Cultural Competence AmongHospice NursesStephanie Myers Schinn, PhD, RNArdith Z. Doorenbos, PhD, RNNagesh N. Borse, BPharnn, MS

• The purpose of this study was to examinevariables associated with cultural competenceamong hospice nurses. In a cross-sectionaldescriptive design, a convenience sample of107 hospice nurses from five different hospiceagencies completed a survey that included theCultural Competence Assessment instrument.Regression analysis revealed a significantassociation between higher education andcultural awareness and sensitivity, as well asan association between diversity training andself-reported cultural competence behaviors.Findings support the need for additionaleducation and training for hospice nurses andprovision of more resources targeted towardenhancing cultural competency.

K E Y W O R D S

cultural competencehospicenurses

Increasing cultural diversity and an aging populationin the US expand the need for culturally competenthospice and end-of-life (EOL) care. Demographic

and cultural changes challenge hospice nurses tomanage complex differences in communication styles,attitudes, expectations, and world views, as well asmultiple languages.^ Beyond traditional considerationsof racial and ethnic differences, issues of culturallycompetent care for people of different socioeconomicclasses, genders, or sexual orientations have becomeequally important.'^ The provision of culturally compe-tent care is essential in today's hospice and palliative careenvironments. Professional nurses, in addition to beingthe major providers of hospice services, can also provide

I

Stephanie Myers Schim, PhD, RN, is an AssociateProfessor in Family, Community, and Mental HealthNursing at Wayne State University, Detroit, Ml.

Ardith Z. Doorenhos, PhD, RN, is an AssistantProfessor in the School of Nursing at University ofWashington, Seattle, WA.

Nagesh N. Borse, BPharm, MS, is a student at theBloomberg School of Public Health, Johns HofjkinsUniversity, Baltimore, MD.

Address correspondence to Stephanie MyersSchim, PhD, RN, College of Nursing, Wayne StateUniversity, 240 Cohn Building, Detroit, MI 48202(e-mail: s.schim@wayne.edu).

The authors have no conflict of interest.

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leadership in enhancing culturally congruent care withdiverse populations. The purpose of this study was toexamine variables associated with cultural competenceamong hospice nurses.

Culturally congruent nursing care occurs when nursesand clients come together with an attitude of culturalhumility and respect. Hospice nurses can then negotiatemutually satisfactory strategies to achieve a "dignifieddeath," as defined by the individual and family need-ing care. In order for culturally congruent care to oc-cur, nurses need to have a knowledge base, attitudinalframework, and skill set that enable them to engagewith others in adaptive ways. Nurses need to appreciate,accommodate, and negotiate cultural and individual vari-ation in beliefs, values, lifestyles, education, and myriadother elements that cultural context comprises.

In a 2004 report from the National Hospice andPalliative Care Organization (NHPCO), 77% of hos-pice patients were identified as Caucasian/white, 8%as black/African American, 6% as Hispanic/Latino,2% as Asian/Pacific Islander, and 6% as multiracial.^Although more Hispanic/Latino and multiracialpatients and their families were served by hospice in2004, there continues to be a great gap between theethnic distribution in the US and those being served byhospice. Better understanding of factors related tocultural competence among hospice nurses suggests di-rections for future enhancement of practice, education,and research.

Three-Dimensional Puzzle Model of CulturallyCongruent Care

One conceptual model has been described using theanalogy of a three-dimensional (3-D) jigsaw puzzle,with pieces representing provider elements.'* Culturalcompetence is the demonstration of knowledge, at-titudes, and behaviors based on diverse, relevant, cul-tural experiences. It is not expected that healthcareproviders achieve complete cultural competence, butrather that they continue to strive to match theircompetencies to the specific populations, subgroups,and individuals with whom they work.

Cultural diversity is a fact. In the US nonwhitegroups and those of Hispanic or Latino heritagecontinue to grow. As of the last census, the AfricanAmerican/black population was 34 million or 12.3%,people of Asian descent accounted for roughly 2.5million or 3.6%, and 12.5% ofthe population reportedbeing of Hispanic or Latino origin regardless of racial

background.^ Additionally, in the US there is a grow-ing awareness of the impact of differences in lan-guage, religion, gender, sexual orientation, ability anddisability, and access to technology on provider-patientinteractions.' Even when a nurse and a client share thesame ethnic or racial heritage, other aspects of diversitystill remain to be addressed.

Cultural awareness is a knowledge phenomenon.Awareness of both intergroup and intragroup variationin lifestyles, values, beliefs, and practices is essential toassessment, planning, and intervention. Knowledge ofall groups and individuals is not possible; however,knowledge of patterns of differences and ways tounderstand specific individual and group variation isnot only possible but critical.

Cultural sensitivity involves the recognition of per-sonal attitudes, values, beliefs, and practices. Nursingcommunication skills reflect sensitivity and require thewillingness to develop and use listening skills. Nonverbalcommunication (body language), careful use of silenceand touch, respect for conversational distance, and use oflanguage patterns in an attuned manner also characterizesculturally sensitive nursing.

Cultural competence is the incorporation of personalcultural diversity experience (fact), awareness (knowl-edge), and sensitivity (attitude) into everyday nursingpractice. In addition to sensitivity to self and others,competence behaviors are dependent on personal expo-sure, experience with people from diverse groups, andawareness of individual and group similarities anddifferences.

• METHODS

Design and Procedures

A cross-sectional descriptive design was used to examinevariables associated with cultural competence amonghospice nurses. Approval for the study was grantedby the university's Human Investigation Committee.Nurses represented a convenience subsample of hospiceemployees and volunteers in attendance at hospicemeetings where data were collected. Whereas the over-all response rate was 95%, the nurse-specific responserate could not be calculated. Each potential participantwas approached before the start of the meeting andasked to complete a paper-and-pencil survey. Potentialparticipants were advised that participation was com-pletely voluntary and the survey would take 20 to

JOURNAL OF HOSPICE AND PALLIATIVE NURSING • VoL 8, No. 5, September/October 2006 303

- • * • f!X *,. • >

30 minutes to complete. An information sheet on thecover of the survey oudined the study purpose andstated that participants could choose not to partici-pate and could withdraw or stop at any time. Surveyswere returned in unmarked envelopes to maintainparticipant anonymity. Completion and return of thesurvey constituted informed consent.

Instrument

The Cultural Competence Assessment (CCA) tool was a26-item instrument designed to measure cultural diversityexperience, awareness and sensitivity, and competencebehaviors. Cultural diversity experience was addressedwith a single item asking respondents whether they hadcared for people of various cultural groups in the past 12

.months. The item score was a simple count of thenumber of groups selected with higher numbers indicat-ing greater diversity of experience.

The combined subscale for cultural awareness(knowledge) and sensitivity (attitude) (CAS) was mea-sured with a 5-point Likert-like response set of "stronglyagree, agree, disagree, strongly disagree, and no opin-ion." The subscale for cultural competence behavior(CCB) had response categories of "always, often, attimes, never, and not sure." In both cases, no-opinionand not-sure responses were coded at the midpoint (3of 5). The items were summed for each subscale score;higher scores indicate higher levels of knowledge andmore positive attitudes and greater self-reported fre-quency of competence behaviors. Internal consistencyreliability for the CCA has been reported in previouswork at over 0.80: construct, content, face validity,and test-retest reliability have been established.^''^ Inthe current study, CAS subscale reliability was 0.72and the CCB subscale reliability was 0.88.

Demographic items on the CCA included questionsassessing age, prior cultural diversity training (yes/no),self-identified race or ethnicity, and level of educationalattainment (associate, bachelor, graduate degree). Cen-der was not identified in this study to avoid thepossibility that unique combinations of other demo-graphic variables, when combined with gender, wouldbreach subject anonymity.

Analysis

All analyses were performed with SPSS for Windows13.0 (SPSS, Chicago, IL). An a priori .05 level was used

to determine significance. Descriptive analyses wereconducted to describe participant characteristics and toevaluate assumptions for regression analysis. Standardmultiple regressions were used to determine the amountof variance accounted for by independent variables of(1) age, (2) cultural competency training, (3) educationalattainment, and (4) self-identified race or ethnicity onthe CAS and CCB subscaies, respectively. Using theTabachnick and Fidell^ formula (N = 50 + 8m) for amedium-sized relationship between the four independentvariables and the dependent variable for each regressionanalysis assuming an a level of .05 and P of .20, a samplesize of 82 would have been sufficient for the analysis.The achieved sample of 107 was deemed to haveadequate power to support the regression analysis.

• FINDINGS

Descriptive analysis yielded a profile of the character-istics of the 107 hospice nurses representing five differenthospice agencies (see Table 1). The mean age of thenurses was 45 years; 50% (n = 53) of the nurses reportedhaving an associate degree in nursing and the other53 (50%) reported completing either a bachelor's degree

»^,| T a b 1 e 1?-_-: Dennographics of Hospice

Age

Self-identified race/ethnicityCaucasian/whiteHispanic/LatinoAfrican American/blackAsianNative AmericanOther

EducationAssociate degreeBachelor's degreeGraduate degreeMissing data

Prior Cultural Competence TrainingYesNoMissing data

Nurses (n = 107)

n (%)

Range 22-66;Mean 45 ±11

68 (63)1(1)

20 (19)8(7)6(6)4(4)

53 (49)31 (29)22 (21)

1 (1)

49 (46)56 (52)

2(2)

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fl^^3 .Ar .̂. i . _..••

in nursing or some graduate level education. The major-ity of the nurses reported their racial/ethnic backgroundas Caucasian/white (n = 68; 63%). The next mostprevalent background was African American/black (n -20; 19%) followed by small percentages representingother groups.

Responses to the cultural diversity experience item areprovided in Table 2. The number of groups that hospicenurses reported working with in the past year rangedfrom one to seven, with a mean of 3.4 (SD = 1.4). Allparticipants reported having worked with Caucasian/white clients. The second most cited group was AfricanAmerican/black with 65% (n = 69)., followed byHispanics at 56% (n = 60).

Analysis of the behavior subscale of the CCA yieldeddescription of items means and standard deviations (seeTable 3). The top-rated behaviors among the hospicenurses were acting to remove obstacles that were pointedout to them by clients, welcoming feedback from clients,and avoiding generalizations. The lowest-rated behaviorswere documentation of cultural assessments, using avariety of resources to learn about cultures, and havingresource materials at hand.

All regression assumptions were met and so no trans-formations of variables were needed. The regressioncoefficient {R) for cultural competence knowledge/atti-tude (CAS) was significantly different from zero (F5107 =2.43, P < .05). This result indicates that the set of in-

T a b l e 2Racial/Ethnic Identities of Individualsand Families Cared For in the Last Year

Types of Racial/Ethnic Groups Cared For Sample Percent*

Caucasian/whiteHispanicAfrican American/blackAmerican IndianAsianOther groups

Number of other racial/ethnicgroups cared for

1076069375526

Mean

3.4

l o o V o ''':•56.?/o .'..;' '

6 5 % ".!••

3 5 % •'•;

51% '̂24%

SD-i,1.4 • ;>

"Total >100% due to endorsement of more than one group perparticipant.

'^I T a b 1 e 3•̂ •' CCA Behavior Subscale

Behavior Subscale

I act to remove obstacles for people ofdifferent cultures when clients andfamilies identify such obstaclesto me.

I welcome feedback from clients abouthow I relate to others with differentcultures.

I avoid using generalizations to stereotypegroups of people.

I welcome feedback from coworkers abouthow I relate to others with differentcultures.

I find ways to adapt my services to clientand family cultural preferences.

[ act to remove obstacles for people ofdifferent cultures when I identify suchobstacles.

I recognize potential barriers to servicethat might be encountered by differentpeople.

I ask clients and families to tell me abouttheir expectations for care.

I learn from my coworkers about peoplewith different cultural heritages.

[ ask clients and families to tell me abouttheir own explanations of health andillness.

I include cultural assessment when I doclient or family evaluations.

1 document the adaptations I make withclients and families.

I seek information on cultural needs whenI identify new clients and families in mypractice.

1 document cultural assessments.[ use a variety of sources to learn about

the cultural heritage of other people.I have resource books and other materials

available to help me learn about clientsand families from different cultures.

Mean

4.10

3.98

3.94

3.94

3.90

3.88

3.75

3.68

3.55

3.32

3.22

3.08

3.05

2.762.75

2.63-

SD

1.08

1.12 ,

1.11 :

1.23

1.09

0.98

0.98

•^;1.23^/''

;l.;17^^'',f

1.31

1.03 V

.,••1:31 ::,;

• ; • • ' • • . • ' " .

, • • • ' • ' - • > • •

""'"i.27"^''\

' • • • ' • ' ' • • : . ' • . . ' • • " •

•'••l:3'0, \J

dependent variables (age, cultural competency training,educational attainment, self-identified race/ethnicity)explains a statistically significant amount (12%) ofthe variance in cultural competence knowledge andattitudes. From this set of independent variables, only

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educational attainment (college or higher) was by itselfsignificantly associated with cultural competence knowl-edge/attitude {P <.O5).

The regression coefficient {R) for cultural competencebehavior (CCB) trended toward significance (F5107 =2.18, P = .06). This result indicates that the set of in-dependent variables (age, cultural competency training,educational attainment, self-identified race/ethnicity)explains a nearly significant amount (11%) of the vari-ance in cultural competence behavior. From the set ofindependent variables, only prior diversity training wasby itself significantly associated with cultural compe-tence behavior (P = .011).

• DISCUSSION

Using the 3-D Puzzle Model of Culturally CongruentCare and the Cultural Competence Assessment instru-ment developed from it, this research yielded a betterunderstanding of the variables associated with culturalcompetence. Findings provide new insights into diversityexperiences, awareness and sensitivity, and behaviorsamong practicing hospice nurses.

Findings related cultural diversity revealed patternsamong both hospice nurses and their clients. The factthat most participants (63%) were Caucasian/white isnot surprising given the Midwestern geographic locationof the five hospice programs from which they wererecruited. Although specific data for the US hospicenursing workforce are not available, findings from theMarch 2000 National Sample Survey of RegisteredNurses suggested that 87% of RNs are white-non-Hispanic.^ That 19% of the nurses in this study self-identified as African American/black may reflect theinclusion of several hospice programs located in majormetropolitan areas with significant African American/black populations.^" The average number of racial/ethnic groups encountered was 3.4, which indicate amoderate level of heterogeneity among clients encoun-tered and moderate diversity experience for the nurses.All of the nurses surveyed had worked with Caucasian/white clients, and many had experience with AfricanAmerican/black and Hispanic groups in the past year asmight be expected from the demographics of theagencies' service communities.

Cultural awareness and sensitivity, as measured usingthe CAS subscale of the CCA instrument, was found tobe significantly associated with educational levels.Nurses holding BSN or higher academic degrees were

significantly more likely to achieve high scores oncultural awareness and sensitivity. This finding may berelated to academic content as well as diversity knowl-edge and attitudes or may be associated with otherexposures that occur with higher education. It isinteresting to note, however, that in this particularconvenience sample, only 50% of the nurses reportedpreparation at the BSN level or higher. Whereas thispattern may not be typical of hospice nurses, findingswould suggest that where there are significant numbersof nurses with less than BSN preparation, greaterattention may need to be focused on cultural competencein-service training.

Culturally competent behaviors, as measured usingthe CCB subscale of the CCA instrument, were found tobe associated with prior diversity training. This findingsuggests that diversity training programs increase thefrequency with which cultural competence behaviors areput into practice. The two items from the behavioralsubscale that were most often cited (removing obstaclesand welcoming feedback) indicate that many hospicenurses are already comfortable with adapting to client-initiated discussions of cultural needs and desires.However, items that are related to the nurse solicitingspecific information on which to base culturally con-gruent interventions were ranked lower. In-service pro-viders may need to place more emphasis on activeassessment of cultural needs tailored to individualsituations within a larger cultural context.

Another finding from the analysis of the behavioralsubscale was that hospice nurses in this sample reportedlow frequencies for including cultural assessments inclient evaluations, documenting adaptations to care, andusing a variety of resources to learn about cultural is-sues. This finding may be related to lack of trainingregarding the ways to incorporate targeted culturalassessments with the many other tasks required at thetime of hospice admission. There may also be organiza-tional barriers to recording cultural assessments andadaptations of care—for example, forms may have nospace or cues to document these activities. That nursesdid not use a variety of resources to learn about culturalissues is not surprising, given that the activity in the lastplace on the behavioral subscale was, "I have resourcebooks and other materials available to help me learnabout clients and families from different cultures."Clearly, attention to ongoing resource availability is asessential in developing and maintaining cultural com-

' petence behaviors as having appropriate diversity train-ing programs.

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This research had several limitations that suggest theneed for interpretive caution. The use of a conveniencesample of hospice nurses limits the generalizability of thefindings. Recruitment of nurses from only five agenciesin one state also limits the findings, even though theagencies from which the sample was drawn represent abroad range of diverse communities.

• CONCLUSIONS

From this project, it is clear that both nursing educationand ongoing in-service training are important in sup-porting cultural competence among hospice nurses. For-tunately, there are a number of national efforts, such asthe End-of-Life Nursing Education Consortium project,that are working to expand discussions of cultural as-pects of EOL care across programs that prepare profes-sional nurses for practice.^^ Hospice and palliative careprograms and agencies can also support the develop-ment of cultural awareness, sensitivity, and competencebehaviors through in-service education, documentationenhancements, and provision of resources appropriateto the specific populations in the service community.Professional organization supports for cultural compe-tence development are also important. Members of theHospice and Palliative Nurses Association have recog-nized and endorsed the need for more articles andeducational products specific to cultural diversity inEOL care.^'^ Enhancement of cultural competenceamong hospice nurses creates exciting opportunities atthe intersections of nursing practice, administration,education, and research that hold the promise ofimproving EOL care.

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