate strategy effectiveness.
SNAPSHOT SCENARIO
Wanda: I wonder how we can prepare nurses to provide culturally competent care to so many different cultures.
Frank: Yes, it’s also challenging to know what and how to teach about different cultures, especially when there’s increasing diversity among students, new graduate nurses, and foreign-educated nurses.
Ed: Another problem is that most faculty and staff educators have not been formally trained or educated about the teaching–learning process involved in cultural competence. Some faculty and staff are not actively engaged in becoming culturally competent within their roles with learners, patients, or coworkers.
Ernestine: I was really surprised. Despite a hospital-wide in-service program about cultural groups, a follow-up survey indicated that many nurses did not feel confident about caring for patients who they perceived were different from themselves. Their comments indicated that their lack of confidence often prevented them from asking culture-specific questions or performing a cultural assessment to ascertain important cultural values, attitudes, beliefs, and health practices.
Ed: Yes, but some nurses seemed overly confident, stating that they did not think they needed to learn anything about cultural competence, diversity, or the multicultural workplace. They were not motivated to participate in a workshop or to collaborate in revising a unit-specific assessment tool that would incorporate relevant questions concerning culture.
Alva: What’s the big deal? Faculty and staff educators are nurses. Nurses have always been able to wing it when it comes to dealing with different types of people.
Frank: Winging it is not professional. Cultural competence is a big deal and makes a powerful difference in optimizing patient and workplace outcomes. Nursing is a profession, and as such, societal expectation of a lifelong commitment to learning and utilizing evidence-based practices for patient care and/or educational innovations is a standard that should be valued and followed. A profession is guided by conceptual and theoretical foundations and evidence-based practice. This also extends to incorporating theories and evidence from other disciplines such as education and psychology. Teachers and learners are also culturally diverse people with varying desires, motivations, and beliefs about education, learning, and nursing.
Ernestine: Wouldn’t it be wonderful if we could figure out what influences the teaching–learning process for achieving optimal cultural competence, including a desire and commitment for ongoing cultural competence education? And enough confidence for applying cultural competence within the workplace setting?
Wanda: That would mean really understanding our learners and what’s involved in successfully achieving desired outcomes in cultural competence education. Isn’t confidence and motivation important in all this? Isn’t there a model or theory we can use to explore this? What strategies have others used that were successful? What works and what doesn’t, and why?
What do you know about the ways confidence and motivation may influence the development of optimal cultural competence? What do you know about the teaching–learning process involved in developing optimal cultural competence in oneself and in others?
Providing culturally specific and congruent care to the myriad of culturally diverse populations is a growing professional challenge. The expanding number of immigrant and minority populations seeking health care, compounded by the growing diverse student population predicted in the future, suggests that, increasingly, health professionals will care for clients who are “culturally different.” Culturally different clients are clients whose racial, ethnic, gender, socioeconomic, lifestyles, and/or religious backgrounds and/or identities are different from those of the health care professional or student. For educators, preparing culturally diverse students to care competently for culturally different clients will be even more challenging. For health care professionals and health care institutions (HCIs), the challenge is to provide substantive and ongoing educational opportunities to enhance the cultural competency of health care professionals so that quality outcome indicators such as enhanced client satisfaction and positive health outcomes may be achieved.
Another challenge is to create a culturally safe workplace environment through initial and ongoing educational programs focused on preventing multicultural workplace conflict and on promoting multicultural workplace harmony (see Chapter 2). Creating a culturally safe environment also pertains to all types of academic settings (e.g., classroom, clinical, simulation, distance education, etc.). A culturally safe environment openly embraces the diversity of diversity and expects cultural competence at all levels. Creating a culturally safe environment requires initial and ongoing inquiry, action, and evidence-based innovations.
Caring for employees and students and valuing diversity is essential for quality and safety.
Quality outcome indicators include employee satisfaction, job-embeddedness (1–4), enhanced employee retention, decreased absenteeism, and decreased workplace conflicts, which in turn will positively influence patient care and patient outcomes and decrease costs. In academic settings, quality outcome indicators include increased student satisfaction, enhanced recruitment, retention, graduation, licensing/certification results, and postgraduation employment of students including increased representation of underrepresented student groups (5–8). Faculty satisfaction, retention, tenure, promotion, and production of creative projects and scholarship are also quality outcome indicators, including increased representation among underrepresented faculty groups (9).
Unquestionably, implementing creative, evidence-based educational activities that promote positive cultural competence learning outcomes for culturally diverse students and health care professionals (including faculty) must reach beyond competence (a minimum expectation) toward optimal cultural competence. This quest recognizes that all individuals, groups, and organizations have the potential for “more.” Optimal cultural competence embraces the diversity of diversity, requires ongoing active learning, fosters multicultural workplace harmony, and promotes the delivery of the highest level of culturally congruent patient care.
Although the need to prepare students and health professionals to become culturally sensitive and competent is extremely urgent, research in the area of understanding the teaching–learning process of cultural competency has been limited. Research priorities, guided by empirically supported conceptual models, must emphasize strategies aimed at maximizing learner strengths, identifying learner weaknesses, and developing diagnostic-prescriptive teaching interventions. Comprehensively understanding the process, developing strategies for ongoing, optimal cultural competence development for diverse learners and settings, and achieving optimal outcomes can seem like a daunting and overwhelming task without an organizing framework. The CCC model provides an evidence-based, easily applicable theoretical framework that has been a valuable cognitive map guiding educators, researchers, and learners worldwide (10–16). The model offers a comprehensive approach, addressing factors that influence learning, motivation, persistence, and commitment for optimal cultural competency development.
The CCC model recognizes that despite the learning opportunities presented to students, nurses, and other health professionals, some individuals persist at cultural competency development whereas others do not. According to Bandura (17), learning and motivation for learning are directly influenced by self-efficacy perceptions (confidence). Self-efficacy is the perceived confidence for learning or performing specific tasks or skills necessary to achieve a particular goal. Moreover, self-efficacy is the belief that one can perform or succeed at learning a specific task, despite obstacles and hardships, and that one will be able to expend whatever energy is necessary to accomplish the task (17). Self-efficacy has been strongly linked to persistence behaviors and motivation. Motivation has been described as “the ‘power within’ that will generate actions that will result in his or her success” (18, p. 173). Motivation to engage in the process of becoming culturally competent has been termed cultural desire, with such desire viewed as the “pivotal construct of cultural competence” (19, p. 14). As a determinant of performance, persistence, motivation, and the self-regulation of learning, self-efficacy (perceived confidence) is a major component in learning (5–7, 17, 20–29). Consequently, confidence is a vital component in the process of learning cultural competence (see “Educator-in-Action” vignette, Chapter 2).
The CCC theoretical model (see Figure 3.1) aims to interrelate concepts that explain, describe, influence, and/or predict the phenomenon of learning (developing) cultural competence and incorporates the construct of transcultural self-efficacy (confidence) as a major influencing factor. Transcultural self-efficacy (TSE) is the perceived confidence for performing or learning general transcultural (nursing) skills among culturally different clients. (TSE also applies to other health professions whereby TSE is the perceived confidence for performing or learning general transcultural skills needed to provide high-quality culturally congruent care.) Cultural competence is a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective), involves TSE (confidence) as a major influencing factor, and aims to achieve culturally congruent care. The term learning process emphasizes that the cognitive, practical, and affective dimensions of TSE and transcultural skill development can change over time, as a result of formalized education and other learning experiences. Optimal cultural competence is at the core (core value or goal) and has been added to the new illustrated model as a visible reminder of its significance (see Figure 3.1).
This chapter begins by describing the initial conceptualization surrounding CCC theoretical model development, key terms, background information, underlying assumptions, and model overview. The CCC total model illustration provides a general picture for understanding the multidimensional process of cultural competence and confidence by succinctly portraying major components of the learning process. A close-up view of TSE, cultural competence, and culturally congruent care is depicted through the TSE pathway (see Figure 3.2), thereby expanding upon the major components of the CCC model. The seven steps in the process of developing optimal cultural competence are introduced: (1) self-assessment; (2) active promotion; (3) systematic inquiry; (4) decisive action; (5) innovation; (6) measurement; and (7) evaluation. A corresponding graphic diagram depicts continual movement, development, and interaction between all steps signifying ongoing inquiry, action, and innovation (see Figure 3.3). The seven steps are incorporated throughout the book and toolkit and are easily applicable across all settings. Lastly, the model is brought to life through a realistic “Educator-in-Action” vignette featuring cultural competence education in the health care institution (hospital setting).
FIGURE 3.1 Jeffreys’s Cultural Competence and Confidence (CCC) Model—(2016)
What are the various trajectory pathway options for transcultural self-efficacy perceptions? What does transcultural self-efficacy have to do with development of optimal cultural competence?
FIGURE 3.2 Transcultural Self-Efficacy (TSE) Pathway
BEGINNING ROOTS, OBSERVATIONS, AND INITIAL CONCEPTUALIZATION
How was the CCC theoretical framework and model conceptualized?
A brief discussion of the CCC model’s beginning roots from the author’s observations, conceptualization, empirical support, and changes over time is introduced, demonstrating the model as developmental, tentative, dynamic, and evolving as new data become available. The model presents one perspective that will hopefully spark further inquiry into the complex, yet extremely important, process of developing optimal cultural competence.
Initial ideas often evolve from multiple sources. An area of interest may be based on formal or informal observations or derived from issues in professional nursing. In the present case, both informal and formal observations led to the author’s design of a series of studies and the development of the CCC model. Early on, informal observations noted that confidence, lack of confidence, or overconfidence was an intriguingly complex phenomenon that could influence learning and performance. This observation was especially noted in interactions that the author had with aquaphobics and athletes prior to the author becoming a registered nurse. Despite cognitive knowledge and psychomotor ability, learning and performance were often influenced by confidence level either directly or indirectly. Direct effects were manifested through performance outcomes; indirect effects included varying levels of avoidance behaviors, persistence, indifference, commitment, effort, satisfaction, fear, and/or stress.
Later, as an undergraduate nursing student, the author also informally observed confidence to be a factor in learning, performance, and overall success. Fellow nursing students who lacked confidence often performed poorly, despite his or her knowledge, critical thinking ability, manual dexterity, and speaking ability. Others became frustrated, simply gave up trying, and dropped out. Positive thinking peers who studied and practiced skills seemed to like nursing more and achieve better outcomes. When working as a staff nurse, the author also noted confidence to be a factor influencing professional nursing practice, career satisfaction, and career advancement. Among clients, confidence levels were also seen as variables influencing outcomes. All of these observations were informal, yet they made an impression.
In subsequent observations as a nursing faculty member, the author found confidence to be an important component in nursing student achievement, persistence, retention, and success. Interest in enhancing nursing student achievement became a focused area of inquiry. Review of the literature in education and psychology revealed Bandura’s (17) social cognitive theory, with self-efficacy (the perceived confidence for learning or performing specific tasks or skills necessary to achieve a particular goal) as an underlying component of the theory. Self-efficacy is task- or domain-specific and has been correlated with academic achievement, persistence, retention, and success; hence, self-efficacy became a targeted variable for the author’s study within the context of nursing education.
During the author’s doctoral dissertation study concerning first semester nontraditional associate degree student achievement and retention, individual item review of perceived self-efficacy for 60 select nursing skills suggested that students were least confident about learning specific communications skills than they were about skills in other categories (30). Eight of the 10 communication items received responses ranking in the 30th percentile (least confident). More specifically, overall less confidence was reported for interviewing a client about “financial concerns,” “religious practices and beliefs,” and “ethnic food preferences.” These were the only items that dealt with cultural issues in terms of socioeconomic status (class), religion, and ethnicity.
Why were students least confident about communication? Why were students less confident about items related to cultural issues? How would students have responded to items that further delineated the various dimensions of culture? According to Bandura (17), individuals with low confidence are at greater risk for task avoidance and decreased commitment. If students are avoiding tasks or are less committed to tasks associated with culture, then how can cultural assessments, culture-specific nursing care, culturally congruent care, and cultural competence be achieved? Furthermore, cultural assessments must begin with effective transcultural communication, which requires awareness, sensitivity, knowledge, and skills. Of course, transcultural implies the bridging of significant differences in cultural communication styles, beliefs, or practices (31). If students are less confident about general communication skills, how will cultural assessments be performed (or will they be performed)? The obvious gaps and lowered confidence raised the important question, “What teaching interventions are needed to promote culturally congruent care?”
Interest in learning more about students’ self-efficacy perceptions concerning specific transcultural nursing skills necessary for developing cultural competence became the author’s new focused domain of inquiry. Specifically, the area of interest was to develop a composite of students’ needs, values, attitudes, and skills related to transcultural nursing care and the assessment of their changes (outcomes) over time. Assessing students’ needs, strengths, weaknesses, and perceptions would be the necessary precursor to the design of any teaching interventions. “Effective teaching and learning is further enhanced by frequent and ongoing evaluations of students and by adapting educational instruction based on outcome assessments” (32, p. 47). The author believed that the initial and ongoing assessment of students’ self-efficacy perceptions (confidence) concerning culture care of diverse individuals would be a valuable component in transcultural nursing education. Several preliminary studies were undertaken to explore, measure, and evaluate learners’ TSE perceptions (32–36). Subsequently, the author and other researchers embarked upon this directed focus (program) of research and contributed to the growing body of evidence concerning the model and associated questionnaires (see Appendix). (Chapter 4 discusses exploring, measuring, and evaluating learners through the use of the Transcultural Self-Efficacy Tool [TSET].) A description of the CCC model is presented in the following sections.
KEY TERMS
To develop a common knowledge base and avoid discrepancies in definitions, Exhibit 3.1 defines key terms important in understanding the CCC model.
EXHIBIT 3.1
Key Terms Associated With the Cultural Competence and Confidence (CCC) Model
Transcultural self-efficacy (TSE) is the perceived confidence for performing or learning transcultural nursing skills. It is the degree to which individuals perceive they have the ability to perform the specific transcultural nursing skills needed for culturally competent and congruent care. (A broad, conceptual definition applicable for all health professions defines TSE as the perceived confidence for performing or learning transcultural skills needed for culturally competent and congruent care within one’s professional discipline.)
Transcultural nursing skills are those skills necessary for assessing, planning, implementing, and evaluating culturally congruent care. Transcultural nursing skills include cognitive, practical, and affective dimensions.
Culturally congruent care is health care that is customized to fit with the client’s cultural values, beliefs, traditions, practices, and lifestyle. Clients may include individuals, families, groups, institutions, and organizations. According to Leininger,* culturally congruent nursing care refers to “those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are tailor-made to fit with an individual’s, group’s, or institution’s cultural values, beliefs, and life ways in order to provide meaningful, beneficial, and satisfying health care, or well-being services.”
Cultural competence is a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective), involves TSE (confidence) as a major influencing factor, and aims to achieve culturally congruent care. Cultural competence in nursing is a multidimensional learning process that integrates transcultural nursing skills in all three dimensions (cognitive, practical, and affective), involves TSE (confidence), and aims to achieve culturally congruent nursing care. The term learning process emphasizes that the cognitive, practical, and affective dimensions of TSE can change over time as a result of formalized education and other learning experiences.
The cognitive learning dimension is a learning dimension that focuses on knowledge outcomes, intellectual abilities, and skills. Within the context of transcultural learning, cognitive learning skills include knowledge and comprehension about ways in which cultural factors may influence professional nursing care among clients of different cultural backgrounds and throughout various phases of the life cycle. In this context, “different cultural backgrounds” refers to clients representing various different racial, ethnic, gender, socioeconomic, and religious groups and recognizes the diversity of diversity.
The practical learning dimension is similar to the psychomotor learning domain and focuses on motor skills or practical application of skills. Within the context of transcultural learning, practical learning skills refer to communication skills (verbal and nonverbal) needed to interview clients of different cultural backgrounds about their values and beliefs.
The affective learning dimension is a learning dimension concerned with attitudes, values, and beliefs and is considered to be the most important in developing professional values and attitudes. Affective learning includes self-awareness, awareness of cultural gap (differences), acceptance, appreciation, recognition, and advocacy.
Optimal cultural competence goes beyond competence (a minimum expectation) toward the pinnacle or peak performance goal. Optimal cultural competence embraces the diversity of diversity, requires ongoing active learning, fosters multicultural workplace harmony, facilitates cultural safety, and promotes the delivery of the highest level of culturally congruent patient care. Optimal cultural competence involves the ongoing quest to move from one’s starting point (in cultural competence development) toward the pinnacle. The seven steps essential for optimal cultural competence development are: (1) self-assessment, (2) active promotion, (3) systematic inquiry, (4) decisive action, (5) innovation, (6) measurement, and (7) evaluation.
*Leininger, M. M. (1991). Culture care diversity and universality: A theory of nursing. New York, NY: National League for Nursing, p. 49.
How can clear, consistent definitions help develop a common knowledge base and contribute to the advancement of the cultural competence literature and the nursing profession?
PURPOSE AND GOAL OF THE MODEL
The CCC model presents an organizing framework for examining the multidimensional factors involved in the process of learning cultural competence in order to identify at-risk individuals, develop diagnostic-prescriptive strategies to facilitate learning, guide innovations in teaching and educational research, and evaluate strategy effectiveness. The main goal of the model is to promote culturally congruent care through the development of cultural competence. Cultural competence is influenced by TSE, the learning of transcultural nursing skills (cognitive, practical, and affective), formalized educational experiences, and other learning experiences. Although several models have been proposed to describe the process of cultural competence (19, 37) or the process of achieving culturally congruent care through the assessment of cultural diversity and universality (12, 38), the CCC model focuses specifically on learning as influenced by TSE. Hence, TSE was proposed in 1994 as a new construct vital to the process of cultural competence and culturally congruent care (39).
As with most theoretical models that strive to make abstractions immediately relevant, useful, and purposeful in a practice discipline, the CCC model was proposed as tentative, and as requiring modification when new data became available. Subsequently, researchers around the world who applied the model and its corresponding questionnaire (TSET) according to the recommended specifications (e.g., scoring, data collection, etc.) have continued to substantiate many of the testable underlying assumptions originally proposed (see Appendix). In addition, more sophisticated statistical techniques previously not available have expanded the possibilities to substantiate the model and support the excellent psychometric properties of the TSET. Feedback from researchers and educators using the model indicates that they selected and implemented the model for one, several, or all of the proposed purposes, goal, and uses of the model, noting its ease and benefits in providing a comprehensive framework.
