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Cultural competency among nurses with undergraduate and graduate degrees: implications for nursing education.


AIM To compare the level of cultural awareness, knowledge, skills, and comfort of nurses with undergraduate and graduate degrees when encountering patients from diverse populations.

BACKGROUND Cultural competency is a core curriculum standard in undergraduate and graduate nursing programs. Assessing cultural awareness, knowledge, skills, and comfort among nurses can help identify areas to strengthen in nursing curricula.

METHOD A prospective, cross-sectional, descriptive study design was used. Two thousand surveys were sent to nurses in a southeastern state; 365 nurses participated.

RESULTS Undergraduate-degree nurses scored lower than graduate-degree nurses on cultural knowledge. Scores on cultural awareness, skills, and comfort with patient encounters did not vary between groups. Both groups of nurses reported little cultural diversity training in the workplace or in professional continuing education.

CONCLUSION The findings of this study indicate areas of need for undergraduate and graduate nursing education.


Cultural Competency--Undergraduate Graduate --Nursing Education


Over the last two decades, the population of the United States has undergone a tremendous shift with regard to race and ethnicity. Minorities constitute one third of the US population and are expected to increase to 54 percent by 2050 (Passel & Cohn, 2008; US Census Bureau, 2010). Despite these population trends, more than 80 percent of licensed registered nurses in the United States are non-Hispanic whites, highlighting the underrepresentation of Hispanic, black, American Indian, and Alaska native nurses (US Department of Health and Human Services, 2010). Furthermore, the Sullivan Commission (2004) found that only about 10 percent of nurse faculty in the United States represent racial and ethnic minorities.

The Institute of Medicine (IOM, 2003) reported the "unequal treatment" that minorities face within the US health care system. Cultural differences, lack of access to health care, poverty, and unemployment contribute to disparities in health status and outcomes. Coupled with the fact that health care professional (HCP) demographics have not changed along with the population, health care disparities may increase. The IOM report shared the benefits of having a more racially and ethnically diverse health care team, such as greater levels of patient satisfaction with care, increased access to care in underserved areas, and reduced cultural and linguistic barriers.

Cultural competency has been identified as an essential core curricular element in undergraduate and graduate nursing programs. The Commission on Collegiate Nursing Education (2009) and the National League for Nursing Accrediting Commission (NLNAC, 2008) have outlined requirements for ensuring that undergraduate and graduate nurses are able to provide culturally competent nursing care. Furthermore, cultural competency has been specified as a core competency by the National League for Nursing (NLN, 2009) and the American Association of College of Nursing (ACCN, 2008, 2011).

The purpose of this study was to compare the level of cultural awareness, knowledge, skills, and comfort nurses with undergraduate (diploma, associate's, and bachelor's) and graduate (master's) degrees have during encounters with patients from diverse populations. In addition, comparisons were made regarding the amount of cultural diversity training completed between the two nursing groups.


The Process of Cultural Competence in the Delivery of Healthcare Services model by Campinha-Bacote (2000) provided the conceptual framework for examining differences in cultural desire, awareness, knowledge, skills, and encounters between nurses who have obtained undergraduate and graduate degrees. The underlying foundation for the model is cultural desire, which is defined as a nurse's motivation to learn about cultural differences and interact with culturally diverse individuals.

Cultural desire provides the foundation for the other constructs in the model, including cultural awareness, knowledge, skills, and encounters. Cultural awareness is the recognition of one's own attitudes and assumptions toward similarities and differences in others, acknowledging racism, bias, and stereotyping. Cultural knowledge is the awareness of cultural health beliefs and values, including culturally specific incidence and prevalence of health conditions. HCPs demonstrating cultural skills practice culturally competent nursing care, while also engaging in cultural encounters with diverse individuals.


Level of Education

Several studies have examined the effects of education level on cultural knowledge and competence (Brathwaite, 2006; Mahabeer, 2009; Schim, Doorenbos, & Borse, 2005, 2006; Starr & Wallace, 2009). Mahabeer examined the importance of cultural competency education among 58 hemodialysis nurses and found that the majority (52.6 percent) indicated that their educational level did have an influence on their level of cultural competence. Several researchers have examined the impact of education level, cultural diversity training, or both on cultural competence among urban hospital HCPs (Schim et ah, 2005), hospice nurses (Schim et ah, 2006), and public health nurses (Starr & Wallace). Higher levels of education and prior diversity training were found to improve cultural awareness, knowledge, sensitivity, and cultural competence levels (Schim et ah, 2005, 2006; Starr & Wallace).

In a similar vein, Brathwaite (2006) conducted a repeated measures study with 76 public health nurses to examine how nurses' personal and professional characteristics influenced their response on an educational intervention to improve their cultural knowledge and cultural competence. Brathwaite found that higher levels of education had a small but positive effect on cultural knowledge and cultural competence following completion of the education program.

Cultural Competence Training Programs

The effectiveness of education interventions on participant cultural awareness, knowledge, and competence has been reported in the literature (Brathwaite, 2005; Brathwaite & Majumdar, 2006; Majumdar, Browne, Roberts, & Carpio, 2004). Brathwaite evaluated the effectiveness of an instructional course on public health nurses' levels of cultural competence. The three-month course was designed using the five components from the model of cultural competence designed by Campinha-Bacote (2000). Brathwaite reported an increase in the participants' levels of cultural competence from pretest to posttest, with 44.2 percent being classified as culturally proficient following the intervention.

Two other interventional studies demonstrated the effectiveness of training on cultural awareness, knowledge, and cultural competence (Brathwaite & Majumdar, 2006; Majumdar et ah, 2004). Brathwaite and Majumdar found that a short-term, five-week course on cultural competence was effective in increasing the cultural knowledge of nurses. A randomized controlled trial of cultural sensitivity training for 114 HCPs showed promise in increasing cultural awareness and improving the HCP's ability to communicate with individuals from minority groups (Majumdar et al.).



A prospective, cross-sectional, descriptive survey design was used for the current study.


The study took place in a southeastern state. A copy of mailing addresses for all active RNs in the state was obtained from the state board of nursing. Zip codes were used to determine the percentage of nurses living in each county, with a stratified sampling method employed to determine a representative sample from each county. Research surveys were mailed to a sample of 2,000 nurses in the state.

Protection of Research Participants

Prior to initiating data collection, approval was obtained from the university institutional review board. A consent form and survey was mailed to each potential participant. Consent to participate was acknowledged by returning the completed survey by mail or by completing the survey online. Survey responses were anonymous; no Internet protocol addresses were collected from those who completed the surveys online.

Data Collection Procedures

Potential participants were mailed a packet containing the cover letter consent form, the research survey, a gift card raffle postcard, and a self-addressed, stamped, return envelope. The cover letter consent form gave potential participants the option of completing the surveys on paper and mailing them back or completing the surveys online. Participants who completed the survey could participate in a raffle drawing for one of three $50 gift cards by completing a raffle postcard and returning it in the a preaddressed, stamped envelope. Upon receipt, postcards and research surveys were separated to ensure anonymity.


DEMOGRAPHIC QUESTIONNAIRE The researchers developed a nine-item demographic questionnaire for the study. Questions on the demographic survey addressed zip code, age, sex, culture/ethnicity, highest nursing degree, years as a licensed nurse, employment status, primary work setting, and languages spoken other than English.

CLINICAL CULTURAL COMPETENCY QUESTIONNAIRE The Clinical Cultural Competency Questionnaire (CCCQ), developed by Like (2004) and revised by Krajic, Strassmayr, Karl-Trummer, Novak-Zezula, and Pelikan (2005), was used to measure nurses' perceptions of their cultural awareness, knowledge, skills, and comfort level when caring for patients from culturally diverse populations. The subscales use a five-point Likert scale, with scores ranging from 0 (not at all) to 4 (very), with an additional option of "does not apply." The first four subscales address awareness (3 questions), knowledge (10 questions), skills (15 questions), and comfort in patient/family encounters (16 questions). Responses to questions on the first four subscales are averaged, with higher scores indicating higher levels of awareness, knowledge, skills, and comfort with caring for patients from culturally diverse populations.

The CCCQ contains a fifth subscale that reflects cultural desire. This subscale measures nurses' education and training levels in cultural diversity using a five-point Likert scale, with scores ranging from 0 (not at all) to 4 (a lot). Questions on this subscale ask about the amount of education and training nurses received in their work setting, as well as continuing education outside the work setting. Each item is independently measured, with higher scores indicating more cultural diversity education and training.

Data Analysis

Data were analyzed using SPSS for Microsoft Windows, version 18.0, with a level of significance set at 0.5. Descriptive statistics were calculated to describe the sample population, scores from the CCCQ, and nurse training levels in cultural diversity. Independent sample i-tests were used to compare subscale scores from the CCCQ and cultural diversity training amounts between nurses with undergraduate degrees and graduate degrees.



Of the 2,000 surveys mailed, 59 were returned undeliverable and one person declined to participate. A total of 374 surveys were received, indicating a response rate of 19.3 percent. Individuals who earned a doctoral degree (n = 7) and individuals who did not answer the question regarding highest educational level (n = 2) were not included in the analysis, yielding a final sample of 365.

A total of 41.1 percent of participants (n = 150) had obtained undergraduate degrees, while 58.9 percent (n = 215) had earned a graduate degree. The majority of both groups were women who identified themselves as Caucasian. The average ages of nurses with undergraduate and graduate degrees were 49.1 (SD = 11.9) and 47.3 years (SD = 11.3), respectively. Nurses with undergraduate degrees were licensed for an average of 21.6 years (SD = 13.3), slightly less than 22.9 years (SD = 11.5) for nurses with graduate degrees. Table 1 provides additional demographic data about the two groups.

Cultural Competency

Independent sample t-tests were used to compare differences in cultural awareness, knowledge, skills, and comfort in patient encounters between nurses with undergraduate and graduate degrees. There was only one significant finding based on education level. On average, nurses with an undergraduate degree scored lower on the knowledge subscale (M = 2.10, SD = .84) than nurses with graduate degrees (M = 2.29, SD = .79); the difference was statistically significant (t [359] = -2.1, p < .05). Mean scores on the awareness, skills, and comfort with encounters subscales did not vary considerably between the groups and were not statistically significant (Table 2).

Cultural Diversity Training

Both undergraduate-degree (M = .86, SD = .35) and graduate-degree nurses (M = .73, SD = .45) reported very little cultural diversity training in the workplace. A majority of undergraduate-degree nurses reported receiving a little (84 percent) or no (13.7 percent) workplace training. Higher numbers of nurses with graduate degrees reported no workplace training (27.4 percent) or only a little (72.6 percent).

Nurses with undergraduate degrees reported less continuing education in cultural diversity outside the workplace (M = .71, SD = .46) than nurses with graduate degrees (M = .79, SD = .41). Very little continuing education in cultural diversity was obtained by either group. Close to three quarters of nurses with undergraduate degrees (71.1 percent) reported receiving a little continuing education outside the workplace, while 28.9 percent reported none. This trend was similar for nurses with graduate degrees; 79.1 percent reported receiving a little professional continuing education outside the workplace, and 20.9 percent reported receiving no continuing education.

Differences in training were examined by education level. The difference in the mean scores for cultural diversity training in the work setting were statistically significant (t [359] = 3.289, p < .01). The difference between the groups with respect to the amount of outside continuing education in cultural diversity was not statistically significant.


Culturally competent care is a multifaceted concept. This study compared the level of cultural awareness, knowledge, skills, and comfort undergraduate and graduate degree nurses have when encountering patients and families from diverse populations. In addition, this study compared the amount of workplace training and continuing education focused on cultural diversity completed by undergraduate and graduate degree nurses.

Nurses with undergraduate degrees reported slightly lower levels of cultural awareness, knowledge, skills, and comfort in patient encounters and situations than their graduate degree counterparts. No statistically significant differences were found in levels of cultural awareness, skills, and comfort in patient encounters and situations between the two groups. The finding that additional continuing education did not lead to a significant difference in the level of cultural competencies between the two groups of nurses does not reflect previous research. Mahabeer (2009) and Schim et al. (2005) found that educational attainment was important to nurses and was a significant predictor of cultural awareness, cultural sensitivity, and cultural competency. Based on the controversial findings from the current study, further research is needed to understand the relationship between level of educational attainment and cultural competence in nurses.

Level of cultural knowledge was found to have a statistically significant difference between undergraduate and graduate degree nurses. Findings from the current study are supported by previous research that found a relationship between higher levels of educational attainment and cultural knowledge (Brathwaite, 2006; Schim et al., 2006). Findings from this study further support the evidence that level of education has an impact on improving the cultural knowledge of nurses. However, these results also indicate that a higher level of cultural knowledge does not necessarily translate into higher levels of cultural awareness, skills, and comfort in patient encounters among nurses.

Another interesting finding was that nurses with undergraduate degrees had statistically significant higher levels of cultural diversity training at their workplace compared with their graduate degree counterparts. An explanation for this finding may be that more undergraduate degree nurses work within hospital settings than nurses with graduate degrees. Hospital organizations seek accreditation from outside organizations such as the Joint Commission (2004), which emphasizes the importance of culturally competent care.

Graduate-degree nurses reported higher levels of participation in continuing education than undergraduate-degree nurses, although this finding was not statistically significant. Graduate-degree nurses may have to seek out continuing education opportunities if their employers do not offer resources within the work setting. Both groups of nurses reported minimal continuing education, indicating that they are not proactively seeking education to ensure the provision of culturally competent care, even though several continuing education programs have been made freely available online (Healthcare Chaplaincy, 2009; US DHHS, 2008).


There are several limitations to this study. Women made up the majority of the study sample, as did Caucasian nurses. In addition, the sample was drawn from one state located in the southeastern United States, limiting the generalizability of the findings to other populations. Individuals with doctoral degrees were not included in the sample due to a low number of participants indicating that they had received a terminal degree; therefore, examining the cultural competence level of individuals with doctoral degrees is an area for further research.


The findings of the current study have several important implications for faculty who teach in undergraduate and graduate nursing programs. It is important for nurse faculty to reflect on their own cultural competency knowledge, awareness, skills, and comfort in encounters with a diverse population of patients. In order to educate students on cultural competency, faculty must possess the confidence to effectively deliver this content, and they must also serve as role models in clinical practice (see, for example, NLN, 2009).

Another important finding from this study was that cultural competence was related to higher education level. Perceived knowledge level among all nurses was low, as was perceived cultural awareness, skills, and comfort with patient encounters. The implication for educators is that possessing a higher level of cultural competence does not translate into confidence with cultural competency skills, nor comfort in patient and family encounters.

There are several ways that nursing faculty can help students improve their cultural awareness and knowledge. For example, students can complete cultural self-awareness exercises in foundational nursing courses. Cultural competency theories and concepts, including cross-cultural communication, health literacy, health disparities, and health promotion, should be introduced early and addressed throughout in the curriculum (see, for example, NLN, 2009).

Improving cultural competency skills and comfort in encounters with patients from diverse populations can take several forms. Clinical case studies and role-playing may be used in many nursing courses. Simulation is also an avenue for undergraduate and graduate students to practice cross-cultural communication with patients and their families with limited English proficiency in a variety of scenarios. Providing students with opportunities for clinical and volunteer experiences in underserved areas may help increase comfort in nursing students' encounters with diverse populations. After students have encountered diverse populations, it is important to encourage self-reflection on what went well and how they could improve future encounters.

Engaging undergraduate and graduate students in events that highlight cultural diversity is another method to improve awareness, knowledge, skills, and comfort in encounters. For example, schools can host foreign nursing students and plan social events, lectures, and classroom opportunities to encourage cross-cultural interaction among students and faculty. Finally, schools should work to increase study abroad opportunities. Providing avenues for students and faculty who have traveled abroad to share their experiences may benefit the entire learning institution.


Undergraduate and graduate nursing education programs should intentionally integrate cultural competency content into their curriculums. As a first step, it is imperative to increase cultural awareness and knowledge among nursing students. This should then be followed by providing opportunities for students to practice these cultural skills and gain comfort in cultural encounters. With diversity growing in the United States, integrating this content should be a priority for educators at all levels.

doi: 10.5480/12-834.1


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Nicole Mareno, PhD, RN, is an assistant professor, Kennesaw State University WellStar School of Nursing, Kennesaw, Georgia. Patricia L. Hart, PhD, RN, is also an assistant professor, Kennesaw State University WellStar School of Nursing. For more information, contact Dr. Mareno at
Table 1: Demographic Characteristics of the Participants by (Troup
(N = 365)

 Undergraduate Graduate
 Degree Degree
 (n = 150) (n = 215)

 n % n %

 Female 139 92.7 196 92.5
 Male 10 6.7 16 7.4
 Missing 1 .7 3 1.4

Self-Identified Culture/

 African American 14 9.3 27 12.6
 Asian/Pacific Islander 3 2.0 1 0.5
 Caucasian 125 83.3 181 84.2
 Filipino 2 1.3 0 0.0
 Japanese 0 0.0 1 0.5
 American Indian 1 0.7 0 0.0
 Hispanic or Latino 3 2.0 3 1.4
 Other or missing 2 1.3 1 0.5

Primary Work Setting

 Hospital 80 53.3 78 36.3
 Nursing Education 2 1.3 10 4.7
 Occupational Health 1 0.7 4 1.9
 Insurance Claims/Benefits 1 0.7 1 0.5
 Extended Care Facility 2.7 4.0 1.9 4.0
 School Health Services 4 2.7 3 1.4
 Ambulatory Care 14 9.3 72 33.5
 Policy, Regulatory 0 0.0 1 0.5
 Other 44 29.3 42 19.5

Current Employment Status
 Full-Time 101 67.3 156 72.6
 Part-Time or Per Diem 33 22.0 48 22.3
 Not working, not retired 6 4.0 7 3.3
 Retired 10 6.7 4 1.9

Languages Spoken Besides

 No 130 86.7 170 79.1
 Yes 20 13.3 45 20.9

Table 2: Simultaneous Independent t-Tests and Mean Scores for
Variables Associated with Cultural Competence

 N M t

Knowledge 359 - -2.10 *

 Undergraduate degree 2.10
 Graduate degree 2.28

Skills 358 - -1.32

 Undergraduate degree 2.12
 Graduate degree 2.25

Encounters (comfort with) 360 - -.298

 Undergraduate degree 2.18
 Graduate degree 2.20

Awareness 359 - -.145

 Undergraduate degree 3.16
 Graduate degree 3.17

* p< .05.
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Author:Mareno, Nicole; Hart, Patricia L.
Publication:Nursing Education Perspectives
Article Type:Clinical report
Date:Mar 1, 2014
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