Cultural competency of graduating BSN nursing students.
Key Words Cultural Competency--Nursing Curricula--Baccalaureate Nursing Students
RESPONDING TO PATIENTS WITH APPROPRIATE CULTURAL SENSITIVITY IS AN ESSENTIAL COMPETENCY FOR NURSES, THE HEALTH CARE PROVIDERS WITH THE MOST PATIENT CONTACT. As demographic patterns in the United States and worldwide shift and as consumers of health care become more diverse, cultural sensitivity has become imperative among all health care providers. * Driven by both increased diversity among consumers of health care and accrediting board maxims, most nursing programs include cultural competency as a program outcome. However, "despite 50 years of transcultural nursing knowledge development through theory, research, and practice, there remains a lack of formal, integrated cultural education into nursing" (Omeri, 2008, p. x). Current curricular approaches include such activities/programs as service-learning projects (Worrell-Carlisle, 2005); cultural immersion abroad (Jones, 2005; Kollar & Ailinger, 2002; Walsh & DeJoseph, 2003; Woods & Atkins, 2006); cultural immersion within other cultures at home (Sloand, Groves, & Brager, 2004); and free-standing cultural courses. * Integration into the curriculum is the most frequently reported curricular methodology for achieving cultural competency as a program outcome (Kardong-Edgren et al., 2005; Lipson & DeSantis, 2007). However, as Brennan and Cotter (2008) report, such an approach is neither robust nor efficient. Their evaluation of student perceptions of cultural competency as implemented within an integrated undergraduate curriculum revealed a heavy didactic emphasis on culture and cultural competency with little clinical application. They also found that the same content and examples were used repeatedly. * Integration of cultural competency learning processes and activities into an undergraduate curriculum too often translates into "implementation by an ad hoc committed few" (Boyle, 2007, p. 2IS). If a strong curricular thread has not been articulated and documented, content and strategies may be lost when the committed few move on or change teaching assignments. Some programs have used content mapping followed by content leveling across the curriculum to improve integration of cultural competency. A recent surge in special themed issues of nursing education journals may indicate that a tipping point has been reached and that nurse educators are searching for evidence-based teaching practices for cultural content. * THIS STUDY begins examination of the evidence by evaluating the program outcomes of six undergraduate nursing programs. Each employed a different curricular methodology for teaching cultural competency. Graduates from each program completed the same standardized inventory to measure cultural competency. This approach to evaluate the outcomes of different curricular methodologies has not been previously reported in the literature. Preliminary study results on first-semester data from four of the six programs were reported by Kardong-Edgren and Campinha-Bacote (2008).
Theoretical Framework Campinha-Bacote's (2003) Cultural Competency Care Model provided the conceptual framework for the study. Campinha-Bacote argues that the key to cultural competency is cultural desire, wanting to, rather than having to, learn and interact with other cultures. This definition is the basis for the other model constructs: cultural awareness, recognition of ethnocentrism and a willingness to learn about other worldviews, cultural similarities, and differences; cultural knowledge, which provides a strong educational base about other cultural beliefs, health practices including incidence and prevalence of diseases, and treatment efficacies; cultural skill, which relates to the opportunity to practice conducting holistic health assessments, including psychosocial assessments; and cultural encounters, necessary to build real-world experience. For purposes of this study, Campinha-Bacote's definition of cultural competency was used: "The process in which the healthcare provider continuously strives to achieve the ability to work effectively within the cultural context of a client, individual, family or community" (p. 54).
Literature Review Many studies have been conducted to evaluate the cultural competency of both nursing and medical students (Bond, Kardong-Edgren, & Jones, 2001; Krainovich-Miller et al., 2008; Ladson, Lin, Flores, & Magrane, 2006; Napholz, 1999; Nokes, Nickitas, Keida, & Neville, 2005; Park et al., 2005; Schlosser, Bourrand, Warr, & Lowe, 2004; Zorn, Ponick, & Peck, 1995) with mixed results. Senior nursing students were found to experience greater self-confidence with international study abroad experiences (Schlosser et al.; Zorn et al.). When cultural competency measurement scores failed to increase, researchers often cited decreased student naivete concerning the complexity of what was actually involved with providing culturally competent care (St. Clair & McKenry, 1999).
Nokes et al. (2005) evaluated changes in Campinha-Bacote's Inventory for Assessing the Process of Cultural Competency Among Healthcare Professionals-R[R] (IAPCC-R) scores in RN-BSN students after a community-based service-learning project. All scores remained in the culturally aware range but were lower after the intervention. The authors surmised that first scores might have indicated what students thought they knew, whereas second scores indicated that based on actual experiences, students realized they did not know what they thought they knew.
Sargent, Sedlak, and Martsolf (2005) used the IAPCC-R to compare first-year to fourth-year BSN students. They found that 6 percent of first-year students scored in the culturally competent range compared with 13 percent of fourth-year students. However, the majority of fourth-year students scored in the culturally aware range on the IAPCC-R. These authors provide one of the few articles found in the literature evaluating the cultural competency of a program's graduates.
Another factor making assessment of cultural competency in students difficult is a lack of appropriately normed instrumentation for this group. Most cultural competency tools have been normed on practicing nurses. Coffman, Shellman, and Bernal (2004), authors of the Cultural Self-Efficacy Scale (CSES), a tool frequently used for measuring cultural competency, recommended avoiding the use of this tool with students, stating that "students may lack the experience needed to be aware of what they do not know" (p. 184). Both Campinha-Bacote (Fitzgerald, Cronin, & Campinha-Bacote, 2009) and the Association of American Medical Colleges (2005) have developed or are now developing tools normed for students (see www.aamc.org/meded/tacct/start.htm).
Method This descriptive study used a posttest-only design to measure and compare the cultural competency of nursing students graduating from six BSN nursing programs in the United States. Snowball sampling was used to select six programs, whose faculty were known to the primary author through a professional transcultural nursing organization. Each was selected based on meeting the following criteria: different curricular approaches to teaching cultural concepts. Institutional review board approval was obtained by each study site. Cultural competency was measured using Campinha-Bacote's (2010) Inventory for Assessing the Process of Cultural Competency Among Healthcare Professionals-Revised. Data were collected for one academic year (two semesters).
THE SIX NURSING PROGRAMS Program 1 is a private Catholic university located in a large city in the Northeast. Campinha-Bacote's concepts of awareness, knowledge, skill, and encounters are incorporated into this community-based program by courses and educational opportunities. Students are relatively homogeneous in terms of socioeconomic status, gender, and ethnicity. One faculty member is certified in transcultural nursing and has input into curricular planning. No single transcultural theoretical approach is emphasized within the program.
Nursing students are introduced to cultural concepts in a three-credit, freshman, transcultural responses to health care course, which serves as the anchor for integrated cultural content throughout the program. Many clinical experiences take place in one of five underserved neighborhoods in the city. To build experience with a population, students remain in a chosen neighborhood throughout their clinical experiences. A sister school in Nicaragua provides summer clinical experiences for about 15 students biannually.
Program 2, located in a large urban area in the Northeast, incorporates Campinha-Bacote's concepts of cultural awareness, skill, knowledge, and encounters. Cultural competency is integrated throughout the program, and the students develop cultural awareness as they are exposed to a variety of liberal arts courses required by the university. In the freshman-year introduction to nursing course, students are exposed to the concepts of health care disparities and cultural diversity. As sophomores, they learn to do culturally sensitive health histories and assessments and discuss other culturally related topics. Students are introduced to a variety of diverse patient populations in well settings. Juniors and seniors participate in acute and community care placement situations where they meet patients from various backgrounds, as well as international patients who seek treatment at a large health care system. Juniors may elect to participate in international study abroad opportunities. Cultural topics are threaded through the curriculum (e.g., in one course, students evaluate culturally specific research).
Program 3, located in a rural, agricultural western community, also incorporates Campinha-Bacote's concepts of cultural awareness, skill, knowledge, and encounters. Students enrolled in the nursing program and nurse faculty are relatively homogeneous in terms of socioeconomic status, gender, and ethnicity. Faculty, several of whom are certified in transcultural nursing, are committed to cultural competence as a hallmark of quality nursing care.
Cultural competence has become a centerpiece of nursing education at this school of nursing. The curriculum is structured to include cultural content that conceptually builds and expands on knowledge from previous courses. A faculty subcommittee, with expertise in Leininger's culture care theory and practice, regularly evaluates the curriculum and makes recommendations for curricular development and refinement. Feedback from students is also considered.
In response to feedback about students' perceptions of overlap and duplication of content, the curriculum was revised to demonstrate a progression in knowledge, experience, and skill development. The cultural focus of each semester is made explicit. For example, in the first semester, the focus is other: differences and similarities in physiological aspects of the patient, as well as values, beliefs, and practices within the context of family. This is facilitated through patient care and interaction in the acute care and long-term settings. In the following semester, students examine their own cultural values, beliefs, and practices by conducting an ethnographic interview with a family member. They compare and contrast their cultural selves in relation to their peers as well as their patients. Later, students explore the intersection of individual and family cultural beliefs and lifeways within the context of the health care system, in acute or community-based settings. In the practice setting and the classroom, nursing students identify and implement strategies to accommodate and honor the culture care practices of clients and their families.
All nurse faculty use written assignments, classroom activities, and clinical performance guidelines, all of which highlight culture care, to engage in formative evaluation of the cultural knowledge, awareness, and skills of students. Program outcome measures of cultural competence are assessed through quantitative and qualitative measures, including outcome essays and surveys.
Program 4, located in a large, multi-ethnic metropolitan area in the Southwest, incorporates Campinha-Bacote's concepts of cultural skill and encounters. Most students take their prerequisite courses at community colleges and then apply for entry into the nursing program. Recent classes have been composed largely of international students (20 percent), immigrants, and many students who are the first in their families to attend college. Many students have prior degrees.
University requirements mandate several cultural/ethnic courses to be taken as core courses, prior to entry into the nursing program. Cultural content is informally threaded throughout the nursing curriculum, primarily in didactic health assessment and the foundational clinical course, care of the family and child, and community health. In the summer, five to seven students per 100-student class participate in a two-week immersion and cultural study experience in Mexico. They live with Mexican families and attend Spanish language and culture classes.
Program 5, located in a large southern metropolitan area with a large international community, incorporates Campinha-Bacote's concepts of cultural awareness, skill, knowledge, and encounters. Nearly 22 percent of the undergraduate students were born in countries other than the United States; almost half of these students were born in Mexico, the Philippines, Nigeria, or Vietnam. The program is located at a health science center, where students matriculate in the junior year. Freshman and sophomore courses are taken at various academic institutions; students come from community colleges as well as universities, and several already have baccalaureate and graduate degrees. Therefore, nurse faculty have no input into traditional social science courses, where culture is initially taught.
Foreign-born students may be adept in the culture of their countries of birth, but lack knowledge of the many other cultures present in a large metropolitan area. Content on culture is included as a thread in all clinical courses, but is most prominently featured in the community health course, where lecture content is devoted to cultural competency. Other clinical courses feature cultural competency as application content, for example, ways nursing care needs to be modified based on a cultural assessment of the client. The program provides opportunities to provide nursing care on monthly weekend trips to the Texas-Mexico border and On an annual three-week trip to Nicaragua; these are not considered mission trips. Students receive academic credit for their work during the trips. A maximum of 10 students participate in the Nicaragua trip, and the number of students participating on weekend trips is limited by factors such as transportation and housing. Consequently, only a small proportion of graduates from the program have the opportunity to practice as nurses in a different culture where cultural competency is crucial to the provision of care.
Program 6, a large, multi-site undergraduate nursing program in the Pacific Northwest, incorporates Campinha-Bacote's concepts of cultural awareness, skills, knowledge, and encounters. Students and the surrounding community are fairly homogeneous in terms of socioeconomic status, gender, and ethnicity; there is more diversity at two distance undergraduate nursing campuses. The program includes a required two-credit cultural nursing course in the second semester of the junior year; an integrated approach to culture is used within other nursing courses. Several experienced trancultural nursing specialists and researchers teach in the senior-level community health course; integration of cultural principles is built into a weekly student clinical log. A popular elective summer course is taken annually by up to 30 students, who provide health care in remote clinics in Peru for a two-week period. A large nursing student organization that focuses on multicultural activities is well attended on campus.
INSTRUMENT The IAPCC-R is a 25-item tool that uses a four-point Likert scale to answer five questions about each of the five constructs of Campinha-Bacote's model: desire, awareness, knowledge, skill, and encounters. Completion of the survey takes about 10 to 15 minutes. Scores range from 25 to 100, with higher scores indicating greater levels of cultural competency. The IAPCC-R has been used widely, both nationally and internationally, with reliability coefficient Cronbach's alphas ranging from .8 to .9. (See www.transculturalcare.net.) Content validity has been established by several expert panels.
Students completed a demographic information form as well as the IAPCC-R. This form included questions about foreign travel, experiences living abroad, prior degrees, and course work in anthropology, as these factors might have an impact on study findings.
APPROACH The coordinator at each program site received institutional review board (IRB) approval for the program's participation. The IAPCC-R was prepared as a scannable form and mailed to all sites, along with an information form approved by the IRB, in lieu of consent forms. Site coordinators explained the study and distributed surveys to graduating seniors in a course or assembly during the last few weeks of school, after all course content had been completed. The survey was conducted at the end of the fall and spring semesters of the 2006-2007 academic year. Completion of the demographic tool and the IAPCC-R took approximately 15 minutes. Students voluntarily returned the surveys to a table or box in the room.
Each student completing the study was invited to drop his or her name into a hat for a chance to win a $50 money order. Drawings were done immediately after all surveys were handed in at each institution. Site directors mailed completed surveys to the principal investigator in a prepaid envelope for statistical analysis.
STATISTICAL ANALYSES All data analyses were completed using SPSS for Windows version 15. Frequencies and percentages were computed on nominal demographic characteristics data, and mean and standard deviations were computed for the age of students. Scores on each construct of cultural competency were computed using the scoring protocol provided by Campinha-Bacote (Boyle, 2007). The distributional characteristics of these cultural competency scores were examined using descriptive statistics. To evaluate differences in students' cultural competency (total score on the IAPCC-R) associated with curriculum methodology, a univariate analysis of variance was computed. To evaluate differences in students' IAPCC-R subscale or construct scores, a multivariate analysis of variance was computed, with the nursing program serving as the grouping factor and subscale scores on the IAPCC-R serving as the dependent measure. Univariate analyses of variance were examined as dictated by the results of the multivariate analysis. Bonferroni post hoc contracts were computed to assess differences among schools. To evaluate the influence of students' demographic characteristics, including cultural experiences and education, multiple regression analyses were computed. For each analysis, alpha was set to .05.
Results Across the six nursing programs, 764 seniors were eligible for participation in the study; 559 students (73 percent) participated. For 44 students, missing data precluded their inclusion in the data analysis; the resulting sample consisted of 515 students. Response rates by program ranged from 38 percent to 80 percent; the mean overall was 66 percent. Table 1 reports demographic characteristics of participating students, including their prior international and educational experiences. Most students were white (72 percent) and female (89 percent). Almost half (45 percent) were second-degree students (holding an associate, undergraduate, or graduate degree). Students ranged in age from 20 to 60 years (M = 26, SD = 6.7)
The IAPCC-R evidenced good reliability across almost all respondents (Cronbach's alpha = .81). The reliabilities on subscales were much less robust, with Cronbach's alphas of .36, .56, .42, .42, and .75 for cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire, respectively. Table 2 provides the means and standard deviations on subscale scores for the six nursing programs.
Using the total score on the IAPCC-R as the dependent variable, univariate analysis of variance revealed significant differences in total inventory scores associated with the nursing programs (F = 3.7, df = 5,515, p = .03); however, none of the post hoc contrasts were significant at p = .05. None of the score differences for each pair of nursing programs was sufficiently large to conclude that any one nursing program's total score on the IAPCC-R was better than the scores of any other nursing program.
Multivariate analysis of variance on the subscales indicated that the overall effect was significant (F = 5.4, df = 25,1877, p = .00, partial eta squared = 0.5 with an observed power of 1.0). The between-subjects tests (univariate analyses of variance) revealed significant differences associated with the nursing programs in cultural awareness (F = 9.1, df = 5,515, p = .00, partial eta squared = .08 with observed power of 1.0); cultural knowledge (F = 9.1, df = 5,515, p = .00, partial eta squared = 0.8 with an observed power of 1.0); and cultural skill (F = 2.7, df = 5,515, p = .02, partial eta squared = .03 with observed power of .81). The significant post hoc contrasts (Bonferroni) are summarized in Table 3. None of the other pair-wise contrasts were statistically different.
In only one instance, when cultural knowledge served as the criterion, did the multiple regression analysis identify predictors that made a significant contribution to students' performance (F = 1.7, df = 12,483, p = .05). Predictors found to make significant contributions to cultural knowledge were school and holding a graduate degree. Students with graduate degrees tended to have lower cultural knowledge scores than students without graduate degrees.
Discussion On average, students in Program 3, which utilized the integrated culture care theory as a framework, scored better than students in other programs on the IAPCC-R (M = 74.3). These students were among the oldest in the sample (M = 29 years). Also, 83 percent of these students had prior degrees, the largest number in the sample. The potential effect of age and accompanying life experience versus prior education on the IAPCC-R score is intriguing in light of the fact that Program 1 had the youngest students in the sample and the lowest IAPCC-R scores (M = 70.6). It is also possible that having several faculty certified in transcultural nursing teaching undergraduates in Program 3 made a difference in student scores. This information was not collected in the demographic information.
Program 2 had the highest number of students who had vacationed outside the United States (94 percent); the highest number of students who had completed an anthropology course (47 percent); and the second highest number of students who had completed prior undergraduate or graduate education (combined 65 percent). This program also had the second highest IAPCC-R scores (M = 73.9). Of interest, the two programs with the most diverse student populations (Programs 4 and 5, with 53 percent and 63 percent white students, respectively), and tied for oldest students (M = 29), did not score as well as other groups on the IAPCC-R. Clearly, ethnicity alone did not impact survey results. Other possible explanations for Program 2's slightly higher scores may be the large proportion of second-degree students with international work experience beyond vacation, or mission trips or study abroad experiences. Such experiences were not picked up on the demographic form, which asked only if students had lived outside the United States as a child between ages 4 and 18.
CULTURAL AWARENESS The mixed results on cultural awareness scores make interpretation difficult. Notably, at .36, cultural awareness was the least robust of the alpha subscales. Program 2 implements a cultural competency thread, which begins in a freshman nursing course and is carried throughout each semester. Prolonged exposure to deliberate cultural content applied with a nursing focus may be responsible for the higher cultural awareness score. Programs 1 and 6 have free-standing culture courses in the freshman and junior semesters, respectively, and each scored in a lower range. Program 1 also had the youngest students, most students without a prior degree, and students with the least experience living outside the United States. It is possible that culture is not as meaningful to younger students with less life experience.
CULTURAL KNOWLEDGE Program 6 had significantly higher cultural knowledge scores than Program 1, with a free-standing cultural course, and Programs 4 and 5, with integrated curricula. Program 6 employs a free-standing, two-credit cultural course in the junior year, and approximately 30 students annually attend a study abroad program in Peru. These factors may have played a role in the findings although, again, it is difficult to interpret without further data.
CULTURAL SKILL Students in Program 3 scored significantly better than students in Program 4 in cultural skill. As this concept also had a low Cronbach's alpha (.42), this finding is difficult to interpret. If Program 3 had scored significantly higher than all pro grams, one might attribute the scores to the faculty certified in transcultural nursing.
That students with prior graduate degrees scored lower in cultural knowledge than other undergraduate nursing students is an unexpected finding. These students tend to be older and have more life experience. However, prior liberal arts core cultural classes may have had a very different educational focus than the focus of the five questions about cultural knowledge asked in the IAPCCR. Thus, the findings must be interpreted with caution.
Why were results for all schools somewhat similar? Cultural material is not presented in a vacuum. Students are influenced by other experiences within and beyond the university. They take liberal arts courses in a variety of disciplines--some electives, some dictated by the curriculum--and many of these courses address diversity or other issues relevant to cultural competence. The world around the university also has an influence. Students are exposed to other cultures in so many ways.
Another concern is that the tool may telegraph how students should respond. Some individuals are able to select the answers that best reflect cultural competence while not actually practicing cultural competence. While some questions may reflect formal courses, for example, ethnopharmacology, others aim at general cultural competency and fail to reflect how one arrived at the answer.
Students in Program 5 scored highest in cultural desire. These students lived in a large metropolitan area and were the second most ethnically diverse group of students. Perhaps they were aware of their need to learn more about the diverse cultures they could expect to encounter in their nursing practice.
Findings from this study echo those of Nokes et al. (2005), Krainovich-Miller et al. (2008), and Sargent et al. (2005). The majority of undergraduates, regardless of education or intervention, continued to score in the culturally aware range on the IAPCC-R. These findings might be a function of the evaluation tool, and new tools to evaluate student populations and curricula are needed.
Conclusion The findings of this study indicate that no one curricular approach appears to be superior for teaching cultural content. Students scored in the culturally aware range, regardless of the approach or educational strategies used by individual programs. It has been suggested (Kardong-Edgren & Campinha-Bacote, 2008) that cultural awareness, rather than cultural competency, may be a reasonable and appropriate goal for graduating students. Nevertheless, the development of robust methods and tools to evaluate the application of cultural knowledge in patient care situations is needed.
Maltby (2008) reported on a qualitative analysis of a beginning and end-of-program in-class reflection question on students' commitment to serve all populations. While less leading than a multi-item self-report survey, this approach is susceptible to the same problems of political correctness affecting the self-report IAPCCR. Students know what they should say. Rutledge, Garzon, Scott, and Karlowicz (2004) used standardized patient simulations to evaluate cultural competency of nurse practitioner students. Another promising approach was recently presented by Rutledge, Barham, Wiles, and Benjamin (2008), who used patient vignettes written with representatives from underserved populations to present culturally validated learning content. To apply that knowledge, computer-based learning was followed by clinical care simulations using high-fidelity human patient simulators.
These three novel approaches allow evaluation of the application of cultural competency principles by instructors or actual participants from underserved populations, rather than self-report. This is what we, as health care educators, want to validate with our curricular approaches.
Continued evaluation and critique of curricular approaches and cultural evaluation tools are needed. Self-report tools such as the IAPCC-R may not be the best approach to measuring cultural competency.
About the Authors Suzan Kardong-Edgren, PhD, RN, is an assistant professor at Washington State University College of Nursing, Spokane. Carolyn L. Cason, PhD, RN, is a professor and associate dean for research at the University of Texas at Arlington School of Nursing. Ann Marie Walsh Brennan, PhD, RN, is a practice assistant professor at the University of Pennsylvania School of Nursing, Philadelphia. Elizabeth Reifsnider, PhD, WHNP, PHCNS-BC, is a professor at the University of Texas Medical Branch School of Nursing-Galveston. Faye Hummel, PhD, RN, CTN, is a professor at the University of Northern Colorado School of Nursing, Greeley. Mary Mancini, PhD, RN, NE-BC, FAHA, FAAN, is professor, associate dean, and chair for undergraduate nursing programs at the University of Texas at Arlington School of Nursing. Carolyn Griffin, MSN, RN, is an instructor at Duquesne University School of Nursing, Pittsburgh, Pennsylvania. This research was funded by an NLN Nursing Education Research Grant. Write to Dr. Kardong-Edgren at email@example.com for more information.
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Table 1. Ethnic, Racial Distribution, Travel, and Educational Experience SCHOOL 1 SCHOOL 2 SCHOOL 3 n = 49 n = 53 n = 53 ETHNICITY # (%) # (%) # (%) Asian 5 (10) 9 (17) 1 2 Black 2 (4) 2 (4) 0 Native American Alaskan 0 0 0 Pacific Islander 0 1 (2) 1 (2) White 40 (81) 41 (77) 47 (89) Other 1 (2) 0 4 (7) GENDER Male 3 (6) 4 (7) 3 (6) Female 46 (94) 48 (89) 50 (94) Gender not known 0 1 (3) 0 VARIABLE/SCHOOL International student 0 0 0 Lived outside US 1 (2) 7 (13) 6 (11) Vacationed outside US 41 (84) 51 (94) 48 (91) Mission experience 11 (22) 9 (17) 9 (17) Anthropology course 7 (14) 25 (47) 21 (39) AA or AD 1 (2) 0 11 (21) Undergraduate degree 0 32 (59) 27 (51) Graduate degree 2 (4) 3 (6) 6 (11) Doctoral degree 0 0 0 SCHOOL 4 SCHOOL 5 n = 146 n = 65 ETHNICITY # (%) # (%) Asian 22 (15) 12 (18) Black 21 (14) 2 (3) Native American Alaskan 4 (3) 0 Pacific Islander 3 (2) 1 (2) White 78 (53) 41 (63) Other 18 (12) 6 (11) GENDER Male 14 (10) 8 (12) Female 130 (89) 56 (86) Gender not known 2 (1) 1 (1) VARIABLE/SCHOOL International student 13 (9) 2 (3) Lived outside US 31 (21) 16 (25) Vacationed outside US 103 (70) 60 (92) Mission experience 17 (12) 7 (11) Anthropology course 16 (11) 15 (23) AA or AD 30 (21) 19 (29) Undergraduate degree 22 (15) 22 (34) Graduate degree 1 (1) 4 (6) Doctoral degree 0 0 SCHOOL 6 TOTAL n = 149 n = 515 ETHNICITY # (%) # (%) Asian 10 (7) 59 (11) Black 2 (1) 29 (5) Native American Alaskan 1 (1) 5 (1) Pacific Islander 5 (3) 11 (2) White 123 (83) 371 (72) Other 8 (5) 37 (7) GENDER Male 17 (11) 49 (10) Female 131 (88) 461 (89) Gender not known 1 (1) 6 (1) VARIABLE/SCHOOL International student 6 (4) 21 (4) Lived outside US 23 (15) 84 (16) Vacationed outside US 132 (89) 425 (83) Mission experience 36 (24) 89 (17) Anthropology course 46 (31) 130 (25) AA or AD 30 (20) 91 (18) Undergraduate degree 18 (12) 121 (23) Graduate degree 2 (1) 18 (3) Doctoral degree 0 0 Table 2. Cultural Competence Scores of Respondents CULTURAL CULTURAL CULTURAL SCHOOL AWARENESS KNOWLEDGE SKILL 1 14.0 [+ or -] 1.7 12.2 [+ or -] 2.1 14.2 [+ or -] 2.1 2 15.9 [+ or -] 1.8 12.6 [+ or -] 2.0 14.3 [+ or -] 2.0 3 15.4 [+ or -] 1.9 12.7 [+ or -] 2.0 14.8 [+ or -] 2.1 4 14.7 [+ or -] 1.7 12 [+ or -] 1.8 13.9 [+ or -] 1.8 5 14.4 [+ or -] 1.7 11.9 [+ or -] 2.1 13.9 [+ or -] 2.0 6 15.2 [+ or -] 1.8 13.4 [+ or -] 2.1 14.4 [+ or -] 1.9 ALL 14.9 [+ or -] 1.8 12.5 [+ or -] 2.1 14.2 [+ or -] 2.0 CULTURAL CULTURAL SCHOOL ENCOUNTERS DESIRE TOTAL 1 13.8 [+ or -] 2.1 16.3 [+ or -] 2.4 70.6 [+ or -] 7.6 2 13.9 [+ or -] 2.1 17.1 [+ or -] 2.0 73.9 [+ or -] 7.7 3 14.4 [+ or -] 1.8 17.1 [+ or -] 2.1 74.3 [+ or -] 7.4 4 14.2 [+ or -] 1.7 16.9 [+ or -] 1.9 71.6 [+ or -] 6.6 5 13.8 [+ or -] 1.7 17.5 [+ or -] 1.7 71.5 [+ or -] 6.3 6 14.0 [+ or -] 1.8 16.9 [+ or -] 2.2 73.9 [+ or -] 7.4 ALL 14.0 [+ or -] 1.8 17.0 [+ or -] 2.1 72.7 [+ or -] 7.2 Table 3. Summary of Statistically Significant Nursing Program Comparisons IAPCC-R Subscale Significantly different pair-wise comparisons Cultural Awareness Nursing program 2 higher than nursing program 4 Nursing programs 1 and 5 lower than nursing programs 2, 3, and 6 Cultural Knowledge Nursing program 6 better than nursing programs 1, 4, and 5 Cultural Skill Nursing program 3 better than nursing program 4