It is estimated that by 2050, immigrants arriving in the United States will account for 82% of the population increase. Approximately one in five Americans will be an immigrant, compared with one in eight in 2005 (Passel & D'Vera, 2008). The latest U.S. Census report (2012) indicates that while non-Hispanic Whites remain numerically and proportionately the majority, Asians and Hispanics will more than double by 2060. These changing demographics necessitate the incorporation of cultural competence in the nursing curricula. It is vital that health care providers develop a deeper understanding of cultural diversity as it relates to health care and communication with patients of diverse backgrounds.
The Institute of medicine (IOM), the American Association of Colleges of Nursing (AACN), and the Agency for Healthcare Research and Quality (AHRQ) have all focused attention on increasing patient diversity and resultant health disparities (AACN, 2008; AHRQ, 2015; Smedley, Stith, & Nelson, 2003). Despite decades of literature documenting the impact of the steady increase in patient diversity and possible solutions to bridge the communication divide for the provision of equitable care, challenges to overcome barriers still exist.
Understanding the unique manifestations of different cultures and how they impact an individual's health-related practices is meaningless if this cannot be applied in practice. Innovative ways of teaching cultural competence are needed. Simulation offers a platform to expose students to the care of patients of diverse backgrounds and to develop cultural sensitivity and awareness while practicing in a safe learning environment.
Perspectives on Diversity, Cultural Competence, and Communication
Understanding diversity and cultural competence is vital, not only for effective care of patients in the United States but also because of the increasing globalization of nursing. An understanding of the concept of diversity and how it shapes nursing is critical in considering the need to increase diversity in the nursing workforce, nursing education, research, and public policy leadership (de Leon Siantz, 2008).
Diversity has a variety of meanings and is a reflection of what one considers other. Anthropologists have long been concerned with the concept of other and interested in understanding the similarities and differences between others and us (Devita & Armstrong, 2002). How individuals identify themselves is rooted in their culture, as well as lived experiences. This self-awareness is the first step toward cultural competence.
Culture is defined by Leininger (1991) as “learned, shared and transmitted values, beliefs, norms, and lifeways of a particular group that guides their thinking, decisions, and actions in patterned ways” (p. 47). That definition, although not unreasonable, does not account for the complexities of the 21st century. Gregg and Saha (2006) shared an interesting perspective that the technological connectedness and crossover of cultures adds to the complexity of cultural competence.
Interactions among providers, health care systems, and patients are influenced by lived experience. An individual patient's characteristics, values, preferences, and cultural beliefs, as well as perceptions and level of trust, influence this interaction. The health care provider's own set of values, biases, philosophy of care, and workload and time constraints, as well as the accessibility of cultural and linguistic support services available to patients, all play a role in the effectiveness of the therapeutic relationship (Street, Gordon, & Haidet, 2007).
Cultural differences between East and West are well documented. The communication style in Western countries is categorized as being “low context,” which refers to being direct and explicit, as opposed to “high context,” which is observed in Eastern cultures, and refers to implicit and indirect ways of communication (Xu, Lippold, Gilligan, Posey-Goodwin, & Broome, 2004). These differences influence one's sense of self, both as an individual and as a member of a team. For health care teams to function effectively to provide culturally competent care, team members must find common ground. This shared mental model is critical.
Although the necessity of a shared mental model is clear, it is difficult to know how one might respond to situations that challenge the way we learn, communicate, and work with one another. Simulation challenges the learner to see beyond his or her own values, cultural ideals, and lived experience (Jeffries, 2014). During interactions in the simulated environment and debriefing, students are encouraged to reflect on their own values, recognize those of others, and identify ways to work as a team for achieving a shared goal. Communication is at the core of patient-centered care, which entails mutual understanding, shared decision-making, and support of the patient in meeting his or her needs.
Various reports have noted that cultural competence leads to more access to care for those who, by virtue of their ethnicity, socioeconomic status, gender, age, sexual orientation, or disability, have been marginalized (AACN, 2008; AHRQ, 2015; Smedley et al., 2003). The miscommunication resulting from language barriers and lack of awareness of cultural nuances influences a provider's ability to understand patients' needs, challenges, and health beliefs. (AHRQ, 2015).
In developing a graduate course in cultural competence and diversity, Hunter (2008) described a deliberate process of starting by cultural awareness and allowing the learners to reflect on their own values and beliefs. Building on Campinha-Bacote's constructs (cultural awareness, cultural knowledge, cultural encounter, cultural skills, and cultural desire), and constructivist theory, this course was meticulously designed, implemented, and evaluated favorably by learners (as cited in Hunter, 2008).
Many studies from nursing and allied health professionals describe the use of live discussions, case studies, e-learning strategies, journaling, video-recorded vignettes, and simulation in different capacities (Donkers, Bednarek, Downey, & Ennulat, 2015; Gallager & Polanin, 2014; Hawala-Druy & Hill, 2012; Rutledge et al., 2008; West, Cusser, Etengoff, Landsgaard, & LaBond, 2014). One study developed simulation scenarios by garnering information from patients of diverse background. A combination of virtual patient experiences and high-fidelity human simulation was used to familiarize students with the nuances of communicating and caring for those from other cultures (Rutledge et al., 2008).
Cultural competence is particularly relevant to nursing, given the amount of time nurses spend with patients. Provision of culturally competent care is fundamental to patient-centered care. Therefore, since the mid-1980s, national nursing organizations have developed standards and recommended strategies to incorporate cultural competence in nursing curricula. Funding provided by the Nurse Reinvestment Act of 2002 was dedicated to nursing inclusion of cultural competence in education (AACN, 2008).
Despite the saturation of literature with information regarding cultural competence and its association with health disparities and quality of care, the literature is scarce regarding the use of simulation specifically to develop therapeutic communication skills with patients from diverse backgrounds. Cultural competence can be developed by repeated exposure to and engagement with diverse patients in the simulated setting. It is not merely learning how to act toward a person from a different background, but rather understanding their values and meeting their unique needs (Hawala-Dury & Hill, 2012).
Inclusive Curriculum: Recommendations for Integration in Nursing Education
Challenges to teaching cultural competence in nursing curricula include the sensitivity of the topics, stereotypes, biases, standard instructional techniques (lecture, assignments), and possible lack of faculty awareness of how to teach cultural diversity. It is critical to appreciate the social context and lived experiences of diverse patients, as well as to remain sensitive to the learners' experiences (Gregg & Saha, 2006; Hunter, 2008).
Teaching cultural competence in the classroom, without facilitating the application of this knowledge, may provide new information to the learner but may not increase their confidence in their ability to provide culturally informed care to their patients. The simulated environment promotes active learning and reflection. It also provides an opportunity to observe student encounters with different populations of patients in a controlled environment to further their understanding of the unique challenges of these patients (Jeffries, 2005; Ndiwane, Koul, & Theroux, 2014).
High-fidelity simulation using standardized patients (SPs) to play the role of patients with certain health conditions or cultural backgrounds is common in nursing and medical education. The use of SPs as part of a teaching strategy can improve students' assessment skills and provide realism of the clinical setting (Hawala-Dury & Hill, 2012; Ndiwane et al., 2014; Rutledge et al., 2008). Often, SPs evaluate the learner and provide real-time objective feedback on the interaction (Ndiwane & Theroux, 2014).
Beginning the Conversation About Cultural Competence
Recognizing the need to expose students to diversity and cultural competence throughout the curriculum, the authors initiated classroom conversations about these topics during the first semester, which focused on patient-centered care. Due to the use of a facilitator-led group discussion versus a traditional classroom lecture, students were offered the opportunity to share their opinions on diversity and cultural competence. Following this dialogue, a panel of health care team members shared their perspectives on culturally informed care for diverse patients. These panelists—a hospital chaplain, a nurse caring for the homeless, and a nurse practitioner working with lesbian, gay, bisexual, and transgender (LGBT) patients in a specialty clinic—were selected based on their diverse backgrounds and expertise.
The initial conversation about diversity centered on cultural awareness. Students were asked to share their personal views on diversity. Cultural knowledge was gained by exposure to experts caring for a diverse group of patients. Simulated encounters were designed to focus on strengthening culturally competent communication skills.
Weaving Cultural Competence Throughout the Curriculum via Simulation
Over the course of the nursing curriculum, students are exposed to the simulated environment in seven clinical courses: Foundations, Medical–Surgical Nursing, Mental Health Nursing, Obstetrics, Pediatrics, Advanced Medical–Surgical Nursing, and Public Health Nursing. Parallel or congruent with clinical placements and populations in the clinical setting, the authors used the simulation environment to thread diverse patients and topics above and beyond race and ethnic differences.
Threaded themes throughout the simulation curriculum included working with non-English–speaking patients; substance abuse; elder abuse; religious, faith-based diversity; sexual identity issues; poverty; LGBT; victims of gang-related behavior; disability; mental illness; intimate partner violence; military families; and the homeless. The following are some examples of how the pedagogy of simulation was used to make students reflect on their own biases, lived experiences, and stereotypes:
- Intimate partner violence: A pregnant partner in a lesbian relationship was suspected of being physically abused by her partner. This allowed the students to see beyond the stereotype of a man being an aggressor.
- Bullying: An adolescent struggling with his sexual identity was being bullied at school.
- Young inner-city gunshot wound victim: exposure to community violence.
Student Gains From These Experiences
Standardized learning experiences with particular populations can be facilitated in a simulated environment using trained actors. This standard approach to patient scenarios, structured debriefing, and the use of narrative pedagogy help to explore and uncover biases and stigmas and increase cultural awareness and empathy. The learning that occurs in this setting can then be translated to the clinical setting.
The recently released National Council of State Boards of Nursing results of a multisite, longitudinal, randomized control trial of varying percentages of simulation found that simulation can be substituted for up to 50% of traditional clinical experiences. These findings highlight the effectiveness of simulation as a reliable teaching–learning method (Hayden et al., 2014).
Traditionally, clinical practice settings provide opportunities for students to care for patients directly: however, encounters with patients of diverse backgrounds is not ensured. The simulation environment can guarantee encounters with diverse patients and provides a realistic experience. The use of trained standardized actors to portray the patient provides students with the opportunity to respond to verbal and nonverbal patient cues. A debriefing session, led by a trained facilitator, follows the patient interaction and engages the students in active discussion. Debriefing is a crucial element of simulation experience because it guides the students through the learning experience with reflective learning, allowing them to blend theory with practice. It is an opportunity to uncover assumptions and enhance reasoning and thinking beyond actions just performed during the simulation (Dreifuerst, 2012). Through the debriefing process, the students are encouraged to explore their own biases and how they might influence patient care. This deep understanding of culturally informed care can be achieved in the more intimate simulation setting, rather than large lecture halls.