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Journal 2011ine report, indicate that the sources of healthrities occur at several levels, including that of thecare provider (Smedley, Stith, & Nelson, 2002).s are on the front line of health care provision in

organizational strategic goals (Watts, Cuellar, O'Sull2008; Giger et al., 2007). Most schools of nursingoffer students a variety of culturally relevant matewithin the teaching curricula. These materials, howoften vary across institutional settings, thus resultinmixed outcomes. Although examples of various moof cultural competence in nursing schools exist inliterature, few studies explore the effectiveness of tstrategies or the beliefs and perspectives of theaudience they seek to reachthe student. Hence,article describes the results of a descriptive qualitstudy using focus groups, which explored the view

ant Professor, University of Texas at Austin School of Nursing,lphia, PA.rch Associate, University of Pennsylvania School of Nursing,lphia, PA.ress correspondence to Dr. Carthon: University of Pennsylvania,groups are complex, studies, such as the Institute ofamong many racial and ethnic minorities, socioeconom-ically disadvantaged groups, and other marginalizedgroups. Although the causes of poorer health in these

and skill in providing culturally and linguisticallycompetent care. To meet this challenge, many nurseleaders and educators are seeking to increase the levels ofcultural competence among student nurses as a part of223/10

of ProElsevieimprovement. The results of the focus groups yielded three themes: (a) broadening definitions,(b) integrating cultural competence, and (c) missed opportunities. Student suggestions andrecommendations for enhancing cultural competence in the curricula are provided. (Indexwords: Cultural competence; Nursing curriculum; Student perceptions; Focus groups) J ProfNurs 27:4349, 2011. 2011 Elsevier Inc. All rights reserved.

T NURSES ENTERING the current healthena will face a complex, rapidly changingt filled with consumers from diverse back-hnic and racial minorities are now one thirdopulation and are expected to comprise morey 2050 (Day, 1996). These demographic shiftsg in the wake of enduring health disparities

this nation and as such must be prepared andtrained while in school to meet the needs of tpopulation they will serve. The inability toresult in dire consequences and continue topoor health outcomes among minority groupsThe barriers some student nurses encounte

for diverse populations may be due to a lackquestions: (a) what the students' perceptions w

the integration of cultural competence in the nursing curriculum. We sought to answer twoCOMPETENCE IN UNGRADUATE NUR

DANICA FULBRIGHT SUJ. MARGO BROOKS CAR

The rapidly changing demographics of the Uniteknowledge and skills to meet the needs of aneducators seek to meet this challenge througcourse curricula. Few studies have examinedmaterial. As part of a larger school-wide assessmgroups of doctoral and bachelor of science in n/$ - see front matter

fessional Nursing, Vol 27, No. 1 (JanuaryFebruary), 2011: ppr Inc. All rights reserved.TION: STUDENTF CULTURALDERGRADUATE AND

ING CURRICULAPTER, PHD, CRNP ANDHON, PHD, RN, APRN

States require nurses who are equipped withincreasingly diverse patient population. Nurseintegrating cultural competence into nursingtudent perceptions of the integration of thisnt, this qualitative descriptive study used focusrsing students to evaluate their perceptions ofundergraduate and doctoral students regarding their

4349 43doi:10.1016/j.profnurs.2010.09.005

perceptions of cultural competence within the nursingcurriculum. The study was conducted as a componentof a larger initiative to evaluate and integrate culturalcompetence into the nursing curriculum at the Univer-sity of Pennsylvania School of Nursing between 2002and 2008. The results of the study were used as part ofthe development of a blueprint for enhancing culturalcompetence education.

BackgroundUniversity Commitment to Enrich

Cultural CompetenceTo continue its commitment to diversity awareness, theUniversity of Pennsylvania School of Nursing set as itsprimary goal in the 20032008 strategic plan, theintegration of cultural competence throughout theresearch, practice, and education agenda (Watts, Cuellar,O'Sullivan, 2008). Efforts to meet this objective includedthe appointment of a Director of Diversity Affairs and theintroduction of an intensive faculty development pro-gram that included training sessions, regional workshops,and a seminar series on diversity and cultural competence(Watts et al., 2008). Financial resources were alsoallocated to support diversity conferences, curricularconsultations with nationally and internationallyrenowned experts, and diversity recruitment efforts(Anderson, 2002; de Leon Siantz & Meleis, 2007;Watts, Cuellar, O'Sullivan, 2008).In 2002, the Master Teachers Taskforce on Cultural

Diversity was introduced to advance the school's diversityagenda. Composed of standing faculty, course directors,program directors, and students, one of the missions ofthe taskforce was to assess the school's curriculum and toprovide recommendations on methods for integratingcultural competence. Over a period of 5 years, taskforcemembers collected data regarding the state of culturalcompetence in the nursing curriculum through a varietyof methods. One of the major culminating efforts of thetaskforce was the development of a Blueprint forIntegration of Cultural Competence in the Curriculum(BICCC), introduced as a teaching guide and measure-ment tool for faculty and students. Using the BICCC,quantitative and qualitative data from faculty andstudents were collected to gather perceptions of theinclusion of cultural-specific content in their courses(Brennan & Cotter, 2008). The taskforce's desire tosolicit targeted student feedback of their experiences withcultural-related content in their nursing courses led tothis smaller student-conducted study. The researchquestions that guided our study were the following:

1. What are undergraduate and graduate students'perceptions of cultural competence and itsintegration into the school of nursing curriculum?

2. What recommendations do students have forstrengthening the integration of cultural com-

44petence-related information into the school ofnursing curriculum?MethodsIn this qualitative descriptive study, we conducted twofocus groups composed of nursing students at theUniversity of Pennsylvania in the spring of 2006 and2007. This design allowed us to gain a preliminaryunderstanding of the student's views and perceptions ofcultural-specific content in their nursing courses(Sandelowski, 2000). Focus groups provided a formatfor participants to provide spontaneous reactions, reflecton personal experiences, verbalize opinions, and hear theexperiences of others and compare (Bryan et al., 2008;Carey & Smith, 1994; Ruff, Alexander, & McKie, 2005).

Setting and SampleThe study was conducted at the University of Pennsylva-nia School of Nursing. Most of the enrolled students areWhite (62%) females (94%) seeking their first degree(75%). The standing faculty of the school is alsopredominantly White (88%) and female (91%; Table 1).Participants were recruited electronically via the

nursing student body and doctoral student listservs andthrough flyers posted in the School of Nursing. Dinnerwas provided for the students as compensation for theirtime. Inclusion criteria required that all participants hadcompleted at least one semester of course work in orderto participate. Each focus group was demographicallymixed and included students at various stages ofmatriculation. The doctoral focus group participants(n = 5) included one male and four females, three Whitesand two Hispanics, and two first-year and three second-year student. The undergraduate focus group (n = 5)included all female participants, two with a previousdegree and three traditional bachelor of science innursing (BSN) students in either their sophomore, junior,or senior year in the program. The participants in the BSNfocus group did not report race or ethnicity. The numberof participants was in agreement with Kreuger andCasey's (2000) Focus Groups, where the authors state thatthe size of a typical focus group can range from 4 to12 participants. All procedures were reviewed andapproved by the institutional review board of theUniversity of Pennsylvania. Individual verbal consentwas obtained prior to beginning each focus group.

Data CollectionFocus group procedures followed the methods used byRuff et al. (2005) and included two moderators, onefacilitated the discussion, whereas the other recordedverbal and nonverbal communication via digital recorderand field notes. Each focus group lasted between 1.5 and2 hours. Both interview guides consisted of fivequestions, moving from general to specific (Sharts-Hopko, 2001). The main differences between theinterview guides were the focus on clinical practiceapplication for BSN students and on research applicationfor doctoral students. The facilitator used a series ofprobes to guide the focus group sessions. The interview

SUMPTER AND CARTHONguide began with probes to get initial reactions to triggerwords such as culture and cultural competence and to

aestablish a working definition of what students wereevaluating. After the initial probe, participants were askedto carefully evaluate their experience of the presentationof culturally specific content in their nursing courses. Inaddition, they were asked to discuss useful methods usedby some instructors to integrate cultural competence intocourse material and the missed opportunities of others.The facilitator encouraged participation from all mem-bers of the group, and students ended each focus groupby providing concrete suggestions for improvements. Asample of the focus group questions is presented inFigure 1. All audio recordings were transcribed verbatimby a professional transcriptionist. Detailed notes weretaken during the focus group to augment the transcriptsof the audio recordings.

Data AnalysisQualitative content analysis was used to interpret results(Morgan, 1993). First, transcripts were reviewed by teammembers for significant statements, and these statementsand similar concepts were grouped together to generatethemes as data analysis progressed. Second, codes werediscussed and placed into categories. Third, to augmentrigor, the transcripts were coded separately by each

Table 1. Demographics for the School of Nursing

Demographic BSN (n = 507)

Race/EthnicityAmerican Indian 1 (0.2)Asian 92 (18)Black 25 (5)Hispanic 18 (4)White 316 (62)Other 3 (0.6)Not reported 52 (10)

GenderFemale 477 (94)

Note. Percents may not equal 100 due to rounding. Values are expressed

LOST IN TRANSLATIONfacilitator then reviewed together to reach a consensus.The validity of the themes from the doctoral focus groupwas reinforced by performing member checks withanother group of doctoral students. The fourth andfinal step was organizing the data using Atlas.ti 5.0software. Common points of agreement and differencebetween the groups were also identified during theanalysis process.

FindingsParticipants in the doctoral and BSN focus groupsexpressed substantive comments ranging from the contentof the nursing curriculum to their own personal experi-ences in the classroom and clinical settings. Three salientthemes emerged: (a) broadening definitions, (b) integra-ting cultural competence, and (c) missed opportunities.

Theme 1: Broadening Definitions. Members of bothfocus groups expressed concerns regarding the use andmeaning of the term cultural competence. Many believedthat cultural competence and related terms had becomeso overused they lacked contextual meaning and depth.When asked about cultural competence and relatedterms, students gave varying definitions, and onestudent felt what you label them is probably alwaysgoing to be up for debate whereas another studentconfessed, I'm not even sure how you are definingcultural competence.Although definitions of terms appeared ambiguous,

students did share a desire to move past the language andpractice of stereotyping. One student thought that themost important thing to do is to keep an open mind aboutyour patient to think about culture in a broader sense.Another student expressed it this way, I found thatcultural competence in this school of nursing has nothelped me at all. It's just really made me close my eyes toother things that could be going on. Another frustratedstudent recounted a testing experience, they did thiswhole cultural section and they made me so mad becauseit was multiple choice. Depending on what the culturewas, I had to say they would do this. Being forced to putindividuals in boxes led another student to feel thatwhen they do competence hereI feel it's hollow.

Group

PhD (n = 56) Faculty (n = 56)

7 (13) 3 (6)5 (9) 3 (6)1 (2) 1 (2)

35 (63) 49 (88)1 (2) 7 (13)

53 (95) 51 (91)

s number (percentage).

45This desire for amore open-minded approachmay havebeen prompted by self-reflection, as one student stated,she wouldn't want to be stereotyped based on my culturethe way someone outside might expect me to behave.Another student held similar concerns after having beensingled out because of her own cultural identity, lots oftimes teachers really do stuff that isn't okay, but I feel likethey don't realize it. Because there will be times in classand we'll talk about a certain culture and then they'll pickonme, because of whatever culture I have. And they'll say,What do you think? The students in both groupsnever settled on a single definition to describe culturalcompetence and related terms, but each group sought anapproach that diminished stereotyping and fosteredpatient care based on individual attributes versus general-izations about group characteristics.

Theme 2: Integrating Cultural Competence. Althoughthe focus of the undergraduate curriculum and the

xadoctoral curriculum differed, the students in both focus

Figure 1. Interview guide: e

46groups shared similar concerns about their ability tointegrate cultural competence into research and clinicalpractice. Doctoral students expressed concerns regardingtheir ability to conduct culturally competent research.Their comments centered around the ability to recruitand retain representative samples and in obtaining trueinformed consent. One student felt that a class onresearch methods should be abouthow to be sensitiveto getting an adequate distribution of different ethnicgroups in your sample, whereas another saw it as anissue broader than race and ethnicity and regretted thatwe never really talked about consenting people whohave cognitive impairments, consenting people of otherraces, andwho speak other languages, English is nottheir first language; they can't read or write, you knowall of those other issues happen, and it's not all aboutrace and ethnicity, I mean there areissues ofmarginalized groups.Undergraduates were similarly concerned about their

ability to integrate cultural competence into their clinicalpractice, although some students expressed mixed viewson their ability to do so. One student felt moreprepared because my eyes have been opened to the factthat I don't know a lot about this. I think it can cut bothways. I'm more prepared to have trouble with it. I think Icame into nursing school as a second-degree studentfeeling a little bit overconfident about my ability tointeract with other cultures because I had had positiveexperiences in the past and doing it as a nurse is verydifferent than doing it as someone else. Another studentfelt that she would have been more adequately prepared

mple of focus group probes.

SUMPTER AND CARTHONto integrate cultural competence into her nursing practicehad basic communication techniques been stressed. Sheexplained it this way, [And] the best thing I've alwaysfound in any culture is just saying, Is this okay? beforeyou do it. And if they could just teach that in 5 minutes, Ithink that would be more helpful. Like if it was myMuslim man patient I had, I'd be like, Is it okay if I helpyou go to the bathroom? and for him it was and he's notevery single Muslim male patient I'll ever see.

Theme 3: Missed opportunities. Another theme surfac-ing from the focus group involved faculty issues andwhat the students perceived as missed opportunities toteach cultural competence. One student felt there werea lot of opportunities in our classes that have beenmissed and it may just bean inability to integrate itsomehow. And I'm not faulting them, I think it's justkind of obvious though, and maybe they need trainingin how to do it from the school of nursing; maybefunds need to be put into advanced teacher training forthem. Another student felt there were times wheninstructors could have actually done more withcertain classroom situations that arose. Ironically, thiswas especially true with uncomfortable moments as onestudent described, there was sort of like a silence,and that would have been a key moment that we reallyshould've explored more thoughts. Other studentsbelieved research faculty should draw from theirpersonal experiences with diverse research populationsto instruct students on ways to navigate this process.

Discussion

The last half of the 20th century has witnessed anincrease in literature and research supporting theincorporation of cultural competence into holisticnursing practice. During this period, nurse leadershave developed several theoretical models, whichdescribe cultural competence, and its various compo-nents (Campinha-Bacote, 1994; Giger & Davidhizar,1995; Leininger, 1978, Purnell & Paulanka, 1998).These models have served as useful guides forintroducing cultural competence into the nursingcurricula, although as this study demonstrates, theintegration of these models into didactic and practicumsettings has varied.The collective response from the participants in this

study reveals that although nursing students receivecourse content involving cultural competence, thisexposure does not necessarily translate into perceivedmastery of the subject. The participants stressed the needfor teaching methods that more comprehensively probedthe meaning of familiar buzz phrases such as culturaldiversity, cultural sensitivity, and cultural competence,since frequently these phrases were understood alongracial lines, which set up automatic defenses anddiscomfort among some students. Establishing defini-tions that move beyond racial and ethnic identity mayreduce these tensions while at the same time helpstudents to appreciate the differences (and similarities)existing within and between groups. Students expressedthe desire to move away from the stereotyping of groupsand individuals toward having a more open mind and abroader definition of culture. Students were frustratedwith placing people and groups in boxes based onbehaviors that were believed to be group norms. Studentsincreasingly desired a dialogue about these subjects thatinterrogated and probed their current understandingsand challenged them to think about their own biases andthose of others.We acknowledge a significant limitation of this study,

which was the small number of focus groups, that mayhave decreased the representativeness of the studyparticipants and their viewpoints. However, this is oneof the disadvantages of focus group data in general. Weattempted to minimize these limitations by (a) theselection of participants from the same school ofnursing; (b) the composition of the focus groups, thatis, PhD and BSN specific; and (c) the use of a structuredinterview guide.Despite the limitations posed by the small sample size,

our findings are consistent with those of Brennan andCotter (2008), who completed a mixed-methods study ofcultural competence in the undergraduate and master'scurricula at the same university. In their study, studentsanswered an open-ended probe at the end of the BICCC.Results from the qualitative portion revealed thatalthough cultural information was presented throughout

LOST IN TRANSLATIONthe undergraduate curricula, it was often covered at thesame depth throughout the curriculum in a redundantfashion. These results, along with ours, underscore theimportance of measurement and evaluation tools, such asthe BICCC, because it provides a framework toappropriately level the objectives of learners so thatculture-specific content sequentially builds the skills,attitudes, and knowledge of students while avoidingduplication and redundancy of course materials.Doctoral and undergraduate nursing students reported

mixed views on their ability to provide and conductculturally competent care and research. Several reasonsmay account for this occurrence. First, variation in theseresponses may have arisen from students being atdifferent phases in their nursing studies. Previous studiesof nursing students revealed that senior nursing studentsand graduate students reported sufficient levels ofteaching in response to survey questions (87% and90%, respectively), whereas freshman reported lessexposure (25%) to cultural content (Brennan & Cotter,2008). The variation in responses may have also resultedfrom different types of exposures. Students often havecourses with a large array of lecturers, clinical preceptors,and standing professors, as well as exposure to huma-nities courses throughout the university. Each educatormay present this information in a different manner,depending on his or her comfort level and style. Somefaculty may approach cultural competence in a content-oriented way, which places heavy emphasis on theoryand what it is. Other educators teach the process ofobtaining cultural information and applying it to thenursepatient relationship (Lipson & Desantis, 2007).Although each approach has merit, it is difficult to assesswhich is of most benefit to students. As a measure toensure a degree of consistency and to enrich the learningexperience for students, focus group respondents en-dorsed increased faculty training in the subject matter inhopes that it would produce a wider variety of methodsused to introduce the topic of cultural competence. Thistype of training should guide instructors in recognizingteachable moments and avoiding the missed opportu-nities and being mindful of the informal curriculum orbody language and side comments about the subjectmatter (Betancourt, 2007), which may leave students theimpression that the content is mere lip service.Part of the challenge facing instructors in presenting

cultural competence may be associated with culture-related nursing theories framed within the biomedicalmodel, which emphasizes biological/physical traits whileexcluding psychological and social variables (Dorazio-Migliore, Migliore, & Anderson, 2005). Recently, scho-lars have challenged this convention, advocating insteadfor a view that considers culture within broader political,economic, and historical contexts (Anderson, Kirkham,Browne, & Lynam, 2007). These authors contend that itmay be necessary to shift paradigms and ways of knowingand thinking about the concept of culture to more fullygrasp its complexity. Such a challenge moves culturaldiscourse beyond descriptions of culture toward an

47understanding of culture as dynamic and demonstrateshow cultural practices create contexts that have the

potential to foster or impede health (Anderson, Kirkham,Browne, & Lynam, 2007). Although cultural featuresmay be identified and described, it should be emphasizedthat they hold varying degrees of meaning and may beadopted selectively by individuals within that culture.Culture and its associated traditions will not be viewedthe same by all members of that group, and representa-tions of culture as a static set of beliefs and practicesattributable to a particular group are inadequateconceptualizations that mask within-group diversity(Anderson, Kirkham, Browne, & Lynam, 2007).

RecommendationsThe doctoral and undergraduate students did not merelyoffer critique of their nursing curricula, they also offeredconcrete recommendations they thought would improvethe delivery of culture-related content. The studentswould rather have the cultural content saturate thecourse, not just limited to one special lecture but aconstant presence in the curriculum to mimic real life.They thought it should be woven throughout the coursesimilar to the way the life span is integrated into theirundergraduate nursing courses. Both groups suggestedtraining for faculty, including incentives for them toobtain the training. This training would help increase thecomfort level of the instructors with the material andprovide teaching strategies. It would also teach instruc-tors how to utilize their own research and/or clinicalpractice, modeling reflective practice for the students.The students desired more readings from the humanities,which they felt covered cultural topics in more depththan the readings from the sciences they were assigned.They welcomed the idea of being challenged and wantedinstructors to help facilitate the examination of biases andpersonal philosophies about culture. Students alsowished to hear from graduates who are currently puttingthis material into practice and how they navigate theculture-related issues of their respective facilities.The students desired more discussion and dialogue

(and less papers) in the classroom and in their clinicalsites. One way to achieve this goal is through creatingseminar-style discussion opportunities where studentsmight more openly share their thoughts and perspectives.One of the features of the focus groups was that it allowedfree expression. Several students reported that the focusgroup served as the best discussion they had participatedin since beginning nursing courses. They felt attendanceto diversity lectures would increase if students were givencredit for writing a summary, critique, or reflection onthe event.

ConclusionResults from this study add to ongoing efforts to integratecultural competence into the school of nursing curricu-lum. Student feedback such as that provided throughfocus groups serves as a valuable barometer to evaluatecurrent methods for integrating this content. As a result

48of this and other Master Teacher Task Forces efforts, theUniversity of Pennsylvania School of Nursing has addedReferencesAnderson, J. M. (2002). Toward a post-colonial feminist

methodology in nursing research: Exploring the convergence ofpost-colonial and Black feminist scholarship. Nurse Researcher,9, 727.

Anderson, J. M., Kirkham, S. R., Browne, A. J., & Lynam, M.L (2007). Continuing the dialogue: Postcolonial feministscholarship and bourdieuDiscourses of culture and points ofconnection. Nursing Inquiry, 14, 178188.

Betancourt, J. R. (2007). Commentary on current approachesto integrating elements of cultural competence in nursingeducation. Journal of Transcultural Nursing, 18, 25S27S.

Brennan, A., & Cotter, V. T. (2008). Student perceptionsof cultural competence content in the curriculum. Journal ofProfessional Nursing, 24, 155160.

Bryan, C., Wtmore-Akader, L., Calvano, T., Deatrick, J. A.,Giri, V. N., & Bruner, D. W. (2008). Using focus groups toadapt ethnically appropriate, information-seeking and recruit-ment messages for a prostate cancer screening program for menat high risk. Journal of the National Medical Association, 100,674682.

Campinha-Bacote, J. (1994). Cultural competence inAcknowledgmentsJ. Margo Brooks Carthon is supported by funding

from the National Institute for Nursing Research,National Institutes of Health, K-01 from NIH/NINR(K01NR012006, Brooks Carthon, PI), and the Agencyfor Healthcare Research and Quality (RO-1NR-004513,Aiken, PI) and the Center for Nursing OutcomesResearch (T-32-NR-007104, Aiken, PI). This work wasalso supported by a grant from the National Institutesof Health/National Institute of Nursing Research (P20NR008361) awarded to the University of Pennsylvaniaand Hampton University (L.S. Jemmott and B. Davis,PIs) from September 30, 2002 to June 30, 2007.several new courses to the nursing curricula and a newminor in Multicultural/Global Healthcare. They have alsoinstituted monthly informal brown bag-style discussionsopen to all students, faculty, and staff. These sessionsserve several purposes: to create a safe space to freelydiscuss topics in depth that might not be broached in theclassroom or clinical site, to provide faculty an opportu-nity to witness successful navigation of difficult topics(role modeling), and to allow the intellectual exchangebetween individuals at every level of the school of nursingcommunity. The study institution also continues tosponsor a diversity lecture series, which the students didfind valuable. These additions will allow students todevelop advanced knowledge and skills in domestic andnational health care contexts. As schools of nursingcontinue to rise to the challenge of equipping theirstudents with the skills and tools necessary to provideand conduct culturally competent care and research, thestrategies used by the University of Pennsylvania Schoolof Nursing may provide a useful collaborative model.

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de Leon Siantz, M. L., & Meleis, A. I. (2007). Integratingcultural competence into nursing education and practice: 21stcentury action steps. Journal of Transcultural Nursing, 18,(1_suppl), 86S90S.

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Purnell, L. D., & Paulanka, B. J. (1998). Purnell's model forcultural competence. In L. Purnell (Ed.). Transcultural healthcare: A culturally competent approach (pp. 7-51). Philadelphia,PA: F.A. Davis.

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49LOST IN TRANSLATION

Lost in Translation: Student Perceptions of Cultural Competence in Undergraduate and Graduate Nursing CurriculaBackgroundUniversity Commitment to Enrich Cultural Competence

MethodsSetting and SampleData Collection

Data AnalysisFindingsTheme 1: Broadening DefinitionsTheme 2: Integrating Cultural CompetenceTheme 3: Missed opportunities

DiscussionRecommendationsConclusionAcknowledgmentsReferences