Cultural Competence and Cultural Safety in Canadian Schools of Nursing: A Mixed Methods Study

Margo S. Rowan, Ellen Rukholm, Lisa Bourque-Bearskin, Cynthia Baker, Evelyn Voyageur and Annie Robitaille

Abstract

Cultural competence and cultural safety are essential knowledge in contemporary nursing care. Using a three-phase, mixed methods sequential triangulation design, this study examines the extent to which Anglophone Schools of Nursing in Canada have integrated cultural competence and/or cultural safety into the undergraduate nursing curricula. Factors that influence successful integration are identified through the lens of Donabedian’s structure, process, and outcome model. Results suggest that several facilitating factors are present, such as leadership, partnerships and linkages, and educational supports for students. Of particular concern is the lack of policies to recruit and retain Aboriginal faculty, financial resources, and outcome evaluation indicators. A conceptual model of integration is offered to explain how Schools of Nursing function to support the implementation of these concepts into their curriculum. This study provides theoretical and practical implications for initiation and improvement of cultural competence and/or cultural safety integration strategies in Schools of Nursing.

Background

There is worldwide recognition that nurses, among other healthcare professionals, need to add cultural competence and cultural safety to their repertoire of core competencies. Consequently, increasing attention is being paid to integrating cultural competence and cultural safety into Canadian Schools of Nursing with a particular focus on Aboriginal Peoples who include all First Nations, Métis, or Inuit Peoples (Royal Commission on Aboriginal Peoples, 1996). Revised or enhanced curricula are informed or influenced by several pertinent international (Clark et al., 2011; Douglas et al., 2011), national (Canadian Nurses Association [CNA], 2010; 2004; National Aboriginal Health Organization [NAHO], 2008), and provincial/territorial nursing care standards, policies, and/or regulatory directions (Arnold, Appleby, & Heaton, 2008; College of Registered Nurses of British Columbia, 2009; Mahara, Duncan, Whyte, & Brown, 2011). Furthermore, the Aboriginal Nurses Association of Canada (A.N.A.C), the Canadian Association of Schools of Nursing [CASN], and the CNA co-authored a literature review (A.N.A.C., 2009a) of best practices and a Framework (A.N.A.C, 2009b) outlining nursing education competencies to foster cultural competence and cultural safety among nursing educators and students.

Integration of cultural concepts into the curriculum of nursing schools is the subject of a rich body of literature and debate. The bulk of contemporary curricula models is from the United States and focus primarily on the integration of cultural competence at the exclusion of cultural safety, such as Campinha-Bacote Model of Cultural Competence and Giger and Davidhizar’s Model of Transcultural Nursing (American Association of Colleges of Nurses, 2008; Higginbottom, Richter, Mogale, Ortiz, Young, & Mollel, 2011). Several researchers have investigated the implementation and outcomes of model application within a School of Nursing at a given institution (Hughes & Hood, 2007; Hunter & Krantz, 2010; Jeffreys & Dogan, 2012; Sargent, Sedlak, & Martsolf, 2005). Generally, findings are positive; suggesting that integration of cultural content into nursing curricula can result in increased cultural understanding and knowledge. However, the lack of consistent measurement approaches, with instruments that are reliable and valid and perhaps providing normative scores, makes it difficult to interpret differences across studies. Others have assessed several nursing programs applying different curricular approaches for integrating cultural competence to describe and/or determine if one method is perhaps more effective than another (Kardong-Edgren & Campinha-Bacote, 2008; Kardong-Edgren et al., 2010; Lipson & Desantis, 2007). Generally, the researchers conclude that no one approach was better than another at achieving cultural competence. However, these studies lack research design controls needed to confidently answer the question of which model makes students more culturally competent.

In one of the few published Canadian articles on the topic of integrating both cultural competence and cultural safety, Mahara, Duncan, Whyte, and Brown (2011) describe how one School of Nursing prepared to integrate the A.N.A.C. Framework (2009b) into their baccalaureate nursing curriculum. A two-day strategy session was held involving 26 participants, including Elders, Aboriginal nurses, nursing students and faculty, and nurse educators from three other universities. The session provided a starting point for the School’s implementation plan. One key aspect involved the creation of five exemplars that could be used at different levels of the program. Another important activity was the development of an advocacy statement founded on A.N.A.C.’s literature review and framework and intended as a public policy about the cultural values and activities of the School and the wider University.

Setting a course to move nursing’s cultural competency and cultural safety agenda forward successfully calls for an exploration of the present state of affairs in Schools of Nursing across Canada. Thus, the purpose of the research was to determine the extent to which Anglophone Schools of Nursing in Canada have integrated the concepts of cultural competence and/or cultural safety into the undergraduate nursing curricula and to understand the factors that influence successful integration. Much has been written about the complexities, complementarities, and tensions with the terms cultural competence and cultural safety (Bourque-Bearskin, 2011; Browne et al., 2009; DeSouza, 2008; Drevdahl, Canales, & Dorcy, 2008; Johnstone & Kanitsaki, 2007; Woods, 2010) and although important, it is outside our scope of study. In this study cultural competence is defined as the attitudes, knowledge and skills necessary for providing quality care to diverse populations (A.N.A.C., 2009a; 2009b). Cultural safety extends beyond cultural awareness, sensitivity, and skills-based competencies and is predicated on understanding the power differentials inherent in health care service delivery to redress these inequities through educational processes (A.N.A.C., 2009a; 2009b), focusing on reflexive thinking (Doutrich, Arcus, Dekker, Spuck, & Pollock-Robinson, 2012). From this perspective the theoretical framework in which to assess the level of integration was carefully considered.

Theoretical framework

We selected Donabedian’s classic work on assessing the quality of health care, (Donabedian, 1988; 2005) to help organize our work because of its simplicity and current relevance to understanding the quality of nursing education (Barrere, Delaney, Peterson, & Hickey, 2010; Liu, Edwards, & Courtney, 2011). In addition, Watts, Cuellar, and O’Sullivan (2008) selected the same components of this model when describing the integration of cultural competence education at one School of Nursing in the United States. According to Donabedian (1988), when assessing quality in health care, there are three categories of information to draw on: structure, process, and outcome. His three part approach to assessment is founded on the assumption that “good structure increases the likelihood of good process, and good process increases the likelihood of a good outcome” (p. 1745). We adapted Donabedian’s original definitions of these terms to our focus on examining the “quality” of integration of the concepts of cultural competence and cultural safety within nursing programs. Table 1 provides Donabedian’s original definitions along with our adapted definitions. For both, structure is about the setting, process is what is done, and outcome refers to effects.

Table 1

Areas and definitions from Donabedian’s model (1988; 2005).

Structure
Donabedian’s definition: “Structure denotes the attributes of the settings in which care occurs. This includes the attributes of material resources (such as facilities, equipment, and money), of human resources (such as the number and qualifications of personnel), and of organizational structure (such as medical staff organization, methods of peer review, and methods of reimbursement).” (1988, p. 1745)
Our adapted definition: Structural factors concern the attributes of the educational setting in which integration occurs, including recruitment and retention policies for staff and students, leadership to guide integration, committees or working groups to help facilitate integration, internal and external partnerships or linkages, financial resources and finally, staff education and supports.
Process
Donabedian’s definition: “Process denotes what is actually done in giving and receiving care. It includes the patient’s activities as well as the practitioner’s activities in making a diagnosis and recommending or implementing treatment.” (1988, p. 1745)
Our adapted definition: Process denotes what is actually done in the educational setting to integrate these concepts into the curriculum. It includes having a framework or approach to guide the process, curricula planning and development activities, and student delivery methods and curriculum content.
Outcome
Donabedian’s Definition: “Outcome denotes the effects of care on the health status of patients and populations. Improvements in the patient’s knowledge and salutary changes in the patient’s behaviour are included under a broad definition of health status, and so is the degree of the patient’s satisfaction of care.” (1988, p. 1745)
Our adapted definition: Outcome denotes the effects of integration on staff and students. It includes indicators that Schools have developed to measure whether students have learned cultural competence and/or cultural safety concepts and how these results have been applied to make further adjustments to the curriculum if needed.

Methods

A mixed methods sequential triangulation design was used (Creswell & Clark, 2007; Ploeg et al., 2010) involving qualitative and quantitative data collection (see Figure 1). Ethics approval was granted by a Canadian University Ethics Board.

Phase 1

The main purpose of this phase was to identify items for the phase 2 survey grounded in the experience of Schools involved in integrating the core concepts of interest. We reviewed reports describing integration efforts of six Schools of Nursing involved in piloting the A.N.A.C. Cultural Competency and Cultural Safety framework and another from a School not involved in piloting. Finally, we reviewed the Aboriginal Nurses Association of Canada Literature Review (A.N.A.C, 2009a) and Framework (A.N.A.C, 2009b). We extracted relevant information from these reports and populated a table with questions under three main categories from Donabedian’s model (1988; 2005).

Phase 2

We surveyed Directors/Deans associated with Anglophone Schools of Nursing across Canada drawn from CASN’s membership database for 2010 and selected Schools based on delivery of baccalaureate nursing education and granting such nursing degrees. Our focus on Anglophone Schools was to accommodate budget and time restrictions. The 26-item survey was piloted with three Schools of Nursing. Most were dichotomous or Likert-scale items to obtain information in areas such as level and focus of integration, departmental supports for educators and students, and measurement of student competencies. Following a modified Dillman approach (Salant & Dillman, 1994), data were collected on-line via Survey Monkey from April to June, 2011. After cleaning the data, descriptive analyses were performed using SPSS, along with two by two chi-square tests to examine whether having a champion who promoted integration was related to 11 variables of interest, such as having committees and working groups or other bodies to address the integration of cultural competence and/or cultural safety. A content analysis was done on open-ended questions.

Phase 3

We explored the factors that influenced integration in Schools of Nursing self-classified on the Phase 1 survey as having “moderate or extensive integration” of both cultural competence and cultural safety in their curriculum. A qualitative approach (Patton, 2002) was used involving one-to-one, semi-structured interviews. The interview guide was piloted with two Schools of Nursing. Respondents were asked questions that followed-up on the original survey items, such as process activities related to curriculum planning. Twelve audiotaped interviews were held from September to October, 2011 and lasted for about 45 to 60 minutes. Schools were selected to provide a range in size and geographical location. Transcripts were reviewed and cleaned to correct spelling errors and typos by the principal author. Nvivo9 was used to code and classify codes into contextual, structural, process, and outcome categories. Coding summaries for each node were reviewed by two other investigators. Inconsistencies were solved through consensus.

Figure 1:
Figure 1:

Study design: mixed methods sequential triangulation design.

Citation: International Journal of Nursing Education Scholarship 10, 1; 10.1515/ijnes-2012-0043

Findings

Out of the 82 respondents invited to participate, 39 (47.6%) provided informed consent to take part in the survey. One participant was excluded because data were missing for all items, thus leaving 38 valid respondents. Twelve senior administrators and/or faculty members of Anglophone Schools of Nursing participated in the interviews. One School refused to be interviewed because of the lack of time. An equal number of Universities and Colleges were included and all regions of Canada were represented. Most respondents were at the Dean or Director level (see Table 2). Many survey respondents were faculty members. Interview respondents were mostly Deans or Directors and generally indicated having more years in the position than survey respondents. Both study groups most often reported that between one and 10% of undergraduate/graduate nursing students self-identified as Aboriginal and even fewer faculty members did so. Furthermore, a quarter of survey respondents were unaware of self-identification rates of Aboriginal students.

Table 2

Description of respondent groups.

ItemSurvey # (valid %)Interviews (N = 12)
Position
Dean or Director19(52.7)7(58.3)
Faculty Member17(47.2)2(16.7)
Placement Coordinator2(16.7)
Nursing Instructor1(8.3)
Years in position
Less than 5 years18(48.6)2(16.7)
5–10 years12(32.4)8(66.7)
Greater than 10 years7(18.9)2(16.7)
Undergraduate/graduate nursing students self-identified as Aboriginal
Less than 1%9(25.0)1(8.3)
1–10%11(30.6)5(41.7)
11–25%4(11.1)3(25.0)
26–50%1(2.8)1(8.3)
More than 50%2(5.6)1(8.3)
Don’t know9(25.0)1(8.3)
Faculty members self-identifies as Aboriginal
Less than 1%26(72.2)10(83.3)
1–10%4(11.1)2(16.7)
More than 10%0(0)0(0)
Don’t know6(16.7)

The following section describes four categories of factors involved in the integration of cultural competence and cultural safety in the programs of nursing: Contextual, structural, process, and outcome. Contextual issues emerged as a key category during data analysis and was added to the three derived from Donabedian’s model. This category refers to precipitating and facilitating factors affecting institutional readiness for integration. Results for the 12 qualitative interviews are labeled as a couple (n = 2), a few or some (n = 3), many (n = 4–5), most (n = 7–11), and all (n = 12).

Contextual

As with interview respondents, the majority (33, 89.2%) of survey respondents reported integrating both cultural competence and cultural safety. Most interview respondents identified the Aboriginal population as the primary focus for integration. Most also indicated, however, that other multicultural groups were considered. The most commonly identified environmental influence on the integration of concepts was the need to fulfill competency requirements or guidelines written by an organization(s) that governs the practice of nursing in a province or territory, such as the College of Nursing or the Registered Nursing Association. Positive reactions by the institution and the community about the focus of integration were also frequently mentioned by interview respondents. Interview respondents also identified leadership from top ranks such as the President of the Institution or the Dean, Chair, or Director of the nursing program as a key contextual factor influencing the integration of the concepts.

Structural

Structural factors explored included policies, committees/groups, partnerships, and resources. Both respondent groups indicated that they had policies in place to recruit and retain Aboriginal students. Most, however, lacked or were unaware of policies to recruit and retain Aboriginal Faculty. They also lacked policies or a position statement on cultural competence and/or cultural safety within their School of Nursing or Institution-wide.

Despite recruitment and retention policies for Aboriginal students, many issues were raised in interviews around admission and success rates of these students. Most indicated that Aboriginal students were academically disadvantaged because of inadequate preparation before College or University. Some mentioned the availability of tutors to address specific learning needs: “… we offered tutoring … because it was usually anatomy and physiology that caused the attrition in first year” (ID 5). A couple of respondents discussed a more comprehensive, longitudinal support program for Aboriginal students to address academic, social, financial, and personal needs, such as the Access Program. Mentors (staff or Aboriginal students) and advisors or counsellors, often with a background in social work, were frequently mentioned.

Many survey respondents (15, 41.7%), and all but one interviewee, reported having committees, working groups or other bodies within the School of Nursing mandated to address integration of cultural concepts. Furthermore, there was a significant relationship between having a champion and having committees, working groups or other bodies within the School of Nursing mandated to address the integration of cultural competence and/or cultural safety into undergraduate curriculum: χ2(1, N = 36) = 8.23, p < 0.004. The strength of the association was moderate (φ = 0.48). Within the Schools with a champion, 93.3% had committees mandated to address the integration of cultural competence and/or cultural safety, whereas in the Schools without a champion only 6.7% had these committees.

Most survey and interview respondents indicated that they had formed partnerships and linkages with other departments or groups within their Institution and outside the School of Nursing to integrate the concepts into the curriculum. Interviewees noted that often these involved departments or groups with experience and expertise in working with diverse students, such as the Department of Indigenous Studies, First Nations Department, and the International Education Department. Outside partnerships and linkages with hospitals or community organizations were commonly reported by both groups to access teaching resources and provide students with learning experiences or clinical placements: “… we have the partnerships … with our two Field School communities and it’s a pretty close partnership …” (ID 9). Most of these partnerships were informal unless they involved student placements outside the Institution.

Most survey and interview respondents reported a lack of dedicated financial resources to integrate the concepts. Few survey respondents indicated, for example that special project funding was available during the current academic year (mean = 1.91/5, SD, 1.33) or that an annual fund could be tapped to support the integration of the concepts (mean =1.74/5, SD, 1.26). However, a few interview respondents indicated that financial support was available and/or adequate for Aboriginal related matters.

Survey respondents indicated that educators with knowledge of cultural competence and/or cultural safety were mainly available (mean = 3.70/5, SD, 1.24); however, interview respondents noted a significant lack of human resources, particularly faculty: “… the resource that I see most [lacking] is faculty. Recruitment and retention of faculty is ALWAYS a difficult thing” (ID 3). Dedicated time for faculty to plan, implement, and evaluate the integration of the concepts was reported by survey respondents to be less than moderately available (mean = 2.74/5, SD, 1.46). Interview respondents concurred that faculty were not typically provided with dedicated time for integration activities: “… So in terms of time well, it’s our day to day time that we incorporate in order to get prepared … there” (ID 11). Faculty preparedness was also identified as an important integration resource in the interviews. As one respondent indicated: “… make sure your faculty are prepared at the level with the content that they need to be …” (ID 8). Supports were also deemed important to overcome the barrier or difficulty of bringing “traditional along when you are looking at a … different way of teaching … students” (ID 2).

Presentations/workshops/conferences and the like were the most common methods reported by survey (33, 91.7%) and interview respondents to educate faculty and support them in integrating cultural competence and/or cultural safety into their classrooms. While most interview respondents indicated that faculty reacted quite positively to the support that they were provided, they also expressed a need for more information: “… They want to hear more about what they can do and different ways they can do it … and they want to learn more themselves about the Aboriginal culture …” (ID 1).

Process

Most survey (28, 77.8%) and interview respondents indicated that they were aware of the A.N.A.C. document Cultural Competence and Cultural Safety in Nursing Education: A Framework for First Nations, Inuit and Métis Nursing. The A.N.A.C. Framework was commonly used by interview respondents; however, only a quarter of survey respondents reported similar results (9, 25.0%) despite moderate distribution rates to faculty (13, 46.4%). The use of multiple frameworks or approaches was common to survey and interview respondents: “… I think yes you can take any framework and any model and say there are gaps in it but if you look at several of them, then I think it probably covers it…” (ID 10).

Curriculum planning and development methods mentioned by survey and interview respondents were holding strategy sessions or meetings to review or plan the curriculum and building the curriculum around a common thread, weaving, levelling, or imbedding: “…we don’t have a specific course or specific period of time which is devoted to this, it’s something that is threaded through a number of courses and threaded through all of the years of the program” (ID 5). However, the presence of competing threads in the curriculum was identified as a barrier by a couple of interview respondents “… there are many, many threads such as that” (ID 1). There was also a concern that threading results in a lack of depth in teaching cultural competence and/or cultural safety in the curriculum. Full courses on the topic as opposed to threading were deemed important by most interviewees but only 5 (14%) of the survey respondents reported that this existed in their program.

Educational supports for students that were most often mentioned by survey and interview respondents were case studies (30, 88.2%), other learning resources (29, 82.9%), local placements (28, 82.4%), and presentations (27, 77.1%). Most interviewees also mentioned workshops but under half of survey respondents indicated using workshops as an educational approach for students (14, 40.0%).

Outcome

The most frequently mentioned evaluation process to assess the integration of the concepts in the program identified by close to half of survey respondents (16, 45.7%) was the review of course outlines. Most interview respondents had students review the curriculum or course(s) regarding their perception on the integration of the cultural competence and/or cultural safety. Several indicated that they obtained general feedback from students: “We’ve asked the students really to give us feedback on their perception of cultural competence, cultural safety …” (ID 10). Faculty based curriculum evaluation was noted by several interview respondents as was clinical evaluations of student performance.

The minority of survey (10, 28.6%) and interview respondents indicated that they had developed or applied indicators to measure that students had learned the concepts of cultural competence and/or cultural safety. One interview respondent explained what is lacking in indicator development and application: “… I don’t know that there are exam questions for instance that we are putting in there that speaks specifically to cultural competence…” (ID 5). However, there was one respondent who seemed to be further advanced: “I think the thing that worked the very best was sending students to another country to study and then measuring the results and I purchased cultural tools … I did a pre-and a post-measurement, I had them journal every day … and we actually measured the change in the students …” (ID 3). Several challenges and further work were noted to identify suitable indicators for measurement purposes.

Discussion

This study describes a multitude of factors involved in the integration of cultural competence and/or cultural safety concepts in Schools of Nursing. The following conceptual model (Figure 2) emerged from the analysis of the data collected to explain how Schools of Nursing function to support or inhibit the implementation of cultural competence and/or cultural safety into their curriculum.

The proposed model works in the following way. Institutions become “ready” to integrate the concepts of cultural competence and/or cultural safety by having precipitating environmental conditions, such as the need to fulfill competency requirements or to follow guidelines by Nursing Associations. The need to integrate the concepts then becomes a clear focus as institutions prepare for introducing these concepts. Leadership was a driving force in the creation of the structures and process behind many aspects of integration. Coming from top ranks, it facilitated partnerships and linkages and helped to ensure that resources were in place, staff was adequately prepared, and the curriculum was developed through joint planning. This is supported by Pacquiao (2007) and Siantz (2008) who have identified the importance of leadership in fostering an environment, strategic plan, and mandate.

Once an institution is “ready” it develops or strengthens its structures in support of integration. Siantz (2008) notes the importance of building sustainable policies that support the increase of diversity in nursing education. Policies around recruitment and retention of Aboriginal faculty provide a mechanism to build a pool of Aboriginal educators to mentor and provide visible role models for students. Although such policies were clearly lacking in Schools surveyed, there were policies in place to recruit and retain Aboriginal students, particularly in Schools of moderate to high integration. Typically recruitment was done by allocating a number of dedicated seats to Aboriginal students. In writing about Baccalaureate nursing programs in Saskatchewan, Canada, Anonson, Desjarlais, Nixon, Whiteman, and Bird (2008) contend, however, that there is also a need for strategies for First Nations youth to finish health care programs. We learned from our interviewees, however, that issues around suboptimal success rates of Aboriginal students remain unresolved. Larger system issues need to be addressed because it not just about inadequate student preparation before College or University but rather how the system has failed in educating First Nations, Inuit and Métis populations (Association of Universities and Colleges of Canada [AUCC], and National Aboriginal Achievement Foundation [NAAF], 2011).

Figure 2
Figure 2

Conceptual model of integration of cultural competence and/or cultural safety into Schools of Nursing.

Citation: International Journal of Nursing Education Scholarship 10, 1; 10.1515/ijnes-2012-0043

Committees or working groups are necessary structural factors to keep integration on the institution’s agenda and to move it forward collaboratively. These structures were present in Schools of moderate to high levels of integration. In our model, leadership engagement is identified as a contextual factor. Much is written in the literature about the value of champions in promoting and facilitating an innovation (Hendy & Barlow, 2012; Ploeg et al., 2010; Williams, 2011). As noted in our findings, Schools with a champion were more likely to have these mandated committees than those without one. Multiple partnerships and linkages with internal and external groups were valuable to the Schools of Nursing providing not only support to faculty but also educational supports for students. Anderson, Calvillo, and Fongwa (2007) discuss the reciprocal benefits of community partnerships for their School of Nursing: “… When the community is involved, cultural competent nursing education, clinical practice, and research become complementary and linked components of nursing that enhance and reinforce each other …” (p. 57S).

Without question human resources are important to any curriculum or recruitment initiative. Faculty need to understand the concepts of cultural competence and/or cultural safety before they can teach it and require education and supports that may come in various forms. Despite access to a wide variety of tools, our interview findings suggest that faculty wanted more information. These finding are similar to those of many researchers (Kennedy, Fisher, Fontaine, & Martin-Holland, 2008; Lipson & Desantis, 2007; Sealy, Burnett, & Johnson, 2006; Wepa, 2003) who have found that educators need more knowledge preparation and support to deliver a cultural competence and/or cultural safety curriculum.

Processes follow the development of structures or may be introduced in a parallel manner. Having a framework to guide integration provided important content for introducing concepts and helped to ensure that educators were following the same path. Our study suggested that the A.N.A.C. Framework was commonly applied by Schools of moderate and high integration levels augmented by other models. We learned from interviewees that building a new curriculum often involved integrating cultural competence and/or cultural safety concepts throughout various courses and using experiential learning methods rather than loading it into one course exclusively. This approach is supported by other program developers (Calvillo et al., 2009; Jeffreys & Dogan, 2012; Mahara, Duncan, Whyte, & Brown, 2011). Furthermore, experience and wisdom of an esteemed scholar and nurse educator on our team, suggests that students need to first learn more about themselves and one important means of doing this is to live with a culture different than their own. This immersion helps them to become more empathetic, flexible, caring, understanding, and compassionate and thus more open to understanding and providing cultural competent and culturally safe care.

Finally, it is important to assess faculty and student responses to curriculum changes, measure whether students are successfully mastering acquired skills, and identify areas for further improvements. Study findings suggest that outcomes are the least developed area by Schools surveyed and interviewed, with few indicating that they had developed or applied indicators to measure that students had learned the concepts of cultural competence and/or cultural safety. The paucity of outcomes research in this area is confirmed by many investigators (Higginbottom et al., 2011; Hunter & Krantz, 2010). Yet the literature suggests that there are several options available, notably in systematic reviews of over 44 instruments measuring cultural competence conducted by Kumas-Tan, Beagan, Loppie, MacLeod, and Frank (2007) and Gozu et al. (2007). While these instruments may lack rigour, they provide a starting point to create a robust measurement approach for cultural competence. Nonetheless, the complexity of cultural competence and cultural safety suggest that a mixed method approach might be more appropriate than one relying exclusively on instrument scores (Calvillo et al., 2009). Qualitative options could help to meaningfully demonstrate an understanding of these concepts and include student’s cultural competence portfolios (Hughes & Hood, 2007; Tuck, Moon, & Allocca, 2010); standard patients for assessment (Rutledge, Garzon, Scott, & Karlowicz, 2004); and patient vignettes (Kardong-Edgren et al., 2010).

Limitations of the study

This study has a number of limitations. The survey was a self-report and is therefore subject to reporting bias. Sampling for interviews was based on self-perceived levels of integration, which we were unable to verify objectively, and did not include Schools at lower levels of integration. Furthermore, not all respondents were in the position of Dean or Director, which could have limited their knowledge base when answering questions related to resources available as one example. Conversely, since most were from higher-level positions this could have limited their input on activities and issues taking place in the classroom and the contextual factors identified by Faculty members.

Conclusion

This study provides theoretical and practical implications for introducing the concepts of cultural competence and/or cultural safety in nursing education. More specifically, it highlights important contextual, structural, process and outcome indicators that will support the delivery of nursing education in diverse non-traditional/local community clinical placement settings that represent the growing cultural diversity of Canadian society. It is a reminder to Faculty working on expanding the curriculum to include local and/or Indigenous knowledge systems. This approach requires a mindset that values multiply perspectives when incorporating cultural competency or cultural safety constructs into nursing curricula. The potential gain from this diversity must be grounded in political, socioeconomic circumstances if nursing is to truly embrace a social justice framework that is espoused in current practice.

It is recommended that future research be directed at answering the following questions: Does integration of these concepts in baccalaureate programs have a lasting effect through the development of cultural competence or should there be continuing education reinforcement and if so how frequently? What teaching approaches are the most effective? How can we improve recruitment and retention efforts for Aboriginal students and faculty? What are effective means of preparing and supporting faculty? Can improved culturally competent and culturally safe educational systems help educators become more responsive to the needs of diverse student populations? What is an appropriate process and outcome measurement strategy?

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  • Creswell, J. W., & Clark, V. L. (2007). Designing and conducting mixed methods research. Thousand Oaks, CA: Sage.

    • Google Scholar
    • Export Citation
  • DeSouza, R. (2008). Wellness for all: The possibilities of cultural safety and cultural competence in New Zealand. Journal of Research in Nursing, 13(2), 125135.

    • Google Scholar
    • Export Citation
  • Donabedian, A. (2005). Evaluating the quality of medical care. The Millbank Quarterly, 83(4), 691729.

  • Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 17431748.

  • Douglas, M. K., Pierce, J. U., Rosenkoetter, M., Pacquiao, D., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., … Purnell, L. (2011). Standards of practice for culturally competent nursing care: 2011 update. Journal of Transcultural Nursing, 22(4), 317333.

    • Google Scholar
    • Export Citation
  • Doutrich, D., Arcus, K., Dekker, L., Spuck, J., & Pollock-Robinson, C. (2012). Cultural safety in New Zealand and the United States: Looking at a way forward together. Journal of Transcultural Nursing, 23(2), 143150.

    • Google Scholar
    • Export Citation
  • Drevdahl, D. J., Canales, M. K., & Dorcy, K. S. (2008). Of goldfish tanks and moonlight tricks: Can cultural competency ameliorate health disparities? Advances in Nursing Science, 31(1), 1327.

    • Google Scholar
    • Export Citation
  • Gozu, A., Beach, M. C., Price, E. G., Gary, T. L., Robinson, K., Palacio, A., … Cooper, L. A. (2007). Self-administered Instruments to Measure Cultural Competence of Health Professionals: A systematic review. Teaching and Learning in Medicine, 19(2),180190.

    • Google Scholar
    • Export Citation
  • Hendy, J., & Barlow, J.(2012). The role of the organizational champion in achieving health system change. Social Science & Medicine, 74, 348355.

    • Google Scholar
    • Export Citation
  • Higginbottom, G. M. A., Richter, M. S., Mogale, R. S., Ortiz, L., Young, S., & Mollel, O. (2011). Identification of nursing assessment models/tools validated in clinical practice for use with diverse ethno-cultural groups: An integrative review of the literature. BMC Nursing, 10(16), 111.

    • Google Scholar
    • Export Citation
  • Hughes, K. H., & Hood, L. J. (2007). Teaching methods and an outcome tool for measuring cultural sensitivity in undergraduate nursing students. Journal of Transcultural Nursing, 18(1), 5762.

    • Google Scholar
    • Export Citation
  • Hunter, J. L., & Krantz, S. (2010). Constructivism in cultural competence education. Journal of Nursing Education, 49(4), 207214.

    • Google Scholar
    • Export Citation
  • Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students’ transcultural self-efficacy perceptions. Journal of Transcultural Nursing, 23(2), 188197.

    • Google Scholar
    • Export Citation
  • Johnstone, M. J., & Kanitsaki, O. (2007). An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context. Journal of Transcultural Nursing, 18(3), 247256.

    • Google Scholar
    • Export Citation
  • Kardong-Edgren, S., & Campinha-Bacote, J. (2008). Cultural competency of graduating US Bachelor of Science nursing students. Contemporary Nurse, 28, 3744.

    • Google Scholar
    • Export Citation
  • Kardong-Edgren, S., Cason, C. L., Walsh Brennan, A. M., Reifsnider, E., Hummel, F., Mancini, M., & Griffin, C. (2010). Cultural competency of graduating BSN nursing students. Nursing Education Research, 31(5), 278285.

    • Google Scholar
    • Export Citation
  • Kennedy, H. P., Fisher, L., Fontaine, D., & Martin-Holland, J. (2008).Evaluating diversity in nursing education: A mixed method study. Journal of Transcultural Nursing, 19(4),363370.

    • Google Scholar
    • Export Citation
  • Kumas-Tan, Z., Beagan, B., Loppie, C., MacLeod, A., & Frank, B. (2007). Measure of cultural competence: Examining hidden assumptions. Academic Medicine, 82(6), 548557.

    • Google Scholar
    • Export Citation
  • Lipson, J. G., & Desantis, L. A. (2007). Current approaches to integrating elements of cultural competence in nursing education. Journal of Transcultural Nursing, 18(Suppl 1), 10S20S.

    • Google Scholar
    • Export Citation
  • Liu, W., Edwards, H., & Courtney, M. (2011). The development and descriptions of an evidence-based case management educational program. Nurse Education Today, 31, e51e57.

    • Google Scholar
    • Export Citation
  • Mahara, M. S., Duncan, S., Whyte, N., & Brown, J. (2011). It takes a community to raise a nurse: Educating for culturally safe practice with Aboriginal Peoples. International Journal of Nursing Education Scholarship, 8(1), 112.

    • Google Scholar
    • Export Citation
  • National Aboriginal Achievement Foundation [NAAF]. (2011). Moving forward: National working summit on Aboriginal postsecondary education. Ottawa, ON: NAAF.

    • Google Scholar
    • Export Citation
  • National Aboriginal Health Organization [NAHO]. (2008). Cultural competency and safety: A guide for health care administrators, providers and educators. Ottawa, ON: NAHO.

    • Google Scholar
    • Export Citation
  • Pacquiao, D. (2007). The relationship between cultural competence education and increasing diversity in nursing schools and practice settings. Journal of Transcultural Nursing, 18(1), 28S37S.

    • Google Scholar
    • Export Citation
  • Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage.

  • Ploeg, J., Skelly, J., Rowan, M., Edwards, N., Davies, B., Grinspun, D., … Downey, A.(2010). The role of nursing best practice champions in diffusing guidelines: A mixed methods study. Worldviews on Evidence-Based Nursing, 7(4), 238251.

    • Google Scholar
    • Export Citation
  • Royal Commission on Aboriginal Peoples. (1996). The Report of the Royal Commission on Aboriginal Peoples. Retrieved from http://www.parl.gc.ca/Content/LOP/ResearchPublications/prb9924-e.htm

    • Google Scholar
    • Export Citation
  • Rutledge, C. M., Garzon, L., Scott, M., & Karlowicz, K.(2004). Using standardized patients to teach and evaluate nurse practitioner students on cultural competency. International Journal of Nursing Education Scholarship, 1(1), 116.

    • Google Scholar
    • Export Citation
  • Salant, P., & Dillman, D. A. (1994). How to conduct your own survey. Toronto ON: John Wiley & Sons.

  • Sargent, S. E., Sedlak, C. A., & Martsolf, D. S. (2005). Cultural competence among nursing students and faculty. Nurse Education Today, 25, 214221.

    • Google Scholar
    • Export Citation
  • Sealy, L. J., Burnett, M., & Johnson, G. (2006). Cultural competence of Baccalaureate nursing faculty: Are we up to the task? Journal of Cultural Diversity, 13(3), 131140.

    • Google Scholar
    • Export Citation
  • Siantz, M. L. de L. (2008). Leading change in diversity and cultural competence. Journal of Professional Nursing, 24(3), 167171.

    • Google Scholar
    • Export Citation
  • Tuck, I., Moon, M. W., & Allocca, P. N. (2010). An integrative approach to cultural competence education for advanced practice nurses. Journal of Transcultural Nursing, 21(4), 402409.

    • Google Scholar
    • Export Citation
  • Watts, R. J., Cuellar, N. G., & O’Sullivan, A. L. (2008). Developing a blueprint for cultural competence education at Penn. Journal of Professional Nursing, 24(3), 136142.

    • Google Scholar
    • Export Citation
  • Wepa, D. (2003). An exploration of the experiences of cultural safety educators in New Zealand: An action research approach. Journal of Transcultural Nursing, 14(4), 339348.

    • Google Scholar
    • Export Citation
  • Williams, I. (2011). Organizational readiness for innovation in health care: Some lessons from the recent literature. Health Services Management Research, 24(4), 213218.

    • Google Scholar
    • Export Citation
  • Woods, M. (2010). Cultural safety and the socioethical nurse. Nursing Ethics, 17(6), 715725.

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  • Aboriginal Nurses Association of Canada. (2009a). Cultural competence & cultural safety in first nations, Inuit and Métis nursing education: An integrated review of the literature. Retrieved from http://www.anac.on.ca/Documents/Making%20It%20Happen%20Curriculum%20Project/FINALReview ofLiterature.pdf

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  • Creswell, J. W., & Clark, V. L. (2007). Designing and conducting mixed methods research. Thousand Oaks, CA: Sage.

    • Google Scholar
    • Export Citation
  • DeSouza, R. (2008). Wellness for all: The possibilities of cultural safety and cultural competence in New Zealand. Journal of Research in Nursing, 13(2), 125135.

    • Google Scholar
    • Export Citation
  • Donabedian, A. (2005). Evaluating the quality of medical care. The Millbank Quarterly, 83(4), 691729.

  • Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 17431748.

  • Douglas, M. K., Pierce, J. U., Rosenkoetter, M., Pacquiao, D., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., … Purnell, L. (2011). Standards of practice for culturally competent nursing care: 2011 update. Journal of Transcultural Nursing, 22(4), 317333.

    • Google Scholar
    • Export Citation
  • Doutrich, D., Arcus, K., Dekker, L., Spuck, J., & Pollock-Robinson, C. (2012). Cultural safety in New Zealand and the United States: Looking at a way forward together. Journal of Transcultural Nursing, 23(2), 143150.

    • Google Scholar
    • Export Citation
  • Drevdahl, D. J., Canales, M. K., & Dorcy, K. S. (2008). Of goldfish tanks and moonlight tricks: Can cultural competency ameliorate health disparities? Advances in Nursing Science, 31(1), 1327.

    • Google Scholar
    • Export Citation
  • Gozu, A., Beach, M. C., Price, E. G., Gary, T. L., Robinson, K., Palacio, A., … Cooper, L. A. (2007). Self-administered Instruments to Measure Cultural Competence of Health Professionals: A systematic review. Teaching and Learning in Medicine, 19(2),180190.

    • Google Scholar
    • Export Citation
  • Hendy, J., & Barlow, J.(2012). The role of the organizational champion in achieving health system change. Social Science & Medicine, 74, 348355.

    • Google Scholar
    • Export Citation
  • Higginbottom, G. M. A., Richter, M. S., Mogale, R. S., Ortiz, L., Young, S., & Mollel, O. (2011). Identification of nursing assessment models/tools validated in clinical practice for use with diverse ethno-cultural groups: An integrative review of the literature. BMC Nursing, 10(16), 111.

    • Google Scholar
    • Export Citation
  • Hughes, K. H., & Hood, L. J. (2007). Teaching methods and an outcome tool for measuring cultural sensitivity in undergraduate nursing students. Journal of Transcultural Nursing, 18(1), 5762.

    • Google Scholar
    • Export Citation
  • Hunter, J. L., & Krantz, S. (2010). Constructivism in cultural competence education. Journal of Nursing Education, 49(4), 207214.

    • Google Scholar
    • Export Citation
  • Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students’ transcultural self-efficacy perceptions. Journal of Transcultural Nursing, 23(2), 188197.

    • Google Scholar
    • Export Citation
  • Johnstone, M. J., & Kanitsaki, O. (2007). An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context. Journal of Transcultural Nursing, 18(3), 247256.

    • Google Scholar
    • Export Citation
  • Kardong-Edgren, S., & Campinha-Bacote, J. (2008). Cultural competency of graduating US Bachelor of Science nursing students. Contemporary Nurse, 28, 3744.

    • Google Scholar
    • Export Citation
  • Kardong-Edgren, S., Cason, C. L., Walsh Brennan, A. M., Reifsnider, E., Hummel, F., Mancini, M., & Griffin, C. (2010). Cultural competency of graduating BSN nursing students. Nursing Education Research, 31(5), 278285.

    • Google Scholar
    • Export Citation
  • Kennedy, H. P., Fisher, L., Fontaine, D., & Martin-Holland, J. (2008).Evaluating diversity in nursing education: A mixed method study. Journal of Transcultural Nursing, 19(4),363370.

    • Google Scholar
    • Export Citation
  • Kumas-Tan, Z., Beagan, B., Loppie, C., MacLeod, A., & Frank, B. (2007). Measure of cultural competence: Examining hidden assumptions. Academic Medicine, 82(6), 548557.

    • Google Scholar
    • Export Citation
  • Lipson, J. G., & Desantis, L. A. (2007). Current approaches to integrating elements of cultural competence in nursing education. Journal of Transcultural Nursing, 18(Suppl 1), 10S20S.

    • Google Scholar
    • Export Citation
  • Liu, W., Edwards, H., & Courtney, M. (2011). The development and descriptions of an evidence-based case management educational program. Nurse Education Today, 31, e51e57.

    • Google Scholar
    • Export Citation
  • Mahara, M. S., Duncan, S., Whyte, N., & Brown, J. (2011). It takes a community to raise a nurse: Educating for culturally safe practice with Aboriginal Peoples. International Journal of Nursing Education Scholarship, 8(1), 112.

    • Google Scholar
    • Export Citation
  • National Aboriginal Achievement Foundation [NAAF]. (2011). Moving forward: National working summit on Aboriginal postsecondary education. Ottawa, ON: NAAF.

    • Google Scholar
    • Export Citation
  • National Aboriginal Health Organization [NAHO]. (2008). Cultural competency and safety: A guide for health care administrators, providers and educators. Ottawa, ON: NAHO.

    • Google Scholar
    • Export Citation
  • Pacquiao, D. (2007). The relationship between cultural competence education and increasing diversity in nursing schools and practice settings. Journal of Transcultural Nursing, 18(1), 28S37S.

    • Google Scholar
    • Export Citation
  • Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage.

  • Ploeg, J., Skelly, J., Rowan, M., Edwards, N., Davies, B., Grinspun, D., … Downey, A.(2010). The role of nursing best practice champions in diffusing guidelines: A mixed methods study. Worldviews on Evidence-Based Nursing, 7(4), 238251.

    • Google Scholar
    • Export Citation
  • Royal Commission on Aboriginal Peoples. (1996). The Report of the Royal Commission on Aboriginal Peoples. Retrieved from http://www.parl.gc.ca/Content/LOP/ResearchPublications/prb9924-e.htm

    • Google Scholar
    • Export Citation
  • Rutledge, C. M., Garzon, L., Scott, M., & Karlowicz, K.(2004). Using standardized patients to teach and evaluate nurse practitioner students on cultural competency. International Journal of Nursing Education Scholarship, 1(1), 116.

    • Google Scholar
    • Export Citation
  • Salant, P., & Dillman, D. A. (1994). How to conduct your own survey. Toronto ON: John Wiley & Sons.

  • Sargent, S. E., Sedlak, C. A., & Martsolf, D. S. (2005). Cultural competence among nursing students and faculty. Nurse Education Today, 25, 214221.

    • Google Scholar
    • Export Citation
  • Sealy, L. J., Burnett, M., & Johnson, G. (2006). Cultural competence of Baccalaureate nursing faculty: Are we up to the task? Journal of Cultural Diversity, 13(3), 131140.

    • Google Scholar
    • Export Citation
  • Siantz, M. L. de L. (2008). Leading change in diversity and cultural competence. Journal of Professional Nursing, 24(3), 167171.

    • Google Scholar
    • Export Citation
  • Tuck, I., Moon, M. W., & Allocca, P. N. (2010). An integrative approach to cultural competence education for advanced practice nurses. Journal of Transcultural Nursing, 21(4), 402409.

    • Google Scholar
    • Export Citation
  • Watts, R. J., Cuellar, N. G., & O’Sullivan, A. L. (2008). Developing a blueprint for cultural competence education at Penn. Journal of Professional Nursing, 24(3), 136142.

    • Google Scholar
    • Export Citation
  • Wepa, D. (2003). An exploration of the experiences of cultural safety educators in New Zealand: An action research approach. Journal of Transcultural Nursing, 14(4), 339348.

    • Google Scholar
    • Export Citation
  • Williams, I. (2011). Organizational readiness for innovation in health care: Some lessons from the recent literature. Health Services Management Research, 24(4), 213218.

    • Google Scholar
    • Export Citation
  • Woods, M. (2010). Cultural safety and the socioethical nurse. Nursing Ethics, 17(6), 715725.

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The International Journal of Nursing Education Scholarship (IJNES) publishes significant research and scholarship in the broad field of nursing education. The mandate of the journal is to present high quality papers to advance nursing education through research, description of innovative methods, or introduction of novel approaches about all aspects of nursing education in a timely manner.

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    Study design: mixed methods sequential triangulation design.

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    Conceptual model of integration of cultural competence and/or cultural safety into Schools of Nursing.