In a 2006 editorial, Josepha Campinha-Bacote wrote, “In 1986, the American Nurses Association issued its first guidelines on cultural diversity in nursing curricula. Since then, there has been ongoing discussion as to what is the theoretical underpinning of cultural training within nurse education, and 20 years later, nurse educators continue to ask, ‘How do we effectively teach cultural competence in nursing education?’” (p. 243).
These same challenges presented themselves when the need arose to revise a graduate-level course on culture, diversity, and cultural competence in a school of nursing in the midwestern United States. Several questions were asked, including: What would be an applicable theoretical underpinning for cultural education, and what would be its effectiveness in changing cultural competence levels of students?
The theoretical approach for the development of the course was strongly influenced by characteristics of the student population who would be required to take it. Students came from a variety of communities ranging from small rural towns to large metropolitan cities. In addition, students’ extent of travel within and outside the United States and their exposure to diverse versus homogenous populations also varied widely. Students were both domestic and foreign-born; most students were Caucasian of European descent, but the nursing school population also included students of African, Hispanic, and Asian descent. These student groups would bring multiple sociocultural backgrounds, life experiences, values, and perceptions to the course. How could this mix of students most effectively learn? Constructivist learning theory was an appropriate conceptual framework for the course as it acknowledges multiple, socially constructed truths, perspectives, and realities versus a single reality (Guba & Lincoln, 1994). The constructivist learning conceptual framework fittingly undergirded a course structure based on the Process of Cultural Competence in the Delivery of Healthcare Services, a model developed by Campinha-Bacote (2003).
At the time of the class revision, distance education for nurses was growing at a phenomenal rate (American Association of Colleges of Nursing, 1999); thus, the class was to be taught in both online and classroom formats. The development, implementation, and evaluation of these courses presented an opportunity to systematically address the impact of course design, theory, and delivery system on learner outcomes. This article reports the findings of precourse and postcourse assessments of the multiple constructs of cultural competence, as delineated within the Process of Cultural Competence in the Delivery of Healthcare Services model (Campinha-Bacote, 2003). A detailed discussion of the theory, structure, content, and activities within the course has been published previously (Hunter, 2008) and is available as a resource for cultural competence education in other settings.
Constructivist learning theory is situated within a larger constructivist epistemology, or way of knowing, that acknowledges multiple, socially constructed truths, perspectives, and realities versus a single reality (Guba & Lincoln, 1994). Constructivism assumes that meaning and values can differ for different individuals. Its methodology is interpretive, and it involves a constant comparison of differing interpretations. Developing an awareness of differing interpretations among the participants in health care is an essential part of professional cultural competence in a country with an increasingly diversified population.
Constructivist learning theory emerged from the field of education and draws on the developmental theories of Kelly (1991) and Piaget (1977). It suggests that learners make sense of new information by building up what they already know from previous life experiences (Brooks, 1984; Bulman, 2005). Constructivist education, therefore, seeks to capitalize on learners’ previous experiences, multiple perspectives, and opportunities to embed learning in relevant social context (Ernest, 1995; Honebein, 1996; Jonassen, 1991, 1994; Jonassen, Davidson, Collins, Campbell, & Haag, 1995). Learners explore old and new ideas through collaborative discourse and reflection, and construct new meanings through conversation with each other and with the teacher. The process of reconciling differences, negotiating meaning, and continually restructuring thinking is a basic tenet of constructivism (Brooks & Brooks, 1993; Ubbes, Black, & Ausherman, 1999).
Constructivism has been applied in various disciplines, including counseling (Peterson & Benishek, 2001), music therapy (O’Callaghan & McDermott, 2004), health education (Bulman, 2005), health promotion (Labonte & Robertson, 1996; Lattuca, 2006; Lewis, 1996; Lincoln, 1992), grief and bereavement (Gillies & Neimeyer, 2006; Walter, 2005–2006), and social work (Bellefeuille, 2006). Although a case continues to be made for the use of constructivism in nursing education, it has not become a prominent framework in the discipline (Engebretson & Littleton, 2001; Legg, Adelman, Mueller, & Levitt, 2009; Peters, 2000). Exceptions include constructivist epistemology in qualitative research and constructivist learning theory applied to online, active, and self-directed learning in nursing education (Ali, Hodson-Carlton, & Ryan, 2004; Carnwell, 2000; Thurmond, 2002).
The course consisted of units based on four of Campinha-Bacote’s (2003) five constructs:
- Cultural awareness.
- Cultural knowledge.
- Cultural skill.
- Cultural encounters.
Each unit included an introduction, related readings, an assignment, and discussion questions. Assignments, both experiential and cognitive, were aimed at building incremental and interactive bridges between students’ existing knowledge and new information and at leading students toward improved cultural competence levels. Discussions capitalizing on the diversity among the students themselves provided the students with opportunities to defend their views, explore old and new ideas through collaborative discourse and reflection, restructure their thinking, and negotiate and co-construct new understandings and meanings.
The first unit, Cultural Awareness, emphasized building the basic awareness that all individuals (including themselves) are cultural beings. By writing their own cultural autobiography, students were prompted to explore the cultural construction of their values and normal behaviors and to reflect on how others’ values and normal behaviors developed similarly.
The second unit, Cultural Knowledge, included readings concerning different cultures, specific biological variations among ethnic groups, various nursing theorists’ approaches to studying culture, and approaches to cultural assessment. Students were asked to pay close attention to the various approaches to cultural assessment in the readings and then to design their own cultural assessment tool. Although cognitive knowledge about group aspects of a culture was taught as a starting point, communication and asking the right questions was taught as the key to understanding both the group and individual influences that shape a person’s culture.
In the third unit, Cultural Skill, students used the assessment tools they had created to interview an individual from a culture they perceived as being different from their own. Following the assessment interview, students were asked to evaluate both the tool and their own interview skill level (Campinha-Bacote, 1995).
In the fourth unit, Cultural Encounters, students engaged in several cultural activities of their own choosing. This was believed to be the best way to deepen exposure to diversity within cultural groups, to prevent stereotyping, and to continually increase cultural sensitivity in students’ lives and cultural competence in their profession.
The decision to omit a learning unit on Campinha-Bacote’s fifth construct, cultural desire, was influenced by the authors’ belief that desire was not so much something that could be taught as something that would be acquired through gaining more comfort and efficacy with the other four constructs. This assumption and more recent literature on teaching cultural desire are addressed in the discussion.
This research measured the impact of this graduate-level course, taught in both online and classroom formats, on the cultural competence levels of students. The following questions guided the conduct of the research:
- Did the educational experience affect change in students’ measured cultural competence scores using the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals Revised (IAPCC-R) (Campinha-Bacote, 2003)?
- Did any change result in significant upward movement in levels of cultural competence using the nominal categories of cultural incompetence, cultural awareness, cultural competence, and cultural proficiency (Campinha-Bacote, 2003)?
- Did the medium of instructional intervention (online or classroom) influence cultural competence outcomes?
The research questions were addressed using a quasi-experimental, pretest-posttest control group design (Shadish, Cook, & Campbell, 2002). Students enrolled in the course, which was offered in two consecutive semesters, participated in either online or classroom educational formats. To control for the effect of preexisting knowledge and attitude, a pretest was used to determine the equivalence of the groups in the area of cultural competence. No significant differences existed between groups at the administration of the pretest.
After completion of the course offering, a posttest was administered to all students using the same instrument. Posttest scores were compared to pretest scores as a measure of the change in cultural competence levels of students after completing the course. Continuous scores on the pretest and posttest were converted to the nominal categories termed as cultural incompetence, cultural awareness, cultural competence, and cultural proficiency (Campinha-Bacote, 2003) to facilitate clarity of effects. In addition, posttest scores for the two groups were compared as an estimate of the effect of instructional medium on outcome.
The dependent variable, cultural competence, was measured using the IAPCC-R (Campinha-Bacote, 2003). The IAPCC-R consists of 25 items measuring five constructs of cultural competence as well as quantifying total cultural competence. The five constructs, operationalized as subscales of the full instrument, include cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. Scores can be converted into nominal categories, providing an indication of the overall cultural competence level at which the health care professional is operating, as well as a level for each construct. These categories are termed (from lowest to highest) as cultural incompetence, cultural awareness, cultural competence, and cultural proficiency (Campinha-Bacote, 2003).
The tool has been assessed for validity and reliability in previous independent investigations. The reliability estimates, based on Cronbach’s alpha, have been reported as being between 0.77 and 0.87. The content validity of the tool has been supported by reviews of national experts in the field of transcultural health care in three separate national investigations (Brathwaite, 2005; Campinha-Bacote, 1999; Kattner, 2006).
Beyond its psychometric advantages, the IAPCC-R was chosen as a sole quantitative outcome measure for several reasons. First, the subscales included within the IAPCC-R provide a broad concept of cultural competence, inclusive of multiples constructs, and make the use of one instrument tantamount to using multiples scales. Second, the constructs within the research instrument were congruent with the theoretical framework of the course. Third, because these constructs became familiar to the students, they were able to meaningfully interpret changes between their pretest and posttest scores. Finally, the tool required minimal time for students to complete, increasing the internal validity of the findings (Shadish et al., 2002).
Data Collection and Analysis
At the beginning of each of the two courses, students were asked to complete a precourse assessment on their level of cultural competency. Students in both classes were given identical instructions, and it was emphasized that the assessment would have no effect on their grades. Online students completed the assessment online, and classroom students completed a written assessment in class. Students were informed there also would be a postcourse assessment at the end of the class so they could see how the course impacted their level of cultural competence. Students were told the tool was developed by Dr. Josepha Campinha-Bacote, who had published a great deal on cultural competence and who had given permission for the tool to be used in the classes. For the postcourse assessment, classroom students were given access to computers during the last class period; therefore, all students completed the postcourse assessment online. All students submitted both precourse and postcourse assessments; however, only 48 of 52 assessment pairs in the online course and 21 of 24 in the classroom course were complete. Only complete pairs were included in the data analysis. At the end of the course, students were given their scores and nominal interpretation. Otherwise, only the authors had access to the scores.
The research questions were answered using inferential procedures contained within Statistical Package for Social Sciences version 14.0 (SPSS Inc., Chicago, IL). The first question regarding change in cultural competency scores was answered using a one-sample t test to determine the amount of change in raw scores from pretest to posttest. To answer the second question regarding change in nominal categories of cultural competence, raw scores were converted to the nominal categories of culturally incompetent, culturally aware, culturally competent, and culturally proficient using criteria provided by Campinha-Bacote (2003). Chi-squared analysis of the nominal change was calculated from pretest to posttest for all students. The third question regarding influence of instructional medium was assessed by comparing the performance of learners in the online and classroom sections using independent sample t tests for the interval level raw scores and using chi-squared tests for comparison of the nominal categories suggested by Campinha-Bacote (2003).
The course was implemented in consecutive summer and fall semesters. The summer semester students enrolled in the online version of the course, and the students in the fall semester participated in a live, classroom experience. A total of 76 students were enrolled in the courses, with 52 students in the summer course and 24 students in the fall course. The students were enrolled in master’s level tracks for adult, family, pediatric, neonatal, or women’s health nurse practitioners, nurse educators, or nurse administrators at an urban, state-supported university in the midwestern United States. The online course included distance students, whereas participants in the classroom experience lived relatively close to the urban university campus.
Significant changes (p < 0.001) were found in cultural competence scores from pretest to posttest for all learners in both courses when competence was measured on an interval scale. When the nominal categories (Campinha-Bacote, 2003) were used for pretest-posttest analysis, significant differences emerged for cultural knowledge, cultural skill, cultural desire, and overall cultural competence. Nominal category changes were not significant in the areas of cultural awareness and cultural encounters, a finding that was not consistent with our expectations. These results are presented in more detail in Tables 1 and 2. There were no statistically significant differences in the performance of students taking the online versus classroom course.
Table 1: Pretest and Posttest Cultural Competence Scores
Table 2: Pretest and Posttest Cultural Competence Categories
The findings of this study demonstrate that an educational experience, based in constructivist pedagogy, can positively influence the cultural competence levels of learners, whether the course is delivered in a traditional classroom or through an online medium. The effectiveness of constructivism applied to teaching cultural competence will be addressed first. This is the first evaluation reported in the literature of constructivist learning theory applied to cultural competence education in nursing. Statistical analysis of raw scores showed a significant improvement from pretest to posttest (p < 0.001) in all areas: overall cultural competence and subscores of cultural awareness, knowledge, skill, encounters, and desire. When the same data were examined in terms of Campinha-Bacote’s (2003) nominal categories, significant change occurred in the areas of cultural knowledge, skill, desire, and overall cultural competence levels.
Unexpectedly, there was less compelling evidence of change related to cultural awareness and cultural encounters. However, this is consistent with behavioral change theory, which suggests that change is a process and not an event and that self-efficacy is an element that is important for change (Bandura, 1977; DiClemente, Prochaska, & Gilbertini, 1985; Prochaska & DiClemente, 1983; Prochaska, DiClemente, Velicer, & Rossi, 1993). For a number of students, direct encounters with different cultural groups had begun only through class activities. The strongest mediator of self-efficacy, according to Bandura’s (1977) theory, is awareness of one’s previous experiences and what may have caused the experiences to be positive or negative. Thus, one’s awareness and experiences are linked within the concept of self-efficacy, which is the confidence to confront new situations. These results also may be an artifact of the psychometric properties of the tool. Although there were 25 questions assessing the overall competence level, there were only 5 questions addressing each of the subscales. It is possible that these 5 questions were not sensitive enough to pick up significant change in all categories.
Another factor that may have affected the awareness scores is the IAPCC-R cultural awareness questions are written in “othering” terms (i.e., awareness of assessment tools for others, specific diseases among others, others’ barriers to health care, and stereotypical feelings toward others), whereas the course unit on cultural awareness focused predominantly on increasing students’ awareness of themselves as cultural beings and the cultural construction of their own values. This discrepancy between the focus of measurement and the focus of course content could have negatively impacted the change in pretest and post-test scores.
A second unexpected finding was that the most significant change between pretest and posttest continuous scores was in the area of cultural desire, the construct that was not directly “taught.” Campinha-Bacote (2003, 2008) asserts the construct of desire to attain cultural competence precedes and underlies one’s nonlinear movement through cultural awareness, cultural knowledge, and cultural skill. We diverge from the Campinha-Bacote model on this point, proposing that cultural desire can be a product, versus a precursor, of growth in any of the five constructs and that improvement in any one construct will drive improvements in others. In our experience, it has been observed that although nurses and nursing students feel an ethical obligation to provide good care to all patients, this era of mandated cultural competence education has negatively impacted “genuine and authentic desire” (2003, p. 12) to learn about culture, and that many students come to courses such as this one with little desire to be there (Hunter, 2008).
This observed lack of desire also could be attributed in part to frustration with the predominant strategies of teaching cultures as monolithic, bounded entities, versus a more transformative style of cultural education relevant to today’s global world (Duffy, 2001). We believe this course was successful in significantly increasing cultural desire both because of its constructivist approach and because of the underlying postmodern, transformative philosophy driving the content of the course itself. This content has been detailed previously (Hunter, 2008). However, regardless of whether cultural desire is taught or “caught” through effective education and experiences, that desire should continue to drive the process toward cultural competence.
This research also supports that the shared tenet between constructivist learning theory and Campinha-Bacote’s framework, that new learning is built on the learners’ existing knowledge and experiences, makes the two compatible conceptual partners for guiding the structure and activities within an educational experience on culture, diversity, and cultural competence. Constructivism suggests that truth is independently constructed in a learning context by the learners, in contrast to a positivist theoretical framework, which suggests that truth is universal or absolute. Thus, in constructivist learning theory, the view is that learners bring their personal experiences to the learning situation and that these experiences form the foundation of the truth the learners carry away from the instruction. Campinha-Bacote (2003) suggests the movement from cultural incompetence to cultural proficiency begins with background experiences of an individual, particularly encounters with cultures different from one’s own, and proceeds in a nonlinear fashion through cultural awareness, cultural knowledge, and cultural skill. If improved self-efficacy in cultural knowledge and skills promotes behavior change, and if, as Campinha-Bacote (2003) suggests, further growth toward a culturally proficient practice is driven by cultural desire, then it would be expected that all areas of cultural competence would continue to increase over time for these students.
Available standardized measures of cultural competence have been a methodological challenge for this line of research. Doorenbos, Schim, Benkert, and Borse (2005) found that of available tools, only the IAPCC (even prior to its 2003 revision) and their own Cultural Competence Assessment (CCA) instrument measure a broad concept of cultural competence, inclusive of several constructs, and are based on an existing cultural competence model. Although both of these tools are self-assessments completed by the learner, the CCA seeks to evaluate more actual practice behaviors than the IAPCC-R. Considering the probable time involved in behavior change toward cultural competence, the most meaningful outcome evaluation would be a later, posteducational evaluation of behaviors used in practice that are indicative of culturally attuned nursing.
Findings in this research indicated both the online and classroom formats were equally effective. There was no statistically significant difference in changes in scores between online and classroom students, although there was a statistical trend in favor of the learners in the online group. This finding joins a burgeoning literature that provides overwhelming evidence that learning and student satisfaction in an online environment can be as effective, and sometimes more so, than in traditional classrooms (Aragon, Johnson, & Shaik, 2002; Bata-Jones & Avery, 2004; Bello et al., 2005; Brown & Kulikowich, 2004; Buckley, 2003; Caywood & Duckett, 2003; Leasure, Davis, & Thievon, 2000; Neuhauser, 2002; Poirier & Feldman, 2004; Soon, Sook, Jung, & Im, 2000; Tallent-Runnels et al., 2006). There are fewer studies like ours, however, that compare online with traditional classroom settings in terms of teaching and learning, learning outcomes, and application of theory related to online learning, and to our knowledge, the first evaluation in the literature of constructivist learning theory applied to cultural competence education in nursing (Ali et al., 2004; Thurmond, 2002).
Tallent-Runnels et al. (2006) noted current research directions have “shifted focus from simply investigating the effect of different delivery systems to a more sophisticated investigation of the synergistic relationships among the learners, the design of instruction, and the constraints of the delivery system” (p. 112). Studies have shown that required discussion, an element of anonymity (i.e., being unseen), and having time to prepare a written response before posting have contributed to the effectiveness of online discussions (Ali et al., 2004; Althaus, 1997; Cartwright, 2000), in contrast to interaction in the classroom, which is limited to those who choose, or have time, to communicate. Following the premise postulated by McIsaac, Blocher, Mahes, and Vrasidas (1999) that interaction is the single most important activity in an educational experience, other researchers have explored various levels of depth of discussion necessary to allow for construction and co-construction, and thus learning of new ideas (Christopher, Thomas, & Tallent-Runnels, 2004; Kanuka & Anderson, 1998; Thomas, 2002). Overall, research findings regarding online learning are emphasizing that students learn more and engage in higher levels of thinking and interacting in well-designed courses, based on sound educational theory, with instructor-guided participation, instructor presence in the discussions, and a meaningfully scaffolded learning process (Tallent-Runnels et al., 2006).
Implications for Education and Research
The findings of this study suggest important implications for education and research. The expected outcome of enhanced cultural competence supports the effectiveness of constructivism as a conceptual platform for the teaching of cultural competence and underscores the compatibility of constructivist learning theory and the Process of Cultural Competence in the Delivery of Healthcare Services model developed by Campinha-Bacote (2003). The lack of differential effects of the curriculum across different media provides support for the ability of well-structured online education to promote learning with high levels of success and learner satisfaction.
The findings, however, bring into question the assertion that cultural desire is a precursor to movement toward cultural competence (Campinha-Bacote, 2003). In fact, the findings suggest cultural desire may just as well be a consequence of enhanced knowledge, skills, and cultural encounters, as a necessary precursor to them. This suggestion warrants further investigation.
Although more research is needed, this study indicates nursing educators can have increasingly more confidence in the potential effectiveness of online learning and the power of online discussions to promote effective discourse that may be equal to or better than that in classroom settings. The study also contributes to evidence that the best student learning is achieved in online educational experiences that are well designed and well supported by learning theory, and that have instructor guidance and active participation in discussions.
A need remains for further development and testing of measures of cultural competence as demonstrated within nursing practice. The CCA instrument developed by Doorenbos et al. (2005) shows promise for this application. Further study with the same two cohorts of individuals who took the courses described in this article is planned to evaluate cultural competence and related clinical behaviors used in their advanced practice 4 to 5 years after completing the course. The IAPCC-R, the CCA, and narrative interview will be used in this future study.
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Pretest and Posttest Cultural Competence Scores
|Variable||Pretest Score||Posttest Score||t||df||p|
|Cultural awareness||74.5||86.7||66.959||68||< 0.001|
|Cultural knowledge||55.1||72.4||43.915||68||< 0.001|
|Cultural skill||61.2||83.8||56.451||68||< 0.001|
|Cultural encounters||65.2||79.5||66.070||68||< 0.001|
|Cultural desire||83.2||92.0||67.161||68||< 0.001|
|Overall cultural competence||68.2||82.8||83.694||68||< 0.001|
Pretest and Posttest Cultural Competence Categories
|Variable/Category||Pretest n||Posttest n||χ2||p|
|Cultural competence total|
| Proficient||18||40||23.680||< 0.001|