1. Smith, Linda S. PhD, MS, RN, CLNC

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The following article is the second in a two-part series on culturally competent nursing education (CCNE).


AS UNIQUE and diverse individuals, nurses and nursing students have culturally learned beliefs, practices, attitudes, and preferences that may differ significantly from those held by peers and faculty. Thus, culturally competent nurses need to apply cultural competence techniques and strategies when working with peers, colleagues, administrators, and faculty. Achieving a diverse body of nursing students, and thereby a diverse nursing workforce, is essential to the application of culturally competent nursing care. Unfortunately, although nursing student and nursing graduate diversity has improved, we're far from meeting this goal.


Today's nursing student and graduate populations are more diverse than their predecessors, but they're not yet representative of national diversity levels (see Diversity comparison). When identifying race-ethnicity diversity, the number of minorities enrolled in basic RN programs for 2014 was 35.1%.3


The first installment in this series explored culturally competent nursing education (CCNE) from the nurse educator's point of view. Here, the focus is on culturally competent nursing students (CCNSs). Besides discussing the importance of cultural competence, this article examines how and why nursing students can apply cultural competence strategies in the classroom and in clinical settings. Although the focus is on students, experienced clinical nurses can use the same strategies to connect and communicate more competently with their patients, each other, and facility administrators.


Diversity can refer to many different characteristics, but this article deals with cultural diversity; a discussion of age and gender diversity is beyond the scope of this article.

Table Diversity comp... - Click to enlarge in new windowTable Diversity comparison


"First, know thyself," is a phrase that can be traced back to ancient Greece. The phrase applies well to cultural competence. CCNSs first learn to explore their own cultural competence. A lifelong endeavor, cultural competence is a continuous learning process of sensitivity, respect, and understanding of others' diversity.4,5 This process requires students to evaluate their own abilities to be culturally competent and empathetic toward patients, peers, faculty, and administrators.


Self-assessment begins with an understanding of the student's own nursing profession motives and goals. Spending time documenting these beliefs is extremely valuable.6 This analysis helps loosen deeply held beliefs, traditions, prejudices, biases, stereotypes, mistaken beliefs, and assumptions.7


During this self-assessment, CCNSs can ask themselves the following:5,7-10


* Do I resent or fear peers who believe and behave differently than I do, or do I carefully listen to, support, and respect diverse opinions?


* Do I understand how my own cultural background and experiences have molded my thinking and behavior? How are these life themes different from those of my peers, colleagues, faculty, and administrators? How do I respond to these differences?


* Have I chosen learning opportunities that expand my own view rather than simply supporting what I already believe?


* How have my interactions with peers and faculty supported the learning environment?


* How do I interact with diverse colleagues, peers, and faculty, and how do I manage conflict in and out of class? If a video camera were to record these interactions, what verbal and nonverbal behaviors would it capture?


* Do I consistently challenge personal and professional assumptions regarding my peers' diverse characteristics?


* How have I reached out to peers with outsider characteristics? Have I included all diverse peers in the learning process (for example, group work and online discussions)?


* Am I guilty of ethnocentrism, identifying and judging others from my own cultural perspective?


* When I discover unmet learning needs, confusion, or frustration, how have I reached out to faculty and student support services?


* What are my beliefs about learning and the teaching-learning process? How do I respond when others have different beliefs?


* How do I respond to emotionally charged situations, in and outside of class or clinical? How is my response similar/different from my diverse peers'?


* Do I consistently use assertive communication techniques (clear, concise, neutral statements) to describe personal beliefs and perspectives versus aggressive, emotional "you" statements? Do I consider how my behaviors will affect others, prior to speaking?


* How do I respond and behave when witnessing cultural incompetence, incivility, and bullying in educational and clinical settings?



Understanding faculty, colleagues, and peers

Diversity among nurse educators is significantly different from the student groups they teach. Just 14.4% of nurse educators (improved from 10% a decade ago) are from minority groups.2 Thus, the cultural gap between faculty and student groups can be significant. Consequently, unsupported cultural assumptions and misunderstandings may occur. All members of the prelicensure nursing education community understand, however, that quality relationships with faculty and peers is an essential ingredient in a teaching-learning environment that supports education, retention, and successful graduation of each nursing student.11 Each student's goals, engagement, and achievement depend on nurturing culturally competent relationships with educators.11


Furthermore, a student's approach to academic work is culturally linked. For example, Western society's emphasis on independent effort and thought contrasts with other cultural groups that value group achievement above personal gain.12 To avoid or mitigate conflict, CCNSs use diversity competence strategies in their interactions with peers, colleagues, faculty, education administrators, and patients. (See CCNS skills and techniques.)


Assertive communication

Assertive communication is neither aggressive nor passive; rather, it's a nonthreatening way to communicate information, ideas, and beliefs. When a CCNS witnesses cultural incompetence and incivility, such as when peers or colleagues bully, taunt, harass, or challenge others, he or she should intervene assertively and as soon as possible, but in private. Challenging bullying, uncivil, and harassing behaviors enhances the profession and improves patient care.19


Assertive communication addresses the behavior, not the person. Here's an example of how a CCNS could communicate assertively with a peer:


"I believe you're unaware that your comments and assumptions about Vietnamese patients are hurtful and harmful to others, including me. These behaviors also harm the entire education and patient care process for us all. Just like me, I know you're here to be a good nurse but I think your actions are damaging and culturally intolerant. Please refrain from this behavior."


Culturally incompetent and intolerant communication includes nonverbal microaggressions toward others, including faculty and administrators. Examples include eye rolling, loud yawning or sighs, and closed or aggressive postures. These behaviors should also be challenged.


If relevant, consider reminding peers and colleagues who resist changing their behavior of their signed behavioral contract, such as the facility's code of conduct. (See Assertive communication resources.)


Culturally competent clinical strategies

A core belief in nursing is the application of principles of culturally competent care within the patient-care environment. As students, nurses learn cultural competent care concepts and processes in their first nursing course, and implementation of these concepts during clinical performance should be monitored and evaluated. To best formulate and implement these strategies during clinical experiences, CCNSs seek assignments with culturally diverse communities and patients whenever possible and appropriate. They may also wish to engage in cultural emersion activities and projects within their own geographic area, as well as nationally and internationally.


Lifelong learning

Cultural competence is an ongoing, constantly evolving process that requires a commitment to continuous self-assessment and to personal and professional behaviors and experiences that support cultural competence. As new nurses, CCNSs will choose peers and mentors who positively impact their lives and careers.4 Extending cultural competence expertise within the healthcare and teaching-learning environments supports lifelong learning, workforce diversity, and professional nursing practice.


Assertive communication resources












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