Nursing Education Perspectives

Cultural Competence in
Rural Nursing Education:
Are We There Yet?
Connie Diaz, Pamela N. Clarke, and Mary Wairimu Gatua

doi: 10.5480/12-1066.1

Abstract
aim This multimethod study assessed the capacity of nursing education programs to promote culturally congruent
practice in a single rural state.
background An important objective of our HRSA-funded Advanced Education in Nursing grant was to increase nurse
educator proficiency in teaching cultural concepts. This study served as a statewide baseline assessment to inform future
faculty development efforts.
method Subjects included faculty, graduate students, and clinical educators representing all levels of nursing education
programs. Self-report cultural proficiency data were collected via survey while focus groups and electronic surveys were
utilized to assess curricula.
results No significant differences in proficiency were found by faculty age or education. Qualitative data indicated that
concepts of culture are not easily identified across the curriculum.
conclusion There is need for increased and explicit focus on concepts of culture in nursing education programs to
prepare nurses for culturally congruent practice with potential to reduce health disparities.

Cultural competence in the nursing work-
force is critical to reducing health dispari-
ties. The purpose of this multimethod study
was to assess the capacity of nurse educators
and nursing education programs through-
out the state of Wyoming to promote cul-
turally congruent practice. Current nurse
educators, clinical partners, and master’s of
science in nursing students were surveyed
regarding their perceived cultural compe-
tence, and cultural and diversity content
was assessed in nursing education programs
across the state.
Understanding levels of cultural com-
petence and gaps in competence was a first
step toward improving cultural competence
among nurse educators and clinical educators
in this largely rural area. The findings pro-
vide insight into the current capacity to teach
cultural competencies within the full range
of nursing programs, that is, associate degree
(ADN), bachelor’s degree (BSN), RN to BSN,
and master’s level programs.
Wyoming is the ninth largest state in
terms of land mass and the least populated
state in the United States. Approximately
200,000 residents in 17 of the 23 coun-
ties in the state are medically underserved
(Wyoming Office of Rural Health, 2009).
Given that Wyoming has one public uni-
versity and seven community colleges, most
nurses educated in the state are initially pre-
pared at the ADN level.
The Leadership Education to Advance
Practice (LEAP) RN/BSN/MSN Preparing
Nurse Educators project was funded
by the Health Resources and Services
Administration through an Advanced
Education in Nursing grant. The overall
goal of the project was to facilitate nurses’
progression to the MSN education program
and to promote the ability to teach diversity
and increase cultural competency across the
curriculum. The project included an empha-
sis on cultural competence and rurality as
components of diversity for MSN nurse edu-
cator students.
BACKGROUND: CULTURAL COMPETENCE
The Sullivan Commission (2004) recom-
mended promoting diversity and cultural
competence for health professionals, stu-
dents, faculty, and health care providers. The
American Association of Colleges of Nursing
(AACN) also recognized “a strong connec-
tion between a culturally diverse nursing
workforce and the ability to provide quality,
culturally competent patient care” (2013).
The National League for Nursing (NLN,
2009) urged expansion of the definition of

22 JANUARY/FEBRUARY 2015

diversity beyond the context of ethnicity. It
has further called for expansion of public
investment in initiatives that “enrich and
sustain culturally competent nursing educa-
tion that leads to equitable, evidence-based
health care delivery” (2013, p. 2). However,
health disparities persist in the United States.
Underserved segments of the population,
including racial and ethnic minorities, per-
sons in rural and geographically isolated
areas, and those in lower socioeducational
and socioeconomic groups continue to expe-
rience poor health outcomes.
Recent evidence indicates a significant
positive correlation between levels of cul-
tural competence among nursing faculty
and the number of minority nursing grad-
uates from the study school (Ume-Nwagbo,
2012). Further, culturally competent fac-
ulties are more likely to integrate cultural
concepts throughout the nursing curricu-
lum. Promoting diversity in nursing edu-
cation programs, as well as fostering the
development of cultural competence among
all levels of nursing students, is important
when preparing nurses to deliver high qual-
ity, patient-centered care. However, despite
demonstrated links between cultural com-
petence of health care professionals and
the ability to provide higher quality patient
care, as well as the availability of education
strategies and models proposed to improve
the integration of cultural competencies in
nursing education (Engebretson, Mahoney,
& Carlson, 2008), research on competence
reveals that pedagogic approaches inade-
quately prepare nurses to work with peo-
ple from diverse cultures (Larson, Ott, &
Miles, 2010).
Cultural competence encompasses the
capacity to identify, understand, and respect
the values and beliefs of others (Anderson,
Scrimshaw, Fullilove, Fielding, & Normand,
2003; Chipps, Simpson, & Brysiewicz, 2008).
Integrated content directed toward devel-
oping cultural competencies in nursing cur-
ricula must ensure that students have the
knowledge, attitudes, and skills to effectively
work with diverse clients, families, and other
health care professionals. An important
Cultural Competence
element for developing cultural competence
is cultural desire, meaning wanting to —
rather than having to — learn and interact
with other cultures (Kardong-Edgren &
Campinha-Bacote, 2008).
Campinha-Bacote (2002) describes the
seeking and experiencing of cultural encoun-
ters as key in the development of cultural
competence, viewing cultural competence
as “an ongoing journey of unremitting cul-
tural encounters.” Providing health care to
a diverse population extends beyond rec-
ognizing race and ethnicity to include the
totality of beliefs, values, and experiences
that shape the uniqueness of individuals. It
includes gender, religious affiliations, sexual
orientation, age, and socioeconomic status
(Black, Soelberg, & Springer, 2008). Health
professions training programs must enhance
self-awareness and improve care by increas-
ing knowledge and cultural competence
skills (Chipps et al., 2008).
Method
A multimethod assessment included a self-re-
port assessment of current nurse educators
representing all levels of nursing education in
the state, as well as focus group and survey
data.
Instrument
The self-report instrument used in this study
was the Inventory for Assessing the Process
of Cultural Competence in Healthcare
Professionals-Revised (IAPCC-R) developed
by Campinha-Bacote (2003). The instrument
consists of 25 Likert-type items that measure
five cultural constructs meant to lead to cul-
turally appropriate care: desire, awareness,
knowledge, skills, and encounters. Total
instrument scores range from 25 to 100
and indicate the level of perceived cultural
aptitude, with higher scores representing a
greater level of cultural competence.
Procedure
The study compared scores on the IAPCC-R
from university faculty teaching at the BSN
and MSN levels, community college faculty
preparing nurses at the ADN level, clinical
educators serving as preceptors and clin-
ical partners for students at all levels, and
students entering the MSN program at the
university. MSN student participants were
beginning graduate study in either the nurse
educator or family nurse practitioner pro-
grams. Thus, they represented future nurse
academics and clinical leaders.
The IAPCC-R was administered on
three occasions to reach all sample groups.
University faculty were invited to participate
prior to a regularly scheduled fall faculty
meeting. Community college faculty and
clinical educators were reached during their
participation at an annual statewide nursing
education meeting in the spring. MSN stu-
dents completed the instrument during new
student orientation at the beginning of their
graduate program.
Focus groups were conducted with
university faculty representing BSN, RN/
BSN, and MSN programs to collect infor-
mation on the content in courses and the
processes for teaching about culture and
diversity. Additional qualitative data were
obtained regarding cultural content taught
in each of the ADN programs in the state.
An email survey of community colleges
resulted in a 100 percent response rate from
nursing directors.
Sample
The sample consisted of 102 participants:
26 master’s level nursing students, 35 com-
munity college nursing faculty, 24 university
nursing faculty, and 17 clinical educators.
Nearly all respondents (98 percent) were
women, with the majority 40 to 59 years old
(66.7 percent), mirroring the national nurse
educator workforce (US Department of
Health and Human Services, 2010). Ninety-
four percent were Caucasian.
Results
A one-way analysis of variance was used to
examine mean scores among nursing gradu-
ate students, community college nursing fac-
ulty, university nursing faculty, and clinical
educators’ IAPCC-R scores. No significant
differences were found (p = .442; F = 0.905).
Data showed no differences regardless of
group, age, or experience. Cronbach’s alpha
was 0.807 for the total scale, substantiating
V o l u me 3 6 N u mber 1 23

strong internal consistency. All of the sub-
scales were moderate in terms of consis-
tency. The range on the subscales was 0.439
for cultural awareness and 0.652 for cultural
knowledge.
The study was exploratory; nevertheless,
the investigators projected that the more
advanced the age and experience of the nurs-
ing professional, the higher the level of cul-
tural competence. A Spearman rho correla-
tion coefficient was calculated for the rela-
tionship between participant age category
and total cultural competence score. The
correlation indicated that no significant rela-
tionship existed between age categories and
total cultural competence scores (rho [100] =
0.078; p > .05).
A Spearman rho correlation coefficient
was also calculated for the relationship
between participant year of initial degree in
nursing (categoric) and total cultural compe-
tence scores. A negative correlation indicated
no significant relationship existed between
years in nursing and the total cultural com-
petence scores (rho [100] = -0.065; p > .05).
Finally, a multiple linear regression was cal-
culated to predict participant level of cultural
competence based on age, highest nursing
degree, number of years in the nursing field,
and levels of nursing degrees. None of the
variables tested could be used to predict cul-
tural competence levels of nurse educators,
clinical educators, or graduate students in the
study sample.
Qualitative data revealed that faculty
statements reflect beliefs about the impor-
tance of cultural content; however, a review
of university syllabi did not demonstrate
inclusion of this content, except in a limited
number of courses designated as “diversity”
courses. Some faculty did not identify that
concepts such as ageism are related to cul-
ture. One faculty member stated, “I don’t
have cultural content in my course,” even
though ageism was identified as an import-
ant concept in that course. Other faculty
described methods of teaching in which
cultural content was applied through case
studies and a variety of classroom and online
discussions. Compared with the university,
24 JANUARY/FEBRUARY 2015
Nursing Education Perspectives
community colleges provided more compre-
hensive content maps, clearly demonstrating
the integration of cultural content.
University faculty members shared
in focus groups that cultural content was
assigned to particular undergraduate diver-
sity courses and that they did not need to
include cultural content as a specific con-
cept item in practica or theory courses. In
reviewing graduate-level course titles and
course units, those that were not specifically
identified as diversity courses did not explic-
itly identify aspects of culture or diversity
within the syllabi. In focus group discus-
sions, faculty described specific assignments
that included care of individuals from spe-
cific minority groups in case studies, with
an emphasis on socioeconomic factors and
alternative healing. In the graduate program,
the epidemiology course alone included
social determinants of health as well as spe-
cific units on social justice and international
health issues.
All eight nursing programs addressed the
concept of rurality and the American Indian
culture as the primary unique cultures in
the state. From what could be determined,
only university faculty specifically identified
the contrast between rural and urban. The
Purnell Model for Cultural Competence
was the only conceptual framework identi-
fied from community college data (Purnell,
2005). Bushy’s (2008) rural health theory
served as the framework in the graduate pro-
gram in addition to major nursing theories.
Consistently, community college curricula
focused on ethnicity, alternative healing,
religious differences, and lifestyle. Only one
educational setting (a community college)
addressed care and issues involving undocu-
mented persons.
Discussion
No significant differences were seen in the
total scores for age, education level, years of
experience, or level of pre-license nursing
degree in the current study. The lack of dif-
ferences between groups in the current study
sample was not surprising given the homo-
geneity of the overall nursing workforce. In
addition, most participants received at least
one nursing degree from a school represented
in the study.
The current study sample tended to be
more highly educated and older than those
in other nursing studies reported in the lit-
erature (Calvillo et al., 2009; Riley, Smyer,
& York, 2012). Riley and colleagues found
significant differences between total score
and age, as well as a higher total mean score
(75.3) compared with what we reported in
this study (71.6). However, the sample from
Riley and colleagues of RN/BSN students
was younger and practiced in an urban
area, in which there was potential for stu-
dents to encounter a highly diverse patient
population.
A recent study using a sample of health
sciences faculty, most of whom were nurses
(78 percent), found that a majority of faculty
perceived themselves as being culturally
aware (82 percent) at a baseline assessment
preceding a planned cultural competence
workshop (Wilson, Sanner, & McAllister,
2010). Results in the current study were sim-
ilar in that respondent mean scores (71) were
at the level of cultural awareness. In the cur-
rent study sample, cultural desire subscale
scores were ranked highest, and nursing fac-
ulty ranked themselves lowest in the domain
of cultural knowledge.
Qualitative data were obtained from
community college programs through elec-
tronic surveys and from university faculty
through focus groups. As expected, some of
the community college directors submitted
detailed course descriptions, while others
responded only to the survey questions and
provided content maps. In contrast to the
community colleges, most of the university
courses, other than the few with “culture”
and “diversity” in the title, did not empha-
size cultural competence as a specific iden-
tifiable content item in the syllabi. Faculty
members identified emphasis on areas that
could be considered cultural competence,
such as care of the older adult and ageism,
but they did not seem to recognize any con-
cepts related to culture beyond race and
ethnicity.

From the focus group dialogue, it
was clear that university graduate faculty
made assumptions that certain content was
included in undergraduate course work and
did not need to be repeated at the graduate
level. Cultural content was not consistently
listed in the content outlines but appeared
as a somewhat hidden application of cul-
tural concepts in classroom and online dis-
cussions. For example, in the nursing theory
class, students analyzed the application of
transcultural theory and examined cultural
and spiritual concepts from nursing science
in relation to practice with at-risk patient
populations. However, neither the syllabus
nor the objectives clearly identified cultural
competence content. The nursing theory
course included major emphasis on one’s
own professional philosophy of nursing,
which helps identify biases and attitudes, but
one would not be able to determine this from
the syllabus. Applying research in advanced
nursing practice focused on evidence and
included issues such as provider expertise
and patient preference, which could include
cultural preferences.
The highly complex nature of the con-
cept of culture makes it difficult to measure.
The term culture broadly includes the arts
and humanities as well as human patterns
specific to particular groups in terms of
traditions and values. Campinha-Bacote
(2002) used Leininger (2007) as a basis for
her framework. Leininger describes how
she spent a lifetime focusing on cultural
competence and understanding the con-
nection between cultures and nursing care,
coining the term culturally congruent care in
the 1960s (Clarke, McFarland, Andrews, &
Leininger, 2009).
Campinha-Bacote (2008) also refers to
cultural competence as a process of becom-
ing competent, rather than achieving compe-
tence. She asserts that cultural desire is a pro-
cess through which health care professionals
strive to work effectively within the cultural
context of a patient, family, or community.
The nonstatic concept of “process” implies
that the development of competence is not
easily measured at one point in time.
Cultural Competence
A richer understanding of how nurses and
nurse educators define and apply concepts of
culture is essential if we are to address the
increasingly complex health care needs of
diverse populations. Addressing the develop-
ment of cultural competence among faculty
at all levels of nursing education is critical for
preparing a more culturally competent nurs-
ing workforce.
Providing health care to a
diverse population extends
beyond recognizing
race and ethnicity to
include the totality
of beliefs, values, and
experiences that shape the
uniqueness of individuals.
It includes gender,
religious affiliations,
sexual orientation, age,
and socioeconomic
status. Health professions
training programs must
enhance self-awareness
and improve care by
increasing knowledge and
cultural competence skills.
Limitations
This study represented current and future
nurse educators within a single rural state.
Self-perceived levels of cultural com-
petence were measured only one time.
Recommendations for future research
include the repeated assessments of the per-
ceived competencies of nurse educators to
more accurately reflect the process of devel-
oping competence over time.
Recommendations
Curriculum development projects should
include an explicit emphasis on incorpo-
rating and identifying concepts of diversity
and cultural competence. Comparisons of
rural and urban nursing programs could
help to more appropriately identify the cul-
tural aspects of each type of setting. More
research must be performed to identify
barriers to cultural competence educa-
tion in geographic areas in which clinical
opportunities for encounters with patients
from diverse populations may be limited
or unrecognized. Opportunities for fac-
ulty development in diversity and culture
should be offered with ongoing evaluation
to identify gaps in cultural knowledge and
highlight the comprehensiveness and com-
plexity of the concepts and skills involved.
Research with interdisciplinary faculty and
professionals will also be needed to iden-
tify effective practices in order to facilitate
a more culturally competent, collaborative
health care workforce.
Conclusion
In general, nursing faculty, graduate stu-
dents, and clinical educators in this study
rated themselves as being culturally aware.
However, diversity and concepts of cultural
competence were not always clearly inte-
grated into curricula. Community colleges
appear to have more specifically identified
cultural content incorporated throughout
curricula than their counterparts at the uni-
versity level. University faculty seemed to
struggle with integrating content and nam-
ing key concepts, perhaps because they have
more academic freedom in designing their
syllabi.
State leaders in Wyoming have been
working toward a unified, shared, competen-
cy-based nursing curriculum that is expected
to have more defined content and consis-
tency. The findings from this investigation
represent all nursing education programs in
the state; thus, they provide a warning signal
for the future.
More importantly, concerns exist about
the depth and clarity of the concept of cul-
tural competence in curricula. Faculty mem-
bers in this study did not readily identify
issues of diversity and oppression separate
from race and ethnicity (i.e., marginalized
V o l u me 3 6 N u mber 1 25
 Nursing Education Perspectives

groups, older adults, underserved, isolated
populations) and the impact on access to
health care and disparities. Continued explo-
ration directed toward the complexity of the
construct is needed in education, practice,
and research. Broader conceptualization,
with emphases on inclusivity and social jus-
tice, is imperative to address disparities of
health and health equity.
ABOUT THE AUTHORS
Connie Diaz, PhD, RN, PHCNS-BC,
CNE, is a course mentor, College of Health
Professions, Western Governors University,
Salt Lake City, Utah. Pamela N. Clarke, PhD,
MPH, FAAN, is a professor and director of
the Center for Community Health, Fay W.
Whitney School of Nursing, University of
Wyoming, Laramie. Mary Wairimu Gatua,
EdD, MSW, is an assistant professor of social
work at Clarke University, Dubuque, Iowa.
For more information, contact Dr. Clarke at
pclarke@uwyo.edu.
KEY WORDS
Cultural Competence – Rural – Nursing
Workforce – Nursing Education

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26 JANUARY/FEBRUARY 2015
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