1.       Methodology

This work was undertaken to determine if an educational offering related to cultural competency for nursing preceptors in the United States had been developed and/or trialed. The authors included three graduate students and their faculty advisor. The initial work was completed to satisfy some of the requirements of a graduate-level research assistantship course. The authors searched the CINAHL Complete, ERIC, and PubMed databases available online through the university’s library system. The following search terms were utilized: culture, cultural competence, cultural, nursing, nurse, preceptor, preceptorship, internship, training. Items from journals that did not have a peer review process were excluded. Articles published from 2010 were included in the analysis, although older references were utilized to provide background information. Articles from outside of the United States were excluded for this project because the focus was nursing education within the United States. Nineteen articles were ultimately included in the final analysis.

Each author conducted a unique search of the databases utilizing the terms in question. The inclusion list was determined by group consensus as to whether the article addressed an aspect of culturally competent precepting. The articles to be reviewed were then divided into categories based on similarities, and each category was assigned to two authors for review and synthesis. Each category is represented by a heading within this paper. The final paper was formatted and edited by all of the authors.

2.       Cultural Competency

Cultural competency is defined by the National Education Association as “Having an awareness of one’s own cultural identity and views about difference, and the ability to learn and build on the varying cultural and community norms” (2015). The benefits of cultural competency include increased patient satisfaction, trust, adherence, and patient outcomes [2]. As the United States population becomes increasingly more diverse, cultural competency is more important than ever. According to the Institute of Medicine, racial and ethnic minorities receive unequal treatment in health care (2002). Health disparities remain a large problem in the United States. Literature has suggested that a culturally competent nursing workforce can have a positive effect on health disparities [3].

In a literature review for providing culturally appropriate care for midwives, Williamson and Harrison identified two different approaches of defining and providing culturally competent care (2010). They discuss a cognitive approach that focuses on customs and traditions and a second approach that is broader and focuses on the social position rather than behaviors and beliefs [4]. Similarly, Blanchet Garneau and Pepin argue that culture is a relational process and ever-changing, thus requires lifelong dedication to become and remain culturally competent (2015). They point out that many view diversity as race and ethnicity alone but fail to consider age, gender, sexual orientation, or socioeconomic status [5]. By approaching culture with this perspective, current models fall into the trap of encouraging cultural stereotypes. Asad and Kay see a need to define culture in a way that accounts for local variations and avoids generalizations (2015).

It is apparent when reviewing the literature that people view and perceive culture very differently. Asad and Kay explore this oddity when they set out to understand how people perceive culture in relation to health interventions (2015). They interviewed 169 officials of nongovernmental organizations working on health issues in multiple countries and found that perceptions of culture drastically affect an intervention's success [6]. It is easy to view certain cultural practices as laziness or non-compliance, but having an awareness and understanding of culture from a multidimensional perspective allows acceptance. The Journal of Transcultural Nursing has seen the need for culturally competent care and has responded by creating the standards for practicing culturally competent nursing. The twelve standards serve as a resource for nurses and emphasize cultural competence as a priority [7]. These extensive standards reflect the challenges facing nurses providing care in a continually growing diverse setting. Cultural competence is an ongoing education process that is never complete. Waite and Calamaro state that “Cultural competence is not seen as a static end point obtained by virtue of an advanced practice degree; rather, it is a journey and process” (2010).

3.       Cultural Competency Education

Just as perceptions and attitudes towards cultural competency are changing, so are educational methods. The majority of education surrounding cultural competency focuses on cultural awareness and respect, but as beliefs surrounding cultural competency have shifted, so have methods of instilling it. Waite and Calamaro recognize that there is much discussion and writing about cultural diversity, but little is done to directly deal with it (2010). In their article, they present that nursing education needs to prepare students to be lifelong learners recognizing the multicultural, multiracial, and growing diversity in the populations they serve [8].

From 2011 to 2015, a multidisciplinary team of librarians, faculty, staff, and medical students at an emerging medical school set out to explore techniques to address cultural competence [9]. The team created an educational program named Diversity Dialogs that invited students to explore diversity and cultural competency [9]. The dialogues took place 3-4 times per academic year and results were favorable. Similarly, Elminowski [10], developed a Cultural Awareness Workshop for nurse practitioners. This cultural competence workshop took place over 3 hours and also showed improvement in cultural knowledge and competence. Elminowski concluded that workshops can be a cost effective and successful educational tool for increasing cultural awareness and competency (2015). A diverse group of clinicians and educators at Boston Medical Center, a diverse inner-city hospital, set out to attack disparities by creating a RESPECT model [2]. Spurred by the well-documented decline in empathy and the lack of interpersonal skills, the team produced the RESPECT model, an “action-oriented set of communication and relational behaviors.” [2]. The RESPECT model was used with great success in improving the quality of care and communication between patients and clinicians. The study of literature suggests there are multiple ways to address cultural competence. Whether encouraging discussion via a multidisciplinary team, developing a workshop, running empathy simulations, implementing models, or following standards, increasing cultural competence is an urgent and lacking need.

4.       Health Disparities

Research shows that health disparities are a real problem among minorities and underserved populations in the United States. Examples of these disparities include a lack of care in regards to diabetes, maternal and child health, adverse events, cancer screening and child health care [11]. Many researchers feel that health disparities are linked to the lack of diversity within the healthcare field, specifically nursing [12]. Many assumptions exist about the correlation between an increasingly diverse nursing workforce and the improvement of many health disparities. Despite these assumptions, there is little research or data to support these assumptions. It is believed that by increasing the number of minorities in the fields of nursing science (researchers) and nursing leadership, these researchers and leaders will provide an increase in funding and interest in the health of minorities. The National Institute of Nursing Research (NINR) promotes health equity and improves health disparities by providing grants for minority nurse scientists. Through programs such as this, health disparities are decreasing. Further research is needed to accurately demonstrate the correlation between increasing diversity amongst nurses and decreasing health disparities [11].

Nursing leaders can improve the diversity of the body of nurses by establishing culturally safe policies and by mentoring nurses from diverse backgrounds into leadership positions. Phillips and Malone discuss the importance of recruiting minorities as nurse leaders (2014, p. 49). “Ensuring workforce diversity and leadership development opportunities for racial/ethnic minority nurses must remain a high priority if we are to realize the goal of eliminating health disparities, and, ultimately, achieving health equity” [11].  Many racial/ethnic minority nursing organizations exist, and it is their top priority to help diversify the field of nursing and to minimize the occurrences of health disparities. These groups have a strong national presence and they are involved in mentoring others to have a strong presence in healthcare [11].

5.       Diversity

The nursing profession is primarily comprised of white women [13]. This dominance in the field leads to many issues with cultural diversity and the ability of nurses to provide truly culturally aware care. There is a perception of normalcy that is created amongst nurses in the field and within the different nursing schools. This norm can create a problem for the patients and other professionals that do not fall within it. The dominant culture in America expects that equality exists with complete assimilation into the American culture. Increasing diversity into the field of nursing can change this negative aspect of culture [14]. According to the U.S. Census Bureau, projections indicate that America will be a minority majority population by 2043. Due to the increasing diversity amongst the American population, the need to diversify the field of nursing is great [13].

6.       Diversity Programs and their Efficacy

Many programs exist with the goal of diversifying the nursing profession. Funding is available through Nursing Workforce Diversity (NWD) grants from the U.S. Health Resources and Services Administration (HRSA), Bureau of Health Professionals, Division of Nursing to help the education system recruit and retain minority nurses [12]. Minority students may choose health science majors for many reasons including a general interest in the field, the desire to better the community or help people, or financial incentives. Despite the presence of these reasons and even the incentives for this field, many minorities seem to be unaware of these motivating factors.  A thorough assessment of each student’s needs must be completed to provide a successful program for recruitment and retention of minority nurses. Research suggests that in order for a school to be successful they need a structured program for recruitment and retention and the ultimate success of the minority student [15].

Many states are involved with the initiative to increase diversity in nursing. One such program is found in Massachusetts. Massachusetts has taken a comprehensive approach by implementing a program called Bring Diversity to Nursing (BDN). This program engages students from elementary school through graduate school. It utilizes minority nurse recruiters and volunteers to read books about nursing to elementary aged children of a diverse background. They also use open communication to share stories of how nurses can make a difference. In middle school and high-school, they do several workshops to introduce nursing as a career to the students. They provide mentors to help counsel the students and help them with high school class selection to insure their success in high school and to provide direction for those students who are interested in nursing as a career. Another aspect of BDN is to provide financial support for underprivileged students through scholarships and stipends. In 2007, the University of Massachusetts Lowell (UML) nursing program was comprised of 12% ethnic and racial minorities. In 2011, after the implementation of BDN, that percentage increased to 20.2%. UML encourages all nursing students to apply to be a part of the BDN. The BDN offers a retention program that includes individual counseling, the loaning of technology and encouraging its members to volunteer to help the program continue to grow. Throughout the three years that this program has been in place, researchers have found that its success correlates to the dedication of the personnel. They further state that the program must be flexible to meet the needs of as many people as possible [12].

Another program offered group mentoring to counter the influence of cultural hegemony. Cultural hegemony is when a dominant culture maintains its dominance over other cultures through the establishment of policies and procedures that act to reinforce existing cultural structures. This program’s goal is to provide nursing students of all backgrounds the tools needed to counter the negative image of nurses as portrayed through the media. Basically, many people view nurses as submissive, task-oriented non-professionals. This program uses group mentoring as a means to provide education to counter the negative images. This program has modest beginnings with only 17 students enrolled in the first year. Despite the small attendance, the program was well received by those in attendance [16]. Further research is needed to determine the true effectiveness of the above-mentioned programs and all others in the recruitment and retention of minority nurses.

7.       Racism and Bias in Nursing

Racism and bias in nursing are some of many barriers to cultural competency and the elimination of health disparities. Despite continued efforts to diversify, the nursing profession is comprised primarily of white, middle class females [17,18,19]. The demography of the nursing profession has contributed to a white, middle class perspective that often governs and directs nursing practice, research and education [19]. Holland [18], conducted a phenomenological study of white BSN faculty members to explore their ideas, meanings and experiences of race, racism, and antiracism within cultural education. The findings suggest that the pervasive whiteness of the participants influenced their understanding and teaching of race, racism, and antiracism, and that the participants were not well prepared to teach about these topics [18]. White nurses may exhibit macroaggressions, unintended subtle racism and unconscious bias, which can foster unintended discrimination and contribute to health disparities [17,20]. Bellack [20], suggests use of a simple tool known as the Implicit Association Test (IAT) to raise awareness of personal biases and assist in the development of strategies to combat unconscious bias. Health equity and reduced health disparities represent common goals of the nursing profession. To work towards these goals, we must attend to issues of white privilege, power relations and oppressions within the profession [17,19]. Confronting and acknowledging these issues can be a daunting task. When confronted with these realities, white persons may feel shame, denial, guilt, anger and fear of retaliation [17]. To address these issues, Halls and Fields [17] urge for open, energetic dialogue and continued conversation of racism among white nurses. Van Herk, Smith and Andrew [19], describe use of an intersectionality paradigm as an another means to attend to issues of privilege, oppression, inequities and social justice within nursing. Self-examination and reflection to unearth unconscious racism and bias play an important role in the journey towards cultural competency.

8.       Empathy and Cultural Humility

Cultural empathy is the ability to learn to perceive and share experiences through the unique lens of values, beliefs, and perspectives of people from cultural backgrounds different to our own [21]. Some researchers have recently discussed the role as empathy in obtaining cultural competency, acknowledging that empathy may be a required precursor to cultural competence [22]. Everson and company produced a 3D virtual reality simulation for nursing students and found that placing the students in the situation of culturally and linguistically diverse individuals increased empathy [22].

As the nation’s population has and will continue to become increasingly more diverse, the need to interact and engage with culturally diverse individuals and groups is greater than ever before. Hook and Watkins [23] discuss cultural humility as a means to foster positive contact with these culturally different individuals and groups. From an intrapersonal level, cultural humility involves the openness and willingness for self-reflection, and the awareness of personal limitations in understanding other cultural backgrounds and views. From an interpersonal level, cultural humility involves an openness to the ideas and aspects of other cultures [23]. Hook and Watkins [23] argue that cultural humility may be the “foundational cornerstone of any and all cultural contact” (p. 661).

9.       Preceptorship in Nursing

Preceptorship in nursing is a vital part of clinical nursing education, and plays an important role in the development of competent and well trained nurses. The preceptor teaches the student how to engage in clinical practice. The value of the relationship between preceptors and nursing students cannot be underestimated. Interactions within this relationship can make or break the clinical experience [24], and successful preceptorship is determined by the strength of this relationship [25].

A variety of models and theoretical/conceptual frameworks have been developed and discussed within the literature in an attempt to guide and maximize preceptorship within the nursing field. Monterosso and Zilembo [24], propose a conceptual framework which focuses on the interactions that occur within the versatile student/preceptor relationship. This model highlights variations between individual personalities and circumstances, which influence the approach used by the preceptor in order to maximize the learning environment. This model suggests that nursing students will experience positive clinical practice when paired with a preceptor that demonstrates desirable leadership characteristics. The authors stress the importance of preparing both the students and nurse preceptors for the preceptorship experience, and recommend preceptor training as a mandatory competency [24].

In a separate preceptorship model [25], incorporates factors that influence clinical learning from the perspective of the student and the preceptor, with consideration to the university and health care agency as well. She emphasizes the importance of partnership and collaboration among preceptees, preceptors, universities and healthcare organizations in order to achieve quality and effective preceptorship experiences [25]. A longitudinal study by Newton et al. [26], examines how undergraduate nursing students learn through use of a proposed preceptor model in comparison with other educational models. The authors hypothesized that students participating in the preceptor model would have more positive perceptions of the clinical learning environment than students participating in other models. While the survey responses did not fully support their hypothesis, the responses suggest that both student centeredness and continuity of the preceptor/clinical teacher are necessary for an effective clinical learning environment [26]. A successful and ideal preceptorship can provide invaluable nursing experience and education. Preceptorship can be a rewarding and beneficial experience for students, preceptors, patients and organizations [24,25].

10.   Conclusion

While many great strides have been made towards cultural competency, health equity and the elimination of health disparities, there is still ample work to be done. The examination of contributing factors such as diversity in the workforce, cultural competency education, and racism and bias within the profession is necessary to work towards this common goal. It is evident within the literature that cultural competency represents an ongoing journey requiring thorough examination, and a multifaceted and collaborative approach by all members of the nursing profession and healthcare community. While cultural competency and preceptorship are regarded as essential to nursing practice within the literature, there is little to no discussion of cultural competency within the preceptor role itself. The importance of cultural competency education and value of preceptorship is discussed at length, but cultural competency education and training methods specific to the vitally important preceptor role is lacking within the literature.

1.       Smith MC, Parker ME (2015) Nursing theories and nursing practice (4^th ed.). Philadelphia: F.A. Davis.

2.       Mostow C, Crosson J, Gordon S, Chapman S, Gonzalez P, et al. (2010) Treating and precepting with respect: a relational model addressing race, ethnicity, and culture in medical training. Society of General Internal Medicine 25: 146-154.

3.       Fortier JP, Bishop D (2003) Setting the agenda for research on cultural competence in health care: Final report (C. Brach, Ed.). Rock-ville, MD: U.S. Department of Health and Human Services, Office of Minority Health and Agency for Healthcare REsearch and Quality.

4.       Williamson M, Harrison L (2010) Providing culturally appropriate care: A literature review. International Journal of Nursing Studies 47: 761-769.

5.       Blanchet Garneau A, Pepin J (2015) A constructivist theoretical proposition of cultural competence development in nursing. Nurse Education Today 35: 1062-1068.

6.       Asad AL, Kay T (2015) Toward a multidimensional understanding of culture for health interventions. Social Science & Medicine, 144: 79-87.

7.       Douglas MK, Pierce JU, Rosenkoetter M, Pacquiao D, Callister LC, et al. (2011) Standards of practice for culturally competent nursing care: 2011 Update. Journal of Transcultural Nursing 22: 317-333.

8.       Waite R, Calamaro C (2010) Cultural Competence: A Systemic Challenge to Nursing Education, Knowledge Exchange, and the Knowledge Development Process. Perspectives in Psychiatric Care 46: 74-80.

9.       Swanberg S, Abuelroos D, Dabaja E, Jurva S, Martin K, et al. (2015) Partnership for Diversity: A Multidisciplinary Approach to Nurturing Cultural Competence at an Emerging Medical School. Medical Reference Services Quarterly 34: 451-460.

10.    Elminowski NS (2015) Developing and implementing a cultural awareness workshop for nurse practitioners. Journal of Cultural Diversity 22: 105-113.

11.    Phillips J, Malone B (2014) Increasing racial/ethnic diversity in nursing to reduce health disparities and achieve health equity. Public Health Reports 129: 45-50.

12.    Melillo KD, Dowling J, Abdallah L, Findeisen M, Knight M (2013) Bring diversity to nursing: Recruitment, retention, and graduation of nursing students. Journal of Cultural Diversity 20.

13.    Fact sheet (2015) enhancing diversity in the nursing workforce. American Association of Colleges of Nursing.

14.    Ong-Flaherty C (2015) Critical Cultural Awareness and Diversity in Nursing: A Minority Perspective. Nurse Leader 13: 58.

15.    Carthon JMB, Nguyen TH, Pancir D, Chittams J (2015) Enrollment of underrepresented minorities in nursing majors: a cross sectional analysis of U.S. nursing schools. Nurse Education Today 35: 1102-1107.

16.    Kneipp SM, Rowsey PJ, Giscombe C, Hodges EA, Fowler T, et al. (2014) Countering the influence of cultural hegemony on choosing a nursing career: A group-mentoring approach for student recruitment. Journal of Nursing Education 53: 296-299.

17.    Hall JM, Fields B (2013) Continuing the conversation in nursing on race and racism. Nursing Outlook 61: 164-173.

18.    Holland AE (2015) The lived experience of teaching about race in cultural nursing education. Journal of Transcultural Nursing 26: 92-100.

19.    Van Herk K, Smith D, Andrew C (2011) Examining our privileges and oppressions: Incorporating an intersectionality paradigm into nursing. Nursing Inquiry 18: 29-39.

20.    Bellack JP (2015) Unconscious bias: an obstacle to cultural competence. Journal of Nursing Education 54: 63-64.

21.    Wang YW, Davidson MM, Yakushko OF, Savoy HB, Tan JA, et al. (2003) The scale of ethnocultural empathy: development, validation, and reliability. Journal of Counseling Psychology 50: 221-234.

22.    Everson N, Levett-Jones T, Lapkin S, Pitt V, van der Riet P, et al. (2015) Measuring the impact of a 3D simulation experience on nursing students’ cultural empathy using a modified version of the Kiersma-Chen Empathy Scale. Journal of Clinical Nursing, 24: 2849-2858.

23.    Hook JN, Watkins CE Jr (2015) Cultural humility: The cornerstone of positive contact with culturally different individuals and groups? American Psychologist 70: 661-662.

24.    Zilembo M, Monterosso L (2008) Towards a conceptual framework for preceptorship in the clinical education of undergraduate nursing students. Contemporary Nurse 30: 89-94.

25.    Happell B (2009) A model of preceptorship in nursing: reflecting the complex functions of the role. Nursing Education Perspectives 30: 372-376.

26.    Newton J M, Jolly BC, Ockerby CM, Cross WM (2012) Student centredness in clinical learning: the influence of the clinical teacher. Journal Of Advanced Nursing 68: 2331-2340.