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Cultural competence of healthcare professionals : a critical analysis of the construct and its correlates Capell, Jennifer 2006

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CULTURAL COMPETENCE OF HEALTHCARE PROFESSIONALS: A CRITICAL ANALYSIS OF THE CONSTRUCT AND ITS CORRELATES by Jennifer Capell B.Sc (PT) with distinction, University of Western Ontario, 1998 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR THE DEGREE OF M A S T E R O F S C I E N C E in T H E FACULTY OF GRADUATE STUDIES (REHABILITATION SCIENCES) T H E UNIVERSITY OF BRITISH COLUMBIA JULY 2006 © JENNIFER C A P E L L , 2006 A B S T R A C T Background: Globalization has implications for healthcare worldwide including healthcare disparities and outcomes. Cultural competence of healthcare professionals has emerged as a field to address such issues. Purpose: This thesis proposed to (a) critically appraise the construct of cultural competence and its assessment in healthcare professionals, and (b) identify relationships between cultural competence and selected attributes including ethnocentrism and international experience. Design: The construct o f cultural competence and tools to assess it were critiqued. This was followed by a cross-sectional questionnaire study associating the cultural competence of physiotherapists, occupational therapists, and nurses with the attributes of ethnocentrism, international experience, and additional variables. Subjects and Methods: Participants (n=71) were recruited from hospitals in Greater Vancouver, Canada. The questionnaire included demographic and cultural information, the Inventory to Assess the Process of Cultural Competence-revised ( IAPCC-R) , the Generalized Ethnocentrism Scale (GENE) , and exploratory questions regarding international experience and clinical practice. Results: Cultural competence scores did not differ by profession. Cultural competence scores were negatively associated with ethnocentrism, and positively associated with general (but not healthcare specific) international experience and desire to gain international experience. Number of languages spoken and proportion of people from other cultures in a practitioner's caseload were also positively associated with cultural competence. Discussion and Conclusions: Campinhe-Bacote's model and assessment tool ( IAPCC-R) for cultural competence are primary contributions to the field of cultural competence in healthcare. The well established I A P C C - R focuses on practitioner's attributes but does not link these attributes to improved clinical outcomes. Therefore, the I A P C C - R may reflect cultural sensitivity rather than competence. We argue that enhanced patient outcomes may be the more valid indicators of cultural competence in healthcare. Ethnocentrism and international experience were related to cultural competence, however causality within these relationships warrant further study. Studies need to establish the uniqueness of the construct versus general interpersonal effectiveness. If it exists, the construct of cultural competence warrants refinement to reflect its distinctiveness. In this way, its elements perhaps could be taught to healthcare professionals to enhance their clinical effectiveness and outcomes, and new directions for research established. i i i T A B L E O F C O N T E N T S C O N T E N T P A G E Abstract • ii Table of Contents ...iv List of Tables vii List of Figures viii List of Abbreviations ix Acknowledgements x C H A P T E R 1 I N T R O D U C T I O N 1 1.1 Purpose 1 1.2 Research Questions 3 1.2.1 Question 1 3 1.2.2 Question 2 4 1.2.3 Question3 4 1.2.4 Question 4 4 1.3 Rationale 4 C H A P T E R 2 C U L T U R A L C O M P E T E N C E IN H E A L T H C A R E : C R I T I C A L A N A L Y S I S O F T H E C O N S T R U C T A N D ITS A S S E S S M E N T 7 2.1 Introduction 7 2.2 A critical analysis of the construct of cultural competence: from theory to Practice 8 2.3 Assessment tools to evaluate cultural cpmpetence 10 2.3.1 Method used to select and critique the cultural competence assessment tools 10 2.3.2 The Cross-Cultural Adaptability Inventory (CCAI) 11 2.3.3 The Inventory for Assessing the Process of Cultural Competence -Revised ( I A P C C - R ) '. 12 2.3.4 The Cultural Competence Assessment ( C C A ) 13 2.3.5 The Cultural Self-Efficacy Scale (CSES) 13 2.4 Limitations of cultural competence assessment tools . .14 2.5 Advancements in the field o f cultural competence 15 2.5.1 Suh's model o f cultural competence 16 2.6 Future directions 18 2.6.1 Cultural competence versus cultural sensitivity 19 2.7 Conclusion ; !' 20 iv CONTENT T A B L E O F C O N T E N T S ( C O N T I N U E D ) P A G E C H A P T E R 3 T H E A S S E S S M E N T O F C U L T U R A L C O M P E T E N C E I N H E A L T H C A R E P R O F E S S I O N A L S 22 3.1 Background and review of the literature 22 3.1.1 Assessment of cultural competence 23 3.1.2 Ethnocentrism 24 3.1.3 International experience and cultural competence 25 3.1.4 Additional attributes associated with cultural competence 29 3.2 Methods 30 3.2.1 Overview 30 3.2.2 Questionnaire 30 3.2.3 Sample recruitment and data collection 34 3.2.4 Data analysis 36 3.3 Results 42 3.3.1 Demographic and personal characteristics 42 3.3.2 Assessment of cultural competence 42 3.3.3 Ethnocentrism and cultural competence 44 3.3.4 The influence of international experience on cultural competence 44 3.3.5 Additional attributes associated with cultural competence 45 3.4 Discussion 46 3.4.1 Demographic and personal characteristics 46 3.4.2 Assessment of cultural competence 47 3.4.3 Ethnocentrism and cultural competence 50 3.4.4 The influence of international experience on cultural competence 51 3.4.5 Additional attributes associated with cultural competence 54 3.4.6 Participants' perspectives on cultural competence 57 3.4.7 Study limitations and future directions 58 C H A P T E R 4 D I S C U S S I O N A N D C O N C L U S I O N 60 4.1 Discussion and implications 60 4.1.1 Overall discussion 60 4.1.2 Implications 67 4.1.3 Future directions 69 4.2 Summary 71 4.3 Conclusion 72 v C O N T E N T T A B L E O F C O N T E N T S ( C O N T I N U E D ) P A G E T A B L E S 74 F I G U R E S 86 R E F E R E N C E S 88 A P P E N D I C E S 96 A P P E N D I X 1 C O N S E N T F O R M A N D Q U E S T I O N N A I R E 96 Consent form 96 Questionnaire 98 A P P E N D I X 2 U B C R E S E A R C H E T H I C S B O A R D C E R T I F I C A T E O F A P P R O V A L 1 0 5 L I S T O F T A B L E S T A B L E T I T L E P A G E 1 Summary table of current evaluation tools to measure cultural competence in healthcare professionals 74 2a General demographic and personal characteristics 76 2b Demographic and personal characteristics stratified by international experience (mean, standard deviation, and range) 77 2c Demographic and personal characteristics stratified by international experience (frequencies and percentages) 78 3a Scale reliability: item-total statistics for the I A P C C - R 79 3b Scale reliability: item-total statistics for the G E N E 80 4a Comparison of mean I A P C C - R scores by profession and hospital 81 4b Comparing I A P C C - R mean differences between hospitals (Post hoc ScheffeTest) 81 5 Outcomes believed to be most important in culturally competent care (mean rankings stratified by international experience) 82 6a Relationship between international experience or desire to gain this experience and cultural competence (Pearson's r correlations) 83 6b Predicting cultural competence scores from the variables 'months spent working internationally' and 'desire to work internationally' (Multiple regression model) 83 7 Relationship between specific attributes and cultural competence scores (Pearson's r, Spearman's r s, or r\ correlations) 84 8a Select immigrant populations (IP) in Vancouver, North Vancouver, and Richmond 85 8b Healthcare professional's place of birth 85 L I S T O F F I G U R E S FIGURE TITLE P A G E 1 Leininger's Sunrise Model 86 2 Suh's Model of Cultural Competence 87 L I S T O F A B B R E V I A T I O N S A B B R E V I A T I O N T I T L E I A P C C - R Inventory to Assess the Process of Cultural Competence Among Healthcare Professionals - Revised G E N E Generalized Ethnocentrism Scale N G O s Non-governmental organizations a Cronbach's alpha C C A I The Cross-Cultural Adaptability Inventory C C A Cultural Competence Assessment C S E S Cultural Self-Efficacy Scale V H H S C - U B C Site Vancouver Hospital and Health Sciences Centre - University of British Columbia Site A N O V A Analysis of variance n Sample size r Pearson's r r s Spearman's rho n Eta SD Standard deviation IP Immigrant population ix A C K N O W L E D G E M E N T S "I f you have knowledge, let others light their candles at it". 1 To my advisory committee, the flame that you offered me not only lit my way, but fueled my knowledge and my quest for higher learning. Thank you to my supervisor, Dr. Elizabeth Dean and my 'super-advisors', Dr. Jerry Spiegel, and Dr. Gerry Veenstra. Through your advice, lessons, and most of all your support, you have mentored and inspired me. To my friends and family, especially at Green College and at the School of Rehabilitation Sciences, thank you for enriching my education and motivating me by your example. Also , to the participants of this study, thank you for giving me your time and your responses. Finally, to my parents Rob and Rosemary, and my partner, Murray, I hope you can share in my joy o f reaching this goal as much as you shared in the journey of getting here. For your endless support and encouragement, I am forever grateful. I acknowledge the Social Science and Humanities Research Council of Canada (SSHRC) , the Anne Collins Whitmore Foundation and the Physiotherapy Foundation of Canada, the B C Medical Services Foundation, the Health Sciences Association, and the University of British Columbia for their financial support. 1. Margaret Fuller (1810-1850) ~ American journalist, critic, and woman's rights activist x C H A P T E R 1 I N T R O D U C T I O N 1.1 P U R P O S E Cultural competence is the ability to understand and to work effectively with patients whose beliefs, values, and histories are different from one's own. 1 With increasing ethnic diversity in high-income countries such as Canada, and documented ethnic disparity in health and healthcare, 2 ' 3 the construct of cultural competence in healthcare has emerged as a potential means of better meeting people's healthcare needs and optimizing health outcomes. This construct has been described as an ongoing process, not an endpoint, in which the healthcare professional strives to function effectively within the cultural context of an individual, family, or community from a diverse cultural/ethnic background. 4 Indeed, cultural competence in healthcare could be a useful construct for the informed selection and training of healthcare providers. Identifying attributes that influence a healthcare professional's cultural competence could be an important step towards enhancing care for patients from different cultures. Further, an improved understanding of the construct of cultural competence could have some value in providing supplemental training for healthcare providers, whether trained in Canada or abroad. This thesis is divided into four sections. Following this introductory chapter, Chapter 2 provides a critical analysis of the construct and assessment of cultural competence. A s the study and practice of culturally competent healthcare evolve, the theoretical foundations of cultural competence and emerging evaluative tools need to be scientifically rigorous. A s well as reviewing and critiquing the construct of cultural competence, this chapter provides an objective 1 comparison and appraisal of the most common tools currently used to evaluate the cultural competence of healthcare professionals. Directions for future research are proposed. Chapter 3 describes a study conducted (a) to determine the cultural competence of a group of healthcare professionals using one of the tools critiqued in Chapter 2, (b) to determine i f a relationship exists between international experience and cultural competence, and (c) to further explore the construct of cultural competence by assessing relationships between a series of attributes of the professionals and cultural competence. Finally, Chapter 4 presents an overall discussion and conclusion that includes implications for research, clinical practice, and healthcare professional education. Four main purposes were identified for this thesis. First, the construct and evaluation of cultural competence in healthcare were critically analyzed. Second, the cultural competence of a sample of physiotherapists, occupational therapists, and registered nurses was assessed using the Inventory to Assess the Process of Cultural Competence Among Healthcare Professionals -Revised (IAPCC-R). 4 Third, the less established construct of cultural competence was benchmarked against the century-old sociocultural attribute of ethnocentrism. To determine the relationship between these constructs, the IAPCC-R 4 and the General Ethnocentrism Scale (GENE) 5 were used to assess cultural competence and ethnocentrism respectively. Fourth, based on the literature, we examined the relationships between several attributes and cultural competence. Of particular interest was international experience. The relationships between cultural competence (using IAPCC-R 4 scores as an index of cultural competence) and (a) international experience working in healthcare, (b) general international experience (not necessarily specific to healthcare) and (c) desire to work internationally in healthcare were 2 assessed. The term 'work' is used in throughout this thesis to describe either paid or unpaid (i.e. volunteer) work in healthcare. Finally, the relationship between cultural competence and demographic, educational, and clinical attributes were explored. A s the critical analysis of cultural competence illustrates, the current tools to assess the cultural competence of healthcare professionals fail to include variables relating to clinical or patient outcomes. We propose that the ultimate indices of culturally competent care are patient outcomes such as improved health, shortened hospital stay, compliance with treatment, and patient satisfaction. However, no cultural competence assessment tool to date relates clinical outcomes to the attributes of and care provided by the healthcare professional. Thus, results based on these tools should be interpreted with caution. Nonetheless, the findings from this study have helped to validate the construct of culturally competent healthcare, while exposing some of the limitations of the present methods of evaluating cultural competence. The findings also shed light on key attributes of healthcare providers who have high cultural competence scores, based on current assessment tools. 1.2 RESEARCH QUESTIONS 1.2.1 Q U E S T I O N 1 Do physiotherapists, occupational therapists, and registered nurses practicing in British Columbia's Lower Mainland differ with respect to cultural competence, based on their scores on the Inventory to Assess the Process of Cultural Competence - Revised ( I A P C C - R ) ? 4 3 1.2.2 QUESTION 2 Are cultural competence (as determined with the I A P C C - R 4 ) and ethnocentrism (as determined with the G E N E 5 ) associated? 1.2.3 QUESTION 3 Is there a relationship between the cultural competence (as determined with the I A P C C - R 4 ) of healthcare professionals and international experience (general or specific to healthcare), as well as desire to gain international work experience? 1.2.4 QUESTION 4 Is there an association between cultural competence (as defined by the I A P C C - R 4 ) and specific attributes of healthcare providers, such as years of clinical experience, cultural identity and number of languages spoken. 1.3 R A T I O N A L E Marked disparities in healthcare and in health outcomes in North America have been well documented. 2 ' 3 Members of racial and ethnic minorities have higher rates of disability, disease, and death,2 and receive a lower quality of healthcare3 when compared with the dominant cultural group. Thus, as the Canadian Romanow Report, 6 and Ki rby Commission, 7 as well as the United States Health and Human Services Initiative have identified, improving healthcare for the growing immigrant population is a leading priority in both Canadian and United States' health services del ivery . 8 4 Even though racial and ethnic disparities in healthcare have existed for many years, there is limited evidence to explain these differences.9 The causes of these disparities are complex and multifaceted, with solutions being sought at the levels of the healthcare system, the healthcare professional, and the patient. It has been argued that healthcare professionals who are able to provide care that is specific to the cultural needs of patients, may help reduce such disparities in healthcare. 1 0 A s a result of both the diversification of patient populations, and the probable association between the provision of culturally competent healthcare and improved patient outcomes, the study of cultural competence is expanding. A s this expansion occurs, care is needed to ensure scientific rigor in the field. The theoretical background for cultural care has been in existence for a number of years, 1 1 however it is only recently that this theoretical foundation has been translated into assessment of clinicians' ability to provide this care. A t present, most assessment tools focus on the attributes of the healthcare professional. A critical analysis of the construct and assessment of cultural competence is warranted to refine the definition of cultural competence, to improve the assessment methodology, and to examine factors that may predict cultural competence in healthcare professionals. To our knowledge, this study was the first to use the available tools to assess the cultural competence of practicing rehabilitation therapists (physiotherapists and occupational therapists), and one of the first evaluating Canadian registered nurses. These data provide a baseline for future research and training to improve clinicians' cultural competence and thus aid in improving the quality of care to different cultural groups. 5 A cause-and-effect relationship between cultural competence and attributes such as healthcare professionals' experience internationally cannot be determined through exploratory research such as this. However, an understanding of the attributes of individuals who are thought to produce superior outcomes in patients who are culturally different from themselves is warranted. Determining if, for example, a correlation exists between international experience and cultural competence scores may provide support for cultural immersion programs. Our results should yield new directions for further investigation. The findings of this study w i l l be of interest to researchers, clinicians, educators, and non-governmental organizations (NGOs). They may contribute toward improved healthcare both for individuals from minority groups in Canada and for those l iving in low- and middle-income countries. Further, this information could aid in increasing the effectiveness of cultural competence training and international experiences for the healthcare professionals and for their treatment of patients both in culturally diverse Canada and in other countries in which they may work. The findings may also assist N G O s in their recruitment and training programs. 6 C H A P T E R 2 C U L T U R A L C O M P E T E N C E IN H E A L T H C A R E : C R I T I C A L A N A L Y S I S O F T H E C O N S T R U C T A N D ITS A S S E S S M E N T 2.1 INTRODUCTION Culture is the learned patterns of thought and behavior including language, values, actions, religion and rules of conduct, which distinguish a particular social group. 1 2 ' 1 3 B y extension, cultural competence has been defined as an ongoing process in which the healthcare provider continuously strives to function effectively within the cultural context of the client. 4 The use of the term 'effectively' in this definition of cultural competence implies the achievement of a result or an improved outcome. However, what this definition fails to provide is a guideline as to which outcomes to measure, and how to link these outcomes to the care provided by the healthcare professional. For example, does such care increase patient satisfaction, adherence to treatment, or provider satisfaction with a treatment session? Further, i f one (or more) of these outcomes is assessed without a concurrent evaluation of the healthcare professional's behavior, the effect of the healthcare professional can not be differentiated from effects such as the healthcare system, or the patient's interactions with other healthcare providers. Consequently, the evaluation of a healthcare professional's cultural competence is a challenging task. Cultural competence is fundamental to effective interpersonal interaction, particularly in healthcare. 1 2 ' 1 3 It is one's culture that determines how one defines health, wellness, illness, youth, and old age. It is also one's culture that influences health-seeking behaviors and defines the roles and expectations of the patient and healthcare provider. 1 4 A s the diversity of patient and healthcare professional populations increases, the need for effective interactions between these two groups becomes even more relevant. The term cultural competence, though designed to 7 capture healthcare professionals' ability to meet the unique cultural needs of diverse patient groups, is still in its infancy. A s this important component of healthcare evolves in the 21 s t century, it must do so in a scientifically rigorous manner. The purpose of this chapter is to critique the literature on cultural competence in healthcare, with particular emphasis on the current models of cultural competence and the tools used to assess this construct in healthcare professionals. In addition, directions for further study are described. 2.2 A CRITICAL ANALYSIS OF THE CONSTRUCT OF CULTURAL COMPETENCE: FROM THEORY TO PRACTICE During the 50 year evolution of the study of cultural competence, several theories and models have emerged. Since the 1950s, researchers such as Leininger have been studying the effect of culture on healthcare.1 1 Researchers have used various approaches to the theoretical study of cultural competence, some providing a broader, more theoretical framework, 1 5 ' 1 6 others offering 17 18 a more practical approach. ' Leininger's Culture Care Diversity and Universality Theory, 1 5 for example, focuses on the act of caring for a patient, relating factors such as religion, education, economics, and environment as well as broader influences such as cultural and social structure and the world view of the healthcare provider and recipient. Figure 1 illustrates Leiniger's Sunrise Model , which she developed to accompany her theory, and which depicts factors that influence care. 1 9 Described as a major contributor to nursing in the 20 t h century, and potentially more so in this present 8 century hallmarked by globalization and multiculturalism, this broad theory has had a major 20 influence on cross-cultural caring in the nursing profession. A theory is a set of interrelated assumptions, concepts, and definitions that presents a systematic view of a phenomenon by specifying relationships among variables, with the purpose of explaining and predicting the phenomenon. 2 1 Theories vary in their levels of abstraction, and thus in their ease of translation to clinical practice. 2 2 Cases in which the transition from theory to practice may not be obvious, an intermediate step such as a practice model may be required to bridge this gap. 2 1 Leininger's theory, although comprehensive in nature, is challenging to translate into a practical assessment tool for researchers or clinicians. In contrast, models such as Campinha-Bacote's 'The Process of Cultural Competence in the Delivery of Healthcare Services' 4 focuses on the attributes of the healthcare professional, identifying the domains of cultural desire, cultural awareness, cultural knowledge, cultural skil l , and cultural encounters as necessary for culturally competent care. 1 7 This narrow focus allowed for expedient translation to practical applications such as evaluation tools or cultural training sessions, but disregards important components that fall outside the realm of the healthcare professional. These current theories and models provided a basis for developing tools to evaluate clinicians' level of cultural competence. Due to the challenges of adapting comprehensive theories of cultural competence into practical evaluation tools, the majority of current clinical and research tools have assessed the cultural competence of healthcare professionals based on narrow models. Consequently, despite an emphasis on 'effective treatment' in the definition of cultural competence, current cultural competence evaluation tools focus on personal attributes of healthcare providers, without linking these attributes to patient outcomes. Accordingly, only a 9 portion of the construct of cultural competence is being assessed by such tools. The following section provides an overview and evaluation of cultural competence assessment tools most commonly used in the nursing and rehabilitation literature. 2.3 ASSESSMENT TOOLS TO EVALUATE CULTURAL COMPETENCE Using models of cultural competence, researchers have defined a set of domains or qualities that are identified as core to the construct of cultural competence. Four tools designed to assess an individual's level of cultural competence through a self-reported questionnaire are compared and contrasted. The tools all use Likert-type scales, and have an internal consistency of 0.77 or higher when analyzed with Cronbach's alpha (a). ' " Given that a scores greater than 0.70 are considered satisfactory for scales that are used as research tools or to compare groups, the internal consistency of these tools is good. 2 7 Further, evaluation tools can be classified as either culture-specific or culture-general. Culture-specific tools assess the ability of healthcare professionals to care for the needs of patients from a particular cultural background whereas culture-general tools do not distinguish between cultural groups. Table 1 is a summary of the following critique. 2.3.1 M E T H O D U S E D T O S E L E C T A N D C R I T I Q U E T H E C U L T U R A L C O M P E T E N C E A S S E S S M E N T T O O L S The literature search included the use of the terms such as: cultur* (to include culture and cultural) A N D competen* (to included competence, competency, and competence) A N D measure* (to include measurement, measurement tool, and measure). In addition, a combination of the terms 'culture' or 'cultural' with 'sensitivity', 'safety', or 'evaluate' was conducted using the Cumulative Index of Nursing and Al l i ed Health Literature ( C I N A H L ) and Medline data 10 bases. From this initial set of articles, additional articles were identified through reference lists and snowballing. Abstracts or articles that were retrieved, were reviewed to determine how researchers evaluated or measured the construct of cultural competence in healthcare professionals. Four primary tools for assessing cultural competence were identified. A comprehensive evaluation of these assessment tools was conducted, including: (a) the purpose of the tool, (b) the domains that the tool assesses, (c) the tool's content validity, or the extent to which the tool measures or reflects the construct of cultural competence, and (d) the limitations of the tool, particularly for use by healthcare professionals in the fields of physiotherapy, occupational therapy, and nursing. 2 . 3 . 2 T H E C R O S S - C U L T U R A L A D A P T A B I L I T Y I N V E N T O R Y (CCAI) This culture-general inventory was designed for cross-cultural training and research, and to assess an individual's potential for adaptability when living or traveling in a different culture.23 The tool is based on a review of relevant research and a polling of experts, as opposed to a foundation in a single theory or model. Using expert opinions for construct validity, the investigators identified the most consistently cited traits and skills associated with cultural adaptability. The CCAI examines the domains of emotional resilience, flexibility/openness, perceptual acuity, and personal autonomy. Scores across these domains can be totaled, with totals from each sub-scale providing insight into the specific areas of cultural competence that an individual may focus on developing further. The CCAI is not specific to healthcare, but has been used in at least two 9 R 9 0 studies on physiotherapy student and faculty populations in the United States, ' as well as several nursing populations 2 9 The main limitations of this tool are the transparency of the questions, many of which have a positive bias, and its focus on ability to live in another culture 11 rather than to treat patients of another culture. For example, the scale includes questions regarding ability to enjoy life anywhere (question 18) and ease of making friends (question 2 1 ) . 2 . 3 . 3 T H E I N V E N T O R Y F O R A S S E S S I N G T H E P R O C E S S O F C U L T U R A L C O M P E T E N C E A M O N G H E A L T H C A R E P R O F E S S I O N A L S - R E V I S E D ( I A P C C - R ) Campinha-Bacote's revised I A P C C - R 4 , a culture-general tool, is an expansion of her earlier scale. 1 7 In the later scale, she added the domain of cultural desire to the existant domains of cultural awareness, cultural knowledge, cultural ski l l , and cultural encounters. Campinha-Bacote defines cultural desire as the motivation of the healthcare professional to 'want to' engage in the process of becoming culturally competent, rather than to 'have to ' . 1 7 Campinha-Bacote asserts that the purpose of her tool is to determine the cultural competence of healthcare providers for educational, clinical, and research purposes. The I A P C C - R 4 is based on Campinha-Bacote's conceptual model of cultural competence, 1 7 thus providing sound construct validity, but potentially confounding existent biases. This evaluation tool views cultural competence as a process, rather than as a state; a concept that is gaining greater acceptance, especially in the nursing literature. 1 0 Despite its lack of validation in terms of outcomes, this inventory has been widely used in the nursing literature. ' " Although the tool has not been used extensively in other disciplines, Campinha-Bacote advocated its application to other disciplines with appropriate modification. Comparable to similar tools, many of the questions in the I A P C C - R are transparent to the most 'socially acceptable' response, potentially biasing responses towards socially desirable responses. 1 2 2 . 3 . 4 T H E C U L T U R A L C O M P E T E N C E A S S E S S M E N T ( C C A ) The culture-general C C A was designed to assess the cultural competence of healthcare providers and staff.2 4 The domains chosen by its developers are divided into two sub-scales. Sub-scale A includes cultural diversity, awareness, and sensitivity, while sub-scale B is devoted to cultural competence behaviors. The theoretical model on which this index is based, Schim and Miller 's ( 1 9 9 9 ) Mode l of Cultural Competence, is less cited than other models, potentially limiting the C C A ' s construct validity. The tool, however, was correlated with the well-established I A P C C . 2 4 The C C A was designed for and initially tested on healthcare workers; the developers do not specify whether rehabilitation therapists were included in this group. They did note, however, that all participants were Caucasian Americans, limiting the tool's external validity to countries other than the United States and to healthcare professionals from other cultural or ethnic groups both within and outside the United States. 2 . 3 . 5 T H E C U L T U R A L S E L F - E F F I C A C Y S C A L E (CSES) In 1 9 9 3 , Bernal and Froman described one of the earliest cultural competence evaluation tools, the C S E S . 2 5 Unlike the previous three tools, the C S E S has culture-specific components designed to assess the cultural competency of nurses caring for Black, Hispanic, and Asian patients. The purpose of the C S E S is to determine the level of confidence that nurses have in caring for members of these diverse cultural groups. The developers use the domains of knowledge of 3 6 cultural concepts and patterns, as well as skills in performing transcultural nursing functions. The C S E S is based on the concept of self-efficacy, 3 7 and is congruent with the Giger and Davidhizar Transcultural Assessment Model and Theory. The nursing bias and culture-specific nature of the C S E S limit its use by rehabilitation therapists and by nurses caring for patients from cultures not assessed by the tool. A further limitation of the tool is the broad nature of the 1 3 cultural or racial groups used in the C S E S . For example, "Black" can refer to a large number of cultural groups. 6 2.4 LIMITATIONS OF THESE CULTURAL COMPETENCE ASSESSMENT TOOLS The domains chosen for each of the assessment tools are similar, yet cultural competence remains a construct that arguably eludes understanding or assessment. Do the domains chosen capture and explain the complete nature of cultural competence? Who decides - the researchers, the consumers of the literature (predominantly Western), or the patients who require this care? If the domains identified do not fully capture the construct of cultural competence, then the relevance of the scores obtained from an assessment tool w i l l be limited and clinicians' ability to provide culturally competent care w i l l be unknown. Consequently, the role that culturally competent healthcare plays in the elimination of ethnic and cultural health disparities w i l l , in turn, remain unclear. Further, evaluating solely the domains or qualities inherent to the healthcare professional may under describe cultural competence in patient care. The effect of this care on clinical outcomes warrants attention. The current assessment tools do not address this aspect of cultural competence. The current tools, though purported to assess cultural competence, may be only evaluating a portion of this construct and may need to be named and referred to accordingly. A n alternative term, we propose the phrase 'cultural sensitivity', may better describe characteristics that are inherent to healthcare professionals. Distinction could therefore be made between this terms' exclusive focus on the professional, at the exclusion of patient outcomes such as improved patient health, patient satisfaction, or adherence to treatment, and true cultural competence. For the purpose of clarity, when the assessment of cultural competence is referred to in this work, it 14 refers to the domains present or absent in the healthcare professional, as assessed by the available scales. Thus, the inferences drawn from this study wi l l be subject to this limitation. A further limitation of the cultural competence literature is its inherently biased nature. Because cultural competence models and assessment tools have been developed in high-income countries such as the United States and Great Britain, they are likely biased to the world views prevalent in these countries. Who is to say, for example, that the criteria that Western researchers and healthcare professionals deem vital for culturally competent care are actually important to those from different cultural backgrounds and systems of medicine? A s noted previously, culture defines one's views on health and healthcare; these views may fall within the realm of the Western biomedical paradigm, the basis for both the Canadian, American, and British healthcare systems, or they may fall outside this realm, limiting the ability of healthcare professionals to provide culturally competent care within these healthcare systems. 2.5 ADVANCEMENTS IN T H E FIELD OF CULTURAL COMPETENCE The importance of a healthcare professional's culturally knowledge or awareness is limited i f these attributes do not improve health outcomes such as satisfaction with care, knowledge of how to care for oneself after discharge, and treatment outcomes. In order to accurately assess whether care is culturally competent, clinical outcomes must be evaluated in relation to these domains. Recently, Suh developed a model of cultural competence 1 0 that explores aspects of this construct that extend beyond the healthcare professional; to date, however, this model has not been adapted into a practical assessment tool. Her work emerges from the nursing literature, but with minor adjustments may have application to other disciplines. 15 2.5 .1 S U H ' S M O D E L OF C U L T U R A L C O M P E T E N C E Similar to the previously described models, Suh's model of cultural competence identifies domains of the healthcare professional believed necessary for culturally competent care. 1 0 However, Suh makes the unique contribution of incorporating outcomes, or consequences, of cultural competence that result from the provision of culturally competent care. She divides these outcomes into receiver-based (patient), provider-based, and health outcomes. 1 0 Her model was developed through an extensive review and synthesis of the cultural competence literature from the fields of nursing, medicine, psychology, social work, and education. 1 0 It has been subjected to a preliminary critical appraisal using Fawcett and D o w n s ' 2 2 ' 3 8 criteria for the evaluation of a theory: theoretical and social significance, internal consistency, parsimony, and testability. These criteria were chosen for their emphasis on the testability of the model, a topic central to this thesis. The integration of clinical outcomes and provider-specific domains in Suh's model of cultural competence is of major importance in both the theoretical and clinical arenas. It attempts to establish a connection between the perceptions and actions of the healthcare provider and clinical outcomes - the basis for clinical practice. This connection is essential; until a direct association is established between these components, the construct of cultural competence can not be fully explained, nor practice of this type of care be effectively assessed. The concepts and propositions presented in the model are generally clearly defined and consistently referred to within the model. The operational definitions that Suh provides for cultural competence and its domains are similar to those presented by other researchers.4 She 1 6 uses four domains: the cognitive domain of cultural awareness and knowledge, the affective domain of cultural sensitivity, the behavioral domain of cultural skills, and the environmental domain of cultural encounters. Suh attempts to expand on Campinha-Bacote's 4 domain of cultural encounters by labeling this domain "environment". This extension had the potential to include a wide range of influential factors such as the organizational structure of the healthcare setting or the socioeconomic status of the patient, yet Suh considers only 'encounters with individuals' under this heading. Suh presents a schema o f the model and its components. (Figure 2). A criticism of this schema is its linear nature, which omits important feedback loops that could help the clinician to reflect on and learn from each cross-cultural interaction. Wi th respect to the testability of the model, two issues arise. First, the testing or assessment of a clinician's cultural competence (as defined by Suh) would require the development of an appropriate assessment tool. To date, this is not available. However, Suh's domains of cultural awareness, knowledge, skills, and encounters1 0 equal four of Campinha-Bacote's domains, 4 with Suh's fifth domain, cultural sensitivity, being somewhat distinct from Campinha-Bacote's cultural desire. It is plausible that a correlation exists between the two investigators' domains, resulting in clinicians who have high scores on Campinha-Bacote's I A P C C - R 4 possessing many of the qualities identified in Suh's model. Although Suh's model differs in only one domain from Campinha-Bacote's, the relative weighting of these needs to be elucidated. Other domains may also need to be included based on further studies. A major limitation associated with the testability of Suh's model relates to her outcomes. A s suggested previously, the linking of domains and outcomes as components of cultural competence is a valuable contribution to the study of cultural competence. Suh references 17 several articles to support her claim that positive clinical outcomes result from culturally competent care. However, these articles 3 9 - 4 2 did not effectively link culturally competent care with positive outcomes such as improved patient quality of life, satisfaction, and treatment or cost effectiveness. To link outcomes to cultural competence, the specificity of the outcomes relating to particular interventions provided by healthcare professionals needs to be refined. To date, there is limited evidence establishing this link. This needs to be a priority as the field of culturally competent healthcare advances. 2.6 FUTURE DIRECTIONS The evaluation of cultural competence has traditionally focused on the patient-practitioner interaction solely from the perspective of the healthcare professional. A s Suh's model of cultural competence 1 0 suggests, assessment of cultural competence should include the evaluation of outcomes related to the patient and her/his health in addition to the attributes of the healthcare professional. Given that the currently available cultural competence assessment tools evaluate only the qualities of the healthcare professional, the meaning that can be interpreted from scores on these tools is limited. The nursing and psychology literature has played a leading role in the development of cultural competence models and evaluation tools; however, to the best of our knowledge, none has emerged from the rehabilitation literature to date. The applicability of these tools to rehabilitation therapists (physiotherapists and occupational therapists), or the development of models or tools specific to rehabilitation warrants future consideration. 18 2.6 .1 C U L T U R A L C O M P E T E N C E V E R S U S C U L T U R A L S E N S I T I V I T Y The lack of assessment of patient outcomes in the current measures of cultural competence precludes them from providing a comprehensive analysis of the competence of healthcare professionals when managing patients from different cultures. However, the information gathered with the current cultural competence measures are informative. A s the field advances, it may become increasingly important to differentiate between true culturally competent care (care that results in improved clinical outcomes for patients from different cultures), and 'cultural competence' assessment tools that solely consider qualities relating to the healthcare professional (such as the current measures). We propose that both components: the attributes related to the healthcare professional and the patient, and the clinical outcomes, are important and should be distinguished from one another. Accordingly, the use of the term 'cultural sensitivity' is proposed to refer to the qualities of the healthcare professional that are thought (but not proven) to lead to culturally competent care. The term 'sensitivity' has been extensively reviewed in the scientific and general community. 4 3 Although the term's meaning varies with context, its roots lie in its definition. The Oxford English Dictionary defines sensitivity as "the degree to which a device, test, or procedure responds to small amounts of, or slight changes in, that to which it is designed to respond". 4 4 This sensitivity in the cultural context may reflect more than an awareness or understanding of other cultures. The healthcare professional may not only need to be cognizant of subtle changes in a patient's behaviors but to respond to these changes. The effectiveness of these responses, the outcome of the care of the patient, is beyond the scope of both the term sensitivity and the current assessment of cultural competence. It may, therefore, be more appropriate to restrict the term cultural competence to actions that can be quantified or qualified to produce positive outcomes 1 9 for the patient, and to use the term cultural sensitivity to describe the behaviors of the healthcare professional believed to result in culturally competent care. 2.7 CONCLUSION A s globalization continues to diversify populations, culturally competent healthcare is a concept that could augment healthcare outcomes. To facilitate such care, critical assessment of culturally competent healthcare, as well as the evaluation of the outcomes of this care is required. To date, most studies have focused on culturally competent care from either the perspective of the healthcare professional, using tools such as those described in this critique, or from the perspective of the patient. Though valuable, studies that focus solely on the patient's perspective are generally unable to differentiate which of the myriad of factors that can influence a patient's clinical outcomes have the greatest effect on the patient. Thus, to fully describe the construct of cultural competence, studies w i l l need to evaluate this competence from the perspectives of both the healthcare professional and the patient. The impact of healthcare professionals' behaviors on patient outcomes need to be elucidated, and perhaps may be the single best indicator of culturally competent care. Unt i l this knowledge gap is bridged, the term 'cultural competence' may be better reserved for care demonstrated to improve patient outcomes. Discussion surrounding the qualities of the healthcare professional that are thought to, but not proven to result in improved patient outcomes, should be referred to by an alternative name, potentially 'cultural sensitivity'. 20 Leininger, a prominent leader in the field of cultural competence proposed that by becoming transculturally grounded, nurses (and we would argue, all healthcare professionals), may best prepare themselves to grow and survive in the 2 1 S T century. For this transcultural grounding to occur, two factors need to be addressed. First the gap between theory and practice needs to be bridged through the translation of theories and models to clinical guidelines and evaluation tools. Second, as this process is occurring, care needs to be taken to ensure that this transition is scientifically sound. In summary, we have provided an overview and critical analysis of cultural competence in healthcare and its assessment in healthcare professionals. We provide arguments supporting the use of the alternate term 'cultural sensitivity'. We proposed several future directions of research aimed at advancing the field and facilitating appropriate translation of theoretical knowledge on cultural competence into clinical practice. 2 1 C H A P T E R 3 T H E A S S E S S M E N T O F C U L T U R A L C O M P E T E N C E I N H E A L T H C A R E P R O F E S S I O N A L S 3.1 BACKGROUND AND LITERATURE REVIEW The purpose of this study was to extend our knowledge of the construct of the cultural competence of healthcare professionals by assessing cultural competence in a group of healthcare professionals (physiotherapists, occupational therapists, and registered nurses), and examining the relationship between selected practitioners' attributes and cultural competence. O f particular interest were the associations between cultural competence and ethnocentrism, and between international experience and clinicians' cultural competence. Our research tool, a single questionnaire, was designed based on a review of the literature. The questionnaire contained four components: (a) a cultural competence scale, the I A P C C - R , (b) an ethnocentrism scale, the G E N E , (c) a series of questions designed to obtain information on participants' experience or desire to obtain international experience (either general or healthcare specific experience), and the perceived effect of this experience on cultural competence, and finally, (d) a variety of questions pertaining to the professional experience, culture, languages spoken, and demographics of each participant. Our research questions were: 1. Do physiotherapists, occupational therapists, and registered nurses practicing in British Columbia's Lower Mainland differ with respect to cultural competence, based on their scores on the Inventory to Assess the Process of Cultural Competence - Revised ( I A P C C - R ) ? 4 22 2. Are cultural competence (as determined with the I A P C C - R 4 ) and ethnocentrism scores (as determined using the G E N E 5 ) associated? If an association exists, the former may be a manifestation or reflection o f the latter. 3. Is there a relationship between the cultural competence (as determined with the I A P C C - R 4 ) of healthcare professionals and either international experience (general or specific to healthcare), or desire to gain international work experience? We hypothesized that experiences abroad contributes to cultural sensitivity or cultural competence. 4. Is there a relationship between cultural competence (as determined with the I A P C - R 4 ) and specific attributes of healthcare providers, such as years of clinical experience, cultural identity, and number of languages spoken? The specific attributes chosen were based on previous literature. The assessment of these relationships was performed as a means of generating questions and hypotheses for future studies. 3.1.1 A S S E S S M E N T O F C U L T U R A L C O M P E T E N C E A s Chapter 2 illustrated, the field of cultural competence is evolving, enabling theoretical models to form the foundation for clinical practice and evaluation. In recent years, a number of tools have been created with the purpose of evaluating the cultural competence of healthcare professionals. These tools primarily focus on the attributes of healthcare professionals and are believed to manifest as culturally competent care for patients from different cultures. The assessment tool selected for the present study was Campinha-Bacote's 'Inventory to Assess the Process o f Cultural Competence Among Healthcare Professionals - revised' ( I A P C C - R ) . 4 The tool is designed for healthcare use, and has been widely used to the assess cultural competence of healthcare professionals, particularly nurses . 2 4 ' 3 0 - 3 5 Its culture-general nature supports 23 applicability to healthcare professionals who are from a variety of backgrounds, and who treat patients from a variety of cultural backgrounds. Campinha-Bacote's model is described by other investigators as comprehensive in content, having a high level of abstraction, conceptual clarity, and logical congruence as well as demonstrating clinical utility. Based on this model, Campinha-Bacote's tool, the I A P C C - R , 4 has been reported to have good content validity and has been used by a number of researchers 2 4 , 3 0 - 3 5 A s with other cultural competence assessment tools, however, the I A P C C - R 4 is limited by its narrow focus on healthcare professionals' internal attributes (or domains), neglecting the link to patient outcomes in the assessment of cultural competence. Because the is the most widely used, we chose this tool for use in our study. 3.1.2 E T H N O C E N T R I S M A related, and more developed area of study is that of ethnocentrism. A s cited by Sutherland, 4 5 this term was first defined by Sumner in 1906 as a "view of things in which one's own group is the center of everything, and all others are scaled and rated with reference to it". More recently, investigators have argued that ethnocentrism is a universal phenomenon that is experienced across cul tures , 5 ' 4 6 ' 4 7 and could therefore affect the practice of all healthcare professionals. Ethnocentrism has been described previously in the healthcare l i terature, 4 5 ' 4 8 - 5 0 as well as fields 51 52 53 such as history and philosophy, psychology, and education. Expanding on earlier conceptualizations of ethnocentrism, Neuliep 5 described this construct as an individual psychological disposition in which the culture (values, attitudes, and behaviors) of the individual's in-group is used as the standard forjudging and evaluating another group's culture. 24 Further, he asserts that aspects of an out-group's culture that are perceived as disparate from one's in-group, are evaluated negatively. Thus, on comparing this construct with cultural competence, or the ability to understand and to work effectively with patients whose beliefs, values, and histories (culture) are different from one's own, 1 the degree of ethnocentrism may be a determinant of cultural competence. One could argue that a healthcare professional's cultural competence merely reflects the degree to which that individual's world view emanates from his or her own cultural roots. However, whether an individual who scores low in ethnocentrism would be likely to have a high cultural competence score is unknown. Since the 1950s, social scientists have measured the construct of ethnocentrism.5 In 1997, the Generalized Ethnocentrism Scale ( G E N E ) was developed, 4 7 and based on factor and item analysis, has since been modified to its present form. 5 The scale was designed to assess the ethnocentrism of any person, regardless of his/her cultural background, and consists of 22 five-point Likert-type items, 15 of which are used in the scoring of ethnocentrism and the remaining 7 items serve as distracters. The G E N E 5 was included in the present study as part of our critical evaluation of the I A P P C - R ' s 4 assessment of cultural competence. Scores on the two scales were compared within participants to determine i f an association existed between the two constructs. High scores on the G E N E 5 were indicative of high ethnocentrism, or a strong view that one's own group is central to everything. Thus, it was hypothesized that low ethnocentrism scores may be associated with high cultural competence scores, a negative correlation. 3.1.3 I N T E R N A T I O N A L E X P E R I E N C E A N D C U L T U R A L C O M P E T E N C E In addition to studying what cultural competence is, and how it can be assessed, some researchers have attempted to identify personal attributes that are consistent with the provision of culturally 25 competent care. One attribute that has received attention is the role of international experience, or immersion in other cultures, on cultural competence. 5 4" 5 7 During these experiences, individuals in the fields such as healthcare, business, and education, gain experience working in their fields in countries or cultures different from their own. Despite insufficient empirical evidence, some researchers, clinicians, and educators believe that cultural immersion enhances cultural competence. 5 4" 5 7 The majority of studies on the effects of cultural immersion programs have used qualitative methods such as self-reflection journals and non-standardized questionnaires for evaluation purposes. This subjective method has identified increased awareness of diverse cultural groups, greater cultural sensitivity, ways of overcoming language barriers, and the importance of educating patients to achieve a lasting impact. 5 7 In addition, immersion experiences were thought by healthcare professionals to benefit their future careers. 5 4 Although the literature is limited with respect to the value of immersion programs, Button and colleagues recently published a critical review of the literature related to the impact of international placements on the lives and practice of nurses. 5 8 Based on the 43 articles reviewed, they reported three main outcomes of immersion programs: learning cultural differences, comparing healthcare systems and nursing practices, and personal development. These primarily qualitative studies have made a contribution to this relatively new field of study. Generalization from these studies, however, must be guarded. For example, following analysis of reflective journal records and post-trip discussions, the conclusion that immersing students in practice in another culture is an appropriate way of improving cross-cultural competence warrants validation. 5 7 These self-reported reflections provide rich and potentially important information but do not provide scientific evidence to support the link between cultural immersion 26 and improved cultural competence. Inglis, Rolls, and Kristy compared the changes in attitudes between nurses who participated in a three-week community health program in Nepal, with their colleagues who did not have this international experience. The immersion group showed improvements in cultural adjustment and adaptation, and became more independent in their professional behavior. These improvements, however, only reflected changes toward Nepalese culture, making the applicability of the benefits of limited value in a culturally diverse country such as Canada. Without prospective studies assessing the cultural competence of professionals before and after an immersion experience, a cause and effect relationship between these two variables cannot be established. However, the literature does support some association between the two, which provided a rationale for this study's examination of the association between cultural competence and international experience. The international experience data provided information about the amount of time the healthcare professional had spent internationally, the number of continents traveled to, and the purpose of travel (general or specific to healthcare). There is ongoing debate regarding the length of time that an individual needs to be immersed in another culture to increase their cultural awareness and sensitivity. Investigators have reported varying lengths ranging from one week to six months. 5 5 Although longer immersion periods may improve understanding of the foreign culture, the increased time and economic cost for longer immersions could limit access to these experiences for healthcare professionals who are volunteering. Further to the discussion on the effects of international experience on cultural competence is the question of purpose of travel. Is healthcare specific experience necessary, or is general traveling or l iving abroad sufficient to reap the proposed benefits of the experience? Researchers have 27 suggested that general international experience enables an individual to gain a better understanding of his or her own culture and to gain new experiences that may enhance clinical practice, 5 9 as well as improving understanding of social justice and globalization issues. 6 0 Most studies that explore the effect of international experience on culturally competent healthcare look specifically at international healthcare experience rather than general international experience. 5 9 ' 6 1 This study investigates the relationship between both general and healthcare specific international experience and cultural competence. However, the question of whether this international experience imparts improved patient outcomes remains. A related variable is that of desire to gain international experience. In her model of cultural competence, Campinha-Bacote 6 2 describes the importance of desire or motivation to engage in the process of culturally competent care. This desire, or a feeling of 'wanting to', is contrasted with the perception of 'having to' participate in the process of culturally competent healthcare, and stems from an aspiration, not desperation. Our study incorporated consideration of a discrete form of desire; we compared cultural competence (scores on the I A P C C - R 4 ) of healthcare professionals with international experience and with desire to gain this international experience. For the purpose of this study, those rehabilitation therapists and nurses who received their professional training in a country other than Canada were included in the group possessing international healthcare experience. A n expectation of physiotherapy, occupational therapy, and nursing training programs is that students w i l l participate in practicums to gain clinical experience. Therefore, those healthcare professionals who received their professional training outside Canada have had experience working internationally in healthcare. We hypothesized that 2 8 these professionals are more aware of intercultural differences as a result of their exposure to at least two cultures (the dominant culture in the country in which they trained, and hte culture dominant in Canada). There is limited research to support or reject this notion, or to evaluate internationally trained healthcare professionals' ability to provide culturally competent care. A recent review of culturally competent care in the nursing literature 6 4 however, argues that nurses from collectivistic societies (those that prioritize the interests of the community over individual needs and desires) 6 5 may opt for less direct methods of communication than is common in individualistic Western cultures. This communication style may be preferred by members of Canada's minority populations, potentially improving these internationally-trained professionals' ability to care for patients from cultures with similar communication styles. 3.1.4 A D D I T I O N A L A T T R I B U T E S A S S O C I A T E D W I T H C U L T U R A L C O M P E T E N C E Related attributes hypothesized to be associated with culturally competent healthcare were also studied. Several attributes have emerged in the literature. A 2005 review of cultural competent care in nursing, 6 4 for example, discussed the effect of differing dominant world views on cultural competence. Based on this literature, the cultural identity and number of languages spoken by the healthcare professional were hypothesized to be associated with culturally competent healthcare; data were therefore collected on these attributes. In addition, data were collected on the profession, level of education, and number of years of clinical experience as a practicing physiotherapist, occupational therapist, or registered nurse. 29 3.2 METHODS 3.2.1 O V E R V I E W A cross-sectional comparative research design was used to test our three hypotheses and to identify additional attributes associated with cultural competence. Data were collected through a paper-and-pencil questionnaire (Appendix 1) consisting of (a) questions pertaining to international experience, demographics, culture, and professional experience, (b) a cultural competence assessment tool, the I A P C C - R 4 , and (c) an ethnocentrism assessment tool, the Generalized Ethnocentrism Scale ( G E N E ) 5 . In addition, exploratory questions were used to provide qualitative data pertaining to participants' perception of the construct of cultural competence and possible associated attributes, their international experiences, and their level of desire and opportunity to work abroad. Participants were physiotherapists, occupational therapists, and registered nurses employed by major acute-care hospitals in the Vancouver Coastal Health Authority of British Columbia. A written information sheet (Appendix 1) preceded the questionnaire. The study was approved by the U B C Ethics Committee (Appendix 2) and the ethics committees of the three participating hospitals. 3.2.2 Q U E S T I O N N A I R E DemoRraphic information and exploratory questions Demographic information and responses to the exploratory questions were collected for analysis, with a special focus on interest and opportunity to volunteer or work internationally. Based on the literature, the following attributes were hypothesized to be associated with cultural competence: o Age o Years of practice 30 o Profession 2 9 64 , 6 6 o Cultural identity1 o Number of languages spoken 6 6 o International travel experience 5 4" 5 7 o International volunteer or work experience in healthcare 5 4" 5 7 o Desire to obtain international experience 6 3 , 6 6 The questions were piloted on physiotherapists and occupational therapists (n = 10) with respect to their content, relevance, and clarity. Feedback was provided through interviews or written comments, and changes were made accordingly. The final questionnaire appears in Appendix 1. Classification of individuals by their cultural identity can be challenging. If the classifications are broad or diverse, the statistical analysis w i l l not identify differences between groups. Conversely, for the purpose of maintaining adequate sample sizes in the analysis of each classification, the cultural groups must be relatively broad. In the United States, there is a body of literature on this topic, however Canada's cultural composition is distinct from that of other countries including the United States, limiting the generalization of these data to the Canadian population. In 2003, Statistics Canada published information on Canada's 'ethnocultural portrait', classifying people into six cultural identities. The categories used in this 'ethnocultural portrait' were adopted for use in our questionnaire. A series of open-ended questions were included to verify the quantitative findings, and to shed light on professionals' understanding of the concept of cultural competence, perceived impact of 31 international experience on care for patients in Canada and abroad, and motivation to pursue international experience or not. Finally, given the cultural diversity of British Columbia's Lower Mainland, where more than 35% of the population were born outside Canada, the participants have likely treated patients from other cultures. We were therefore interested in establishing which clinical outcomes healthcare professionals believed were the most important to culturally competent healthcare. Participants were asked to rank a series of seven outcomes from one to seven, with a score of one being the most important outcome related to culturally competent healthcare, and a rank of seven being least important. Based on the l i terature, 1 0 ' 6 5 ' 6 9 " 7 1 the following outcomes were selected for the study: o Improved patient health o Patient compliance with treatment o Patient satisfaction with the patient-provider interaction o Provider is able to enhance the patient's understanding of what the provider assesses to be the patient's medical problem o Provider satisfaction with the patient-provider interaction o Patient and provider end the interaction with more similar world views than they began with o Provider and patient have equal responsibility/power in their relationship with each other Participants were also given the opportunity to add and to rank other outcomes that they believed to be key to culturally competent care. 32 The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals - Revised ( IAPCC-R) 72 A s part of our preliminary work, a critique of cultural competence and its evaluation, a seminar-based information session, and an informal focus group were used to establish that the I A P C C - R 4 was the appropriate tool to assess the cultural competence of our sample. The I A P C C - R 4 assesses the five domains of cultural awareness, cultural knowledge, cultural ski l l , cultural encounters, and cultural desire. This scale comprised questions 21 to 45 of the questionnaire. Apart from renumbering the questions, the I A P C C - R 4 was not changed from its original form. The internal reliability of this tool was previously reported to be between .77 and .90, using Cronbach's a. ' The Generalized Ethnocentrism Scale (GENE) For benchmarking and comparison purposes, the established G E N E 5 was also included in the questionnaire as part of the critical appraisal of the construct and measurement of cultural competence. Previous studies had calculated the internal consistency of the G E N E 5 to be between a = 0.82 and a = 0.92 using Cronbach's a. 5 We hypothesized that a relationship exists between the older, well established construct of ethnocentrism, and the newer construct of cultural competence. This ethnocentrism scale comprised questions 46 to 58 of the questionnaire. Self-reported cultural sensitivity Participants were asked to rate themselves on their current perceived level of cultural sensitivity when treating patients from other cultures. Responses were given on an eleven-point scale, ranging from 0 = not at all sensitive, to 10 = very sensitive. The use of the term cultural 3 3 sensitivity rather than cultural competence in the question was in response to the pilot findings in which some respondents commented that they either did not have a clear understanding of the term 'cultural competency', or believed that the term was inappropriate. Although broader in its complete definition, the construct of cultural competence has been defined in practical terms as sensitivity to the sociocultural context of patients in the provision of holistic care. 7 3 Further, it has been proposed 7 2 that the term 'cultural sensitivity' may be more appropriate than 'cultural competence' when referring to the attributes of the healthcare professional that are predicted, but not objectively proven, to result in culturally competent care. Self-perception, or simply asking individuals how they rate themselves on a given variable, has been used as an adjunct measure in the health literature. 7 4 We acknowledge the potential inaccuracy of this subjective measure, particularly when assessing an abstract construct such as cultural sensitivity. Recognizing this limitation, we hypothesized that self-reported scores of cultural sensitivity are associated with cultural competence scores on the I A P C C - R 4 3 .2 .3 S A M P L E R E C R U I T M E N T A N D D A T A C O L L E C T I O N Rehabilitation professionals (physiotherapists and occupational therapists) and registered nurses currently practicing in one of three public acute hospitals in British Columbia's Vancouver Coastal Health Authority were included in the study. The three hospitals, Vancouver Hospital and Health Sciences Centre - University of British Columbia Site ( V H H S C - U B C Site), Lion ' s Gate Hospital, and Richmond Hospital represented the three municipalities in this health authority (Vancouver, North Vancouver, and Richmond) that have acute care hospitals with at least 100 beds. The professions of physiotherapy, occupational therapy, and nursing were studied because of their unique role within the healthcare system. These healthcare providers typically 3 4 attend to their patients for extended periods, and focus on restoring a meaningful quality of life. Thus, one can argue that their outcomes would be enhanced with a cultural awareness of and sensitivity to the diverse needs of multicultural patient populations. Participants were excluded from the study i f their case loads did not consist primarily of in-patients in an acute setting. For example, those participants whose primary area of practice was in an out-patient department based in the hospital, were excluded. In addition, those nurses whose primary area of practice was the operating room were excluded given that for the majority of time that their patients are in the operating room, the patients are unable to communicate with healthcare professionals due to the effects of sedation and anesthesia. The relevant administrative heads in physiotherapy, occupational therapy, and nursing were contacted by telephone and in person to gain their support and consent for the project. Following this process, the investigators began a series of at least three visits to each hospital to deliver over 400 surveys, consent forms, and cover letters to potential participants. The goal was to gather as many respondents as possible from the sampling base, thus, surveys were not randomly distributed, but rather distributed to as many physiotherapists, occupational therapists, and registered nurses who met the inclusion criteria. On the initial visit, posters were displayed to publicize the project, and wherever possible, short presentations were given to introduce the project to staff. After two weeks, reminder posters were distributed, and a second copy of the survey accompanied by a new cover letter was redistributed after one month. Surveys were collected within the participating departments either in large, clearly labeled envelopes or directly through the unit clerk. 35 Despite research on assessment tools for cultural competence dating back over a decade/"*'13 none has been established as a gold standard. The tools have had limited use in research, and therefore their robustness is not known. Each tool has potential content validity flaws that could lead to internal errors. To our knowledge, there are no previous studies evaluating the cultural competence of rehabilitation professionals (a large portion of our sample) from which to estimate an effect size. The limited previous literature on similar samples report a range from 14 to 288 participants including physiotherapy faculty, students, and a combination of nursing, dental hygiene, medical laboratory science faculty at universities in the United States. ' ' ' These studies also used a range of measurement tools, precluding an accurate calculation of an effect size from their published scores. The index of cultural competence that we have chosen is expected to provide the most valid assessment to date of the clinician-related attributes of cultural competence in physiotherapists, occupational therapists, and registered nurses; we intend our results to provide a reference for power analysis for sample size estimation in future studies. To determine our sample size using a power analysis, the standard values of a = .05, and power = .8 were used. 7 7 Given that the primary relationships in our study involved correlation coefficients, the population effect size was determined using a correlation coefficient rho = .3. A sample size of 68 was calculated using these parameters and a power calculator designed and provided by the Department of Statistics at the University of California at Los Angeles. 7 8 3.2.4 D A T A A N A L Y S I S The data were analyzed using SPSS Version 12.0 for Windows. The p-value was set at p < 0.05. Based on the research objectives, the analysis was divided into four sections: 36 1. Measurement of cultural competence (with the I A P C C - R 4 ) , including reliability testing and comparison of mean cultural competence scores by profession (physiotherapist, occupational therapist, or registered nurse) 2. Analysis of the relationship between cultural competence and ethnocentrism, as well as between cultural competence and self-reported cultural sensitivity 3. Measurement of the association between cultural competence (based on the I A P C C - R 4 scores) and (a) international experience in healthcare, and (b) desire to gain international experience 4. Bi-variate and multivariate analysis of the relationship between cultural competence or ethnocentrism and the sociodemographic and cultural characteristics of the participants. Prior to analysis, the data were checked for errors in data entry and for missing data. The variable 'self-reported cultural sensitivity on a 0-10 scale' had the lowest sample size (n = 66), the I A P C C - R 4 scale had an n = 68, and the ethnocentrism scale, an n = 70. The sociodemographic and cultural variables used in the analysis each had an n > 68 (out of a sample size of 71). The missing variables were dealt with by inserting the mean of all other scores for that variable. Assessment of cultural competence The cultural competence of physiotherapists, occupational therapists, and registered nurses was evaluated in several ways. The primary measurement was the I A P C C - R 4 . Cronbach's a was calculated to determine the internal reliability of the I A P C C - R 4 . Cronbach's a provides a measure of internal consistency, or the degree of homogeneity within the scale's i t ems . 2 7 ' 7 9 In addition, item-total statistics and a correlation matrix for the I A P C C - R 4 were calculated to 37 determine the strength of the relationship between specific items within each scale, and to determine i f the internal consistency of the scale would change i f any of the items were removed. Several of the questions on the I A P C C - R 4 required reversal of the scores on the Likert-type scales, specifically questions 21, 23, 31, 37, and 41. 4 The proposed purpose of this procedure was to decrease the chance o f participants simply circling high numbers out o f either lack o f attention, or a desire to provide the most socially appropriate answers. Scores on the I A P C C - R 4 were totaled (for a maximum score of 100) and used in the remaining statistical analysis. Analysis o f variance ( A N O V A ) was used to compare group means among the three professions, and among the three hospitals. The Scheffe test, known for its minimal impact on Type I error 8 0 was chosen for post-hoc analysis. To evaluate the participants' perceptions of clinical outcomes that were most important in the provision of culturally competent care, participants ranked seven outcomes (1 to 7) in order of importance. Given the focus of the present study on the effect of international healthcare experience on cultural competence, the sample was stratified based on international experience (those with this experience and those without), and the mean rankings were compared. Ethnocentrism and cultural competence To assess the degree of association between cultural competence and ethnocentrism, our second research question, scores on the G E N E 5 were calculated. Questions 49, 52, and 54 were reversed such that a Likert-type response of 'strongly disagree' would receive five points and a response of 'strongly agree' would receive one point. 5 In addition, six of the questions were distracters 38 and were therefore removed prior to analysis of the results (questions 48, 51, 60, 61, 62, and 64). A s with the I A P C C - R 4 , Cronbach's a and item-total statistics were computed for the G E N E 5 . A s an additional measure, participants were asked to consider their perceived level of cultural sensitivity on an 11-point Likert-type scale (where 0 = not at all sensitive and 10 = very sensitive). This subjective scale was then correlated with the I A P C C - R 4 . The associations among cultural competence score ( I A P C C - R 4 ) and (a) ethnocentrism score ( G E N E 5 ) , and (b) self-reported cultural sensitivity were calculated. Pearson's r correlation was used because the cumulative scores for both the I A P C C - R 4 and the G E N E 5 constitute interval data. Further, given that departures from interval data have been reported to have little influence on Type I and Type II errors, 8 1 ' 8 2 the 11-point cultural sensitivity scale (of which 7 of the points were scored by participants) was also considered as interval data. A linear relationship was observed between I A P C C - R 4 scores and both ethnocentrism and self-reported cultural sensitivity scores using scatter plots with superimposed lowess curves. The influence of international experience on cultural competence In accordance with our third research question, cultural competence scores (based on the I A P C C -R 4 scores) were correlated with the following variables: a) months spent working or volunteering internationally in healthcare, b) months spent traveling or living internationally, and c) desire to gain international experience (on an 11-point Likert-type scale). 39 Scatter plots with superimposed lowess curves demonstrated that linearity was problematic, thus the use of a parametric correlation measure, Pearson's r was precluded. Instead, Spearman's rho (r s) was used. This calculation's use of ranks rather than actual data in the application of the 83 Pearson correlation formula, reduced the likelihood of distortions in the measure. In addition, a multiple regression model was used to determine the joint and independent predictive power of desire to work internationally, and general international experience on cultural competence scores. Normality was assessed using a histogram and the Kolmogorov-Smirnov test. Logarithmic transformation was performed on the cultural competence scores. This transformed dependent variable was used in the regression model. Additional attributes associated with cultural competence Correlations were calculated among a pre-selected set of attributes and the following three variables: (a) cultural competence scores (with the I A P C C - R 4 ) , (b) ethnocentrism scores (with the G E N E 5 ) , and (c) self-reported cultural sensitivity (subjectively reported on a scale of 0-10). The secondary measures of ethnocentrism and cultural sensitivity were used to examine the relationship among these measures and cultural competence. Both the cultural competence and the ethnocentrism scores were computed as the total of the individual's score on each question within each scale. For variable pairs in which both variables provided interval data, scatter plots with superimposed lowess curves were constructed to determine the linearity of the relationship between each variable and cultural competence, ethnocentrism, and cultural sensitivity. Correlations were performed using Pearson's r whenever the linearity assumption was met (when plotted against I A P C C - R 4 scores). These cases were: age, number of years lived in Canada, number of years 40 practicing, percent of caseload that is culturally different from the healthcare professional, and number of continents traveled to. In the remaining interval variable sets, Spearman's r s was used: months spent working internationally, months spent living or traveling internationally, and desire to work internationally. A n additional set of nominal variables were compared with cultural competence, ethnocentrism, and cultural sensitivity. T-tests and eta (n) were used to measure association and significance respectively. Levene's test of equal variances was also calculated for each pair of variables to ensure homogeneity of variance. The calculation of n required the use of analysis of variance ( A N O V A ) in SPSS Version 12.0. However, given that A N O V A and t-tests utilize the same calculations for two variables when the variance is equal, the results of these two analyses were the same. The following variables were analyzed in this manner: gender (female, male), ability to speak more than one language (no, yes), minority (non-European) descent (no, yes), and whether the participant was Canadian trained (no, yes). Responses to open-ended questions were used to validate quantitative findings, and to provide insight into the perceptions of healthcare professionals. The responses were analyzed by 84 categorizing similar descriptive responses and then sorting by category. This analysis ware performed using Microsoft Word®. 41 3.3 RESULTS 3.3.1 D E M O G R A P H I C A N D P E R S O N A L C H A R A C T E R I S T I C S A sample of 71 completed surveys were used for the data analysis. Tables 2a, 2b, and 2c show the demographic and personal characteristics of the entire sample, and the sample stratified by international experience. The uneven gender split in the sample, 7% male, is fairly consistent with the percentage of male students studying to become a physiotherapist (19%), occupational therapist (11%), or registered nurse (9%) at the University of British Columbia. The professional breakdown, was relatively even, with 38% of the sample comprised of physiotherapists, 25% occupational therapists, and 37% registered nurses. For the purpose of comparison, the relatively equal sample sizes is desirable. However, nurses constituted a larger proportion of hospital staff than rehabilitation professionals and are therefore less proportionately represented in the sample. This may have increased the chance of bias in the nursing sample. Given that one of our primary purposes was to examine the relationship between international healthcare experience and cultural competence, the even split of participants with (46%) and without (54%) international healthcare experience is positive. 3.3.2 A S S E S S M E N T OF C U L T U R A L C O M P E T E N C E Reliability of the I A P C C - R Using Cronbach's a, the internal reliability for the I A P C C - R 4 was a = .80. Table 3a presents the item-total statistics, indicating that the removal of any question within the scale would not change this a value by more than .03. Question 21, and to some degree questions 31, and 41, were weakly negatively correlated or uncorrelated (correlation < .1) to the rest of the scale. 42 I A P C C - R scores by profession and hospital I A P C C - R 4 scores were calculated as an index of cultural competence. The mean (and standard deviation, SD) score for the sample, n = 71, was 67.32 (7.11). Scores ranged from 54 to 84 out of a possible range of 0 to 100. Table 4a summarizes the mean (SD) scores by profession and by hospital. Based on A N O V A , the group means between the professions of physiotherapy, occupational therapy, and nursing were compared; the cultural competence across groups was not different (F = 2.97, p = .058). The remaining analyses were performed with the groups combined. The groups did however differ by hospital (F = 7.62, p = .001). The I A P C C - R 4 scores for participants from Lion 's Gate Hospital (mean = 71.78, SD = 7.06) were higher than those for participants from the V H H S C - U B C Site (mean = 64.27, SD = 6.79). The mean difference between the two was 7.50, p = .001 (Tables 4a and 4b). Rankings Table 5 summarizes the mean (SD) rankings of the outcomes by participants who had international experience and those who did not. The ranking order by the two groups differed, particularly the ranking of the outcome: 'Provider is able to enhance the patient's understanding of what the provider assesses the patient's medical problem to be'. Participants with international healthcare experience ranked this outcome third most important, whereas the group without international experience ranked this fifth. 43 3.3.3 E T H N O C E N T R I S M A N D C U L T U R A L C O M P E T E N C E A s with the I A P C C - R 4 , reliability testing was performed on the G E N E , 5 the scale used as an index of ethnocentrism. The internal reliability, using Cronbach's a was calculated to be a = .79 for the G E N E 5 scale. When the effect of deleting each item of the G E N E 5 was assessed against other items in the scale, a changed by .05 or less (Table 3b). Although the item-deleted did not change dramatically for question 66, it was found (using a covariance correlation matrix) to be weakly correlated with 8 of the 14 variables (r < ± .1). A s a secondary measure, participants were asked to report their perceived level of self-reported cultural sensitivity. This measure, as well as the ethnocentrism data ( G E N E 5 ) , were correlated with cultural competence scores assessed with the I A P C C - R . 4 Cultural competence ( I A P C C - R 4 ) was correlated with both ethnocentrism ( G E N E 5 ) (r = -.28, p = .017), and self-reported cultural sensitivity (r = .45, p < .001). Thus, high cultural competence scores corresponded with low ethnocentrism scores and with high self-reported cultural sensitivity scores. Ethnocentrism and self-reported cultural sensitivity were not associated (r = .13, p = .273). 3.3.4 T H E I N F L U E N C E OF I N T E R N A T I O N A L E X P E R I E N C E O N C U L T U R A L C O M P E T E N C E Our third alternative hypothesis was partially supported. Although cultural competence ( I A P C C -R 4 ) and months spent working internationally were not significantly correlated (rs = .18, p = .14), a relationship appeared when cultural competence ( I A P C C - R 4 ) and general international experience (either l iving or working abroad) were considered (r s = .24, p = .043). In addition, a desire to gain international experience and cultural competence scores ( I A P C C - R 4 ) were also associated (r s = .37, p = .002) (Table 6a). 44 The multiple regression model indicated that 19% of the variance in the cultural competence scores was accounted for by a desire to gain international healthcare experience as well as gaining international experience (r - .43, r = .19, p = .001). When each variable was assessed, while controlling for the other, both desire and actual international experience were found to influence cultural competence scores (P = .30, p = .008 and p = .28, p = .013 respectively) (Table 6b). 3.3.5 A D D I T I O N A L A T T R I B U T E S A S S O C I A T E D W I T H C U L T U R A L C O M P E T E N C E Guided by previous literature, we collected data on specific attributes such as years o f clinical experience, healthcare professional's cultural identity, and number of languages spoken. The association between these attributes and cultural competence, as measured with the I A P C C - R 4 , are summarized in Table 7. Correlation with the variable o f cultural competence was o f primary interest in this analysis, however, the additional variables of ethnocentrism ( G E N E 5 ) and self-reported cultural sensitivity were also included in the correlation matrix. The following variables were correlated with I A P C C - R 4 scores assessing cultural competence: months spent l iving or traveling abroad (rs = .24, p = .043), number of continents traveled to (r = .26, p=.027), desire to work internationally (rs = .37, p = .002), percent of caseload that was culturally different from the participant (r = .37, p = .002), and the ability to speak more than one language (n = .34, p = .007). Equal variances could not be assumed in the significance tests for the variable 'able to speak more than one language' because the result of the Levene's test for equality of variances was significant. A l l additional dichotomous variables met the equal variances assumption. 45 3.4 DISCUSSION 3.4.1 D E M O G R A P H I C A N D P E R S O N A L C H A R A C T E R I S T I C S The calculated response rate was 18% (71 returned and completed surveys out of 400 distributed). This rate however is likely artificially low due to a redundancy in the survey distribution. In some departments, nursing or therapy leaders requested that additional questionnaires be provided for their professional staff, in addition to placing one survey in each potential respondent's mailbox. Thus, more questionnaires were distributed than possible respondents. In discussion with professional leaders in the three disciplines, leaders, especially in nursing, stated that some of their staff had remarked that the length of the survey and the amount of thought required to answer some of the questions had dissuaded them from completing the questionnaire. Thus, time and energy constraints, due to the length of the survey (approximately 30 to 45 minutes) and the depth of the questions (requiring both thought and reflection by the participants) may have decreased the response rate. In addition, in at least two of the three hospitals, another survey had been delivered within the past 2 months, perhaps decreasing the response rate. Sample biasing may have occurred. The literature on cultural competence suggests that awareness of cultural issues, and desire to provide culturally competent care are important steps toward providing culturally competent care. Thus, those physiotherapists, occupational therapists, and registered nurses with special interest in cultural care may have been more likely to respond, and have a higher cultural competence score, while those who consider cultural competence irrelevant to clinical practice may have disregarded the questionnaire and the study 46 in general. A second group of potential participants who may have been more likely to respond, were those with international experience, potentially skewing the data of the sample overall. Compared with the relative numbers on physiotherapists, occupational therapists, and nurses employed by the hospitals, nurses were underrepresented in the study. Sampling biases may therefore have had a greater effect on this profession. However, given that one of the major purposes of the study was to compare participants with and without international experience, the fairly equal group sizes was desirable. 3.4.2 A S S E S S M E N T OF C U L T U R A L C O M P E T E N C E Reliability of the I A P C C - R The internal consistency calculated in our study was similar to that reported in the literature (a = .80 as compared with scores ranging from a = .87 to . 9 0 4 ' 2 4 ' 3 2 ' 8 5 ) . Our lower a may reflect the professional diversity in our sample, or a small sample size. A value of a = .80 is considered to be good because scores that are extremely high (a > .90) can indicate redundancy in the questions. Upon examination of specific questions in the I A P C C - R 4 scale, we observed that the scale's first question (question 21 in the questionnaire): "Cultural competence mainly refers to one's competency concerning different ethnic groups" (answer choices: strongly agree to strongly disagree) was uncorrelated correlated with 18 of the 24 variables. The wording of the question may be too vague preventing respondents from clearly understanding the question. Although comments on the question were not solicited, four respondents commented that they were confused by the question, some calling the question "poor', others asking for clarification of its meaning. 47 A n additional concern with the I A P C C - R 4 that was identified by participants was the potential implication in the survey that clients from ethnically/culturally diverse groups should be treated with greater care than culturally similar patients. For example, questions 24, 27, and 39 asked respondents i f they have a personal commitment, are motivated to, and have a passion for caring for clients from culturally/ethnically diverse groups. Though these questions do not explicitly state that this passion, motivation, and commitment should be greater for culturally or ethnically diverse clients than for others, some respondents interpreted the questions in this manner, commenting that these qualities are necessary when treating all clients/patients. I A P C C - R scores by profession and hospital We calculated the mean scores on the I A P C C - R 4 , our index of cultural competence, for each professional group (physiotherapists, occupational therapists, and registered nurses). H igh scores are believed to be associated with a high degree of cultural competence. Campinha-Bacote suggests that scores ranging from 25 to 50 indicate cultural incompetence, scores between 51 and 74 indicate cultural awareness, between 75 and 90 indicate cultural competence, and scores above 90 indicate cultural proficiency 4 According to this classification, the mean scores for the three professional groups fall within the 'culturally aware' category. We suggest that the interpretation of these scores as degrees or levels of cultural competence be taken with caution, because they only evaluate attributes of the healthcare professional, without linking these to patient outcomes. The term 'cultural sensitivity' 7 2 may be a more appropriate term to describe the component of cultural competence referring to the attributes of the healthcare professional associated with culturally competence care. 48 N o statistically significant difference was observed when I A P C C - R 4 scores were compared across professions. Occupational therapists had slightly higher raw scores than physiotherapists or registered nurses, with a p-value approaching, but not reaching significance (p = .058). Future studies are needed to determine whether our study was under powered. The three hospitals chosen for this study are situated within British Columbia's Lower Mainland. Wi th an immigrant population of over 30%, this area is a particularly multicultural region of Canada. 6 8 There is however, marked ethnic and cultural diversity within this region. Based on data from Statistics Canada, 6 8 Table 8a illustrates ethnic differences among the three municipalities of interest in this study. O f particular note is the dramatic difference in the proportion of immigrants relative to the total population of each municipality, as well as the proportion of Chinese and West Asian immigrant populations living within each municipality. North Vancouver's immigrant population comprises only 22% of its population compared with approximately 50% in Vancouver and Richmond. Interestingly, cultural competence scores for participants practicing at Lion 's Gate Hospital in North Vancouver were lower than those of their colleagues at the V H H S C - U B C Site. A potential interaction between the cultural diversity of a community and its health care practitioners warrants further study. B y contrast, most healthcare professionals who were born outside Canada were born in Europe, the United States, Australia, or New Zealand. None was born in China or West Asia , two of the regions of emigration for the populations of these municipalities (Table 8b). Clinicians affiliated with each hospital were therefore treating patients of cultures other than their own. 49 Rankings When asked to rank a list o f outcomes related to cultural competence in order of perceived importance, healthcare professionals with international healthcare experience differed in the order of their rankings from their colleagues without this experience. Those professionals with previous international experience tended to rate enhancing patient understanding higher, and patient compliance lower than those without international experience. However, the standard deviations for the scores are relatively large, limiting the inferences drawn from these results. One hypothesis for this result is that cultural immersion may have given participants who had worked internationally first hand experience of culturally-based misunderstandings related to healthcare, and therefore placed greater importance on facilitating understanding in their patients in Canada. 3 .4 .3 E T H N O C E N T R I S M A N D C U L T U R A L C O M P E T E N C E A moderate correlation (r = -.28, p = .017) was observed between participants' scores on the I A P C C - R 4 (used to assess cultural competence) and the G E N E 5 (used to assess ethnocentrism). The correlation was negative, consistent with the postulate that low ethnocentrism and high cultural competence are related. Although this finding does not address the limitation of the cultural competence tool's failure to include outcomes, the correlation supports a degree of overlap between the constructs of cultural competence and ethnocentrism. Thus, a healthcare professional's cultural competence may reflect the degree to which that individual's world view emanates from his or her own cultural roots, as opposed to cultural competence being a truly distinctive construct. 50 Similarly, correlations between I A P C C - R 4 scores and self-reported cultural sensitivity were observed (r = .45, p < .001). Given the subjective nature of both of these scales, particularly the self-reported cultural sensitivity scale, these results need to be interpreted with caution. They may, however, lend support for our proposal of the phrase 'cultural sensitivity' to describe healthcare professionals' attributes thought to produce culturally competent care (in the absence of assessment of clinical or patient outcomes). 3.4.4 T H E I N F L U E N C E O F I N T E R N A T I O N A L E X P E R I E N C E O N C U L T U R A L C O M P E T E N C E The findings o f the current study relating international experience and cultural competence scores (with the I A P C C - R 4 ) provide a base for further research. International experience specific to healthcare (i.e., working in the healthcare sector in a country other than Canada) was not associated with I A P C C - R 4 scores, yet general experience abroad (i.e., l iving, traveling, or working internationally) was moderately correlated with I A P C C - R 4 scores (r s = .24, p = .043). To our knowledge, this relationship has not been studied previously. Our findings support that individuals may not need to immerse themselves in healthcare settings internationally, but that international travel experience alone may improve their cultural competence scores on scales such as the I A P C C - R . 4 The association in our study between cultural competence scores and general international experience, but not healthcare-specific international experience, are partially supported by previous reports. The literature suggests that learning cultural differences, comparing healthcare systems and nursing practices, and personal development may be outcomes of immersion CQ programs, and that improving one's understanding of social justice and globalization issues, 6 0and gaining a better understating of one's own culture while gaining new experiences 51 may be outcomes of general international experience. It is plausible that the outcomes of learning cultural differences and personal development could emerge from general international experiences, however comparing healthcare systems may require healthcare experience internationally. Further, when evaluating the strength of association between I A P C C - R 4 scores and a desire to work internationally, a moderately strong correlation was observed (r s = .37, p = .002). The multiple regression model supported that even when the desire to gain international experience or actual having international experience was controlled, both remained associated with cultural competence scores. Because one could argue that experience precedes desire, these results are consistent with this interpretation and that desire affects cultural competence scores even when the effect of personal experience is controlled. Thus, a desire to gain international experience may be an independent and important factor in its own right. To our knowledge, no previous studies have examined the impact of desire to gain international experience on cultural competence. Campinha-Bacote emphasizes the attribute of desire to meet the culturally relevant needs of patients. Our finding that desire to work internationally was associated with cultural competence scores may support this contention. The desire to provide healthcare in other countries and to explore other cultures may be a more important attribute than the actual international experience itself. A l l study participants, those with and without international experience, were given the opportunity to describe the influence (if any) that they perceived international healthcare 52 experiences to have on clinical practice. Responses to this open-ended question were coded thematically, and were categorized as follows: o Broaden the healthcare professional's word view o Increase exposure to and familiarization with other cultures o Enable the healthcare professional to experience being part of a cultural minority o Provide insight into alternate methods of healthcare provision o Challenge the healthcare professional's own beliefs and priorities Six respondents did not believe that international healthcare experience would improve the effectiveness of their clinical practice in Canada. None of these six reported having had international experience her or himself. They asserted that Canada is such a multicultural country that cultural exposure could or should occur in Canada. Further, one respondent commented that experience in a single culture may not be relevant to practice in another, or in a multicultural country such as Canada. In addition, those participants who reported having international healthcare experience were asked to reflect on any changes in their clinical practice that they attributed to their international experience. Their responses included: increased awareness and sensitivity to cultural differences, greater ability to develop rapport with patients, better able to incorporate cultural and religious beliefs into treatment without jeopardizing the authenticity of professional practice. In addition, respondents reported taking the Canadian healthcare system for granted less, being more aware of our resources, and realizing the scope and value of being creative with limited resources. One participant, however, reported that she had become more sensitive with age rather than because of her international experience. 53 Plato, over 2000 years ago, philosophized that "human behavior flows from three main sources: desire, emotion, and knowledge". More recently, A jzen 8 7 proposed that the proximal determinant of behavior is behavioral intention. Similarly, Campinha-Bacote refers to desire, or intention as the key to cultural competence. 6 3 Our results relating desire to work internationally with higher cultural competence scores on the I A P C C - R , 4 in conjunction with participants' beliefs regarding the outcomes of international experience, may support the importance of intention or desire. Participants' perception that increased exposure, awareness, or understanding of other cultures may occur with international work experience may suggest an underlying belief that improved cultural competence is an expected outcome of international healthcare experience. Thus, their desire to gain international experience may be an indicator of a desire to achieve their expected outcomes (i.e., improved cultural competence) of international experience, rather than a desire specifically to work internationally. In turn, in keeping with Plato, Ajzen and Campinha-Bacote, 6 3 ' 8 7 this desire to improve their cultural competence may lead to behavior that is consistent with higher cultural competence. Education and training aimed at improving the cultural competence of clinicians or students could foster this desire. 3.4.5 A D D I T I O N A L A T T R I B U T E S A S S O C I A T E D W I T H C U L T U R A L C O M P E T E N C E In this exploratory section of our study, we investigated associations between attributes of the healthcare professional and cultural competence scores on the I A P C C - R . 4 Wi th respect to international experience, time spent internationally (in months) and the number of continents traveled to were both associated with cultural competence scores (r s = .24, p = .043 and r = .26, p = .027 respectively). 54 Two attributes relating to the culture of the healthcare professional were relatively strongly correlated with cultural competence scores on the I A P C C - R 4 The first attribute was the percentage of the clinician's caseload that was culturally different from him or herself (r = .37, p = .002), suggesting that the greater diversity in a clinician's caseload, the higher the clinician's cultural competence scores, and the second attribute was the ability of the healthcare professional to speak more than one language (n = .34, p = .004), such that healthcare professionals who spoke at least two languages scores higher on the I A P C C - R 4 than those professionals who spoke only English. The association between cultural competence scores and culturally diverse caseloads may indicate that the experience o f treating culturally different patients is related to cultural competence. Thus, practitioners may benefit from increasing their exposure to cultural diversity, either by establishing education programs that expose healthcare professionals to diverse healthcare beliefs and practices, or by joining cultural groups or events within the community as a means of increasing exposure to individuals with different world views and thereby enhancing cultural competence. Abi l i ty to speak multiple languages may be a result of any number of life events. One reason is that the multilingual healthcare professional is an immigrant, or at least the child of an immigrant. Niemeier, Burnett, and Whitaker 8 8 suggest that healthcare providers lack knowledge of the impact of the immigration experience and acculturation on a patient's behavior and response to treatment. They also assert that the immigration experience is increasingly being appreciated as traumatic. Healthcare providers who speak more than one language, or who consider themselves to be from cultural minorities may be more likely to be immigrants 55 themselves, and therefore more aware and empathetic of their cultural minority patients and the difficulties that some may face when immersed in the Canadian healthcare system. Alternatively, the ability to speak more than one language may have stemmed from a desire to learn an additional language. Evidence of interest in mastering another language can be considered consistent with the domain in Campinha-Bacote's model related to the desire to engage effectively with individuals from another culture. Language is a fundamental characteristic of a culture and reflects its values and other distinct qualities. When comparing correlations between each attribute and the three dependent variables of I A P C C - R 4 scores, G E N E 5 scores, and cultural sensitivity scores, only the attributes of months spent l iving or traveling internationally, and desire to work internationally were correlated with at least two of the dependent variables: I A P C C - R 4 scores and cultural sensitivity scores. The remaining attributes included in the analysis were associated with either one or none of the three dependent variables. Open-ended questions were used to elicit factors that the participants believed to be important to the provision of culturally competent care. The responses were grouped into the following categories: communication, resources and education, intrinsic characteristics, and personal experiences. Within the category of communication, participants identified the importance of language, or at least learning a few words in different languages, asking patients and families what their expectations are, asking patients and families how the healthcare professional can facilitate the healing process, actively listening, using an interpreter or an English speaking family member when necessary, and soliciting guidance and feedback from the family. Resources and education were also reported to influence the perceived ability of the healthcare 56 professional to provide culturally competent healthcare. Specifically, the availability of interpreters, written material, on-line resources and links, community services, appropriate assessment tools, were deemed important. In addition, having the time and flexibility to discover and meet the specific needs of each patient were highlighted by participants. Education, in the form of formal courses, discussions, workshops, and in-services were identified. The following intrinsic characteristics were identified as important: self-awareness of biases, openness, willingness to compromise, adaptability (to incorporate different beliefs and practices), enthusiasm, respect, understanding, humility, and confidence in skills and commitment to professional growth. Finally, personal experiences that were reported to have influenced professional's cultural awareness and knowledge included: travel and international healthcare experience, repeated exposure to, and experience treating specific cultures in local hospitals, home visits and interactions with family, unique experiences with patients, working with other professionals from other cultures or having friends from other cultures, attending cultural events in the community, and the individual's personal background/culture (particularly for participants from minority cultures). 3.4.6 P A R T I C I P A N T S ' P E R S P E C T I V E S O N C U L T U R A L C O M P E T E N C E A s part of the exploratory component of this study, healthcare professionals were asked to provide their own definition of cultural competence. Similar to Campinha-Bacote's model, 4 participants identified the components of awareness, knowledge, acknowledgement, understanding, and sensitivity of cultural differences. These differences were described by some using a culture-general approach (acknowledging and responding to the fact that differences do exist), and by others using a culture specific method (suggesting healthcare professionals should 57 learn specific cultural beliefs and practices of the common cultures in one's patient population to be culturally competent). Other respondents believed that cultural competence required a respectful, nonjudgmental and inclusive nature, in which the healthcare professional can set aside preconceived notions, and be open minded and wil l ing to learn about cultures and cultural differences. Sti l l others suggested that each client needed to be approached as an individual human being, who should be asked about her/his cultural beliefs and practices, rather than assumed to have a pre-conceived cultural identity. With respect to patient care, the accommodation of cultural differences and incorporation of these differences into a healthcare plan were considered important to cultural competence. Similarly, accommodation and facilitation of specific beliefs with the aim of enabling patients to make educated choices/decisions and to achieve their own goals were suggested. Finally, one respondent remarked that cultural competence should be considered an extension of client-centered care. One serendipitous, anecdotal finding of our study was an apparent increased awareness of the construct of cultural competence in the participants practicing in the hospitals surveyed. The act of taking the time to reflect on and answer the survey questions provided the participants with an opportunity to reflect on their own practices, and the cultural needs of their patients. Although not asked to comment directly, a small number of participants remarked on this opportunity, stating that they appreciated the opportunity just to think about the questions. 3.4.7 S T U D Y L I M I T A T I O N S A N D F U T U R E D I R E C T I O N S Comparable to other studies using the current assessment tools to evaluate cultural competence, one limitation of this study was the absence of patient outcome measures. Though difficult to isolate and prove the effect of a single healthcare practitioner on a patient's outcomes, con-elating 58 patient outcomes with scores on current cultural competence tools would help elucidate the true components of the construct of cultural competence. When only the healthcare professional's attributes are of interest or are being studied in isolation, we propose the use of the term cultural sensitivity to refer the aspect of cultural competence that current assessment tools assess. Our sample size was small, limiting the results of the study. Similarly, a low response rate, especially among the nurses, may have biased the sample. Future studies may need to consider shorter questionnaires and the use of incentives to increase response rates. Attempts were made to gather data from all physiotherapists, occupational therapists, and registered nurses meeting the inclusion criteria (i.e., the use of a convenience rather than a random sample); a random sample would increase the generalizability of the results to a broader population of healthcare professionals. The hospitals however, were purposefully chosen for the study so that the range of cultural groups within the Vancouver Coastal Health Authority in British Columbia's Lower Mainland, was represented. In future studies, random sampling hospitals from a broader region would increase the generalizability of the findings. 59 C H A P T E R 4 D I S C U S S I O N A N D C O N C L U S I O N 4.1 D I S C U S S I O N 4 .1 .1 O V E R A L L D I S C U S S I O N The construct of cultural competence relating to healthcare professionals has become an increasing focus o f clinical and research interest related to quality healthcare delivery. This may reflect shrinking geographical boundaries with considerable migration of people from low- and middle-income countries to high-income countries, and international work and travel opportunities for those from high-income countries in lower-income countries. Migration increased Canada's population, for example, by 5 % over the past decade. 8 9 In addition, professionals, including those practicing in healthcare, are being recruited to other countries or are seeking international practice experiences at an unprecedented rate. 6 6 Consequently, multiculturalism has become a feature of many countries including those that have been less open to outsiders, such as China and Middle Eastern countries. Multiculturalism brings diversity and melds differing world views. The 2 1 S T century w i l l likely be hallmarked by the capacity of diverse cultures to respect and appreciate each other, and to recognize their similarities and differences in working together toward mutual goals. Optimal healthcare outcomes in this century w i l l largely reflect the ability of healthcare providers to manage the needs of people with various conditions, rather than their conditions, per se. Future healthcare priorities are predicted to be those related to lifestyle behaviors. 9 0 Thus, it w i l l be particularly important to optimize communication between healthcare providers and patients for the prevention, diagnosis, management, and health education to affect positive health behaviors. 6 0 Over the past four decades,3 1 cultural competence has emerged as a construct of interest in the healthcare literature, largely in nursing. There is limited literature related to the cultural competence of other healthcare professionals including rehabilitation professionals (i.e., physiotherapists and occupational therapists). The attributes that may be associated with cultural competence have been disputed, thus considerable work remains in establishing whether such a construct can indeed be defined. Further, i f this construct can be defined, what are its components, and can these be augmented such that patient outcomes are enhanced? A greater knowledge and understanding of cultural competence may have several benefits. First, such knowledge may highlight cultural competence and sensitivity as heath care entities that warrant attention to improve the quality of healthcare delivery and its outcomes. This knowledge could be useful to the patient as well as the practitioner in communicating with each other over important issues related to health, clinical outcomes, and patient satisfaction. Enhanced understanding of cultural competence may also have a role in recruiting students into healthcare professional programs or qualified practitioners into positions at home and abroad. Further, this knowledge could be a focus of the education of health professionals and provide a basis for continuing education including in-services and workshops for practitioners. Finally, elucidating the construct and its components would identify directions for further research. The major contributors to this field to date include Campinha-Bacote 4 , 7 5 and Suh. 1 0 Campinha-Bacote described the construct and selected practitioner-related attributes as its components. Based on this model, she has developed a tool which has been widely used in the nursing literature. 2 4 ' 3 0 - 3 5 Suh, on the other hand, produced a model that extended Campinha-Bacote's construct of cultural competence to include patient-related variables and outcomes as well . 61 Although Suh's inclusion of patient variables is compelling theoretically and clinically, no tool is available to date to evaluate these outcomes. This thesis examined the construct and assessment of healthcare professional's cultural competence with three distinct goals. First, we conducted a critical analysis of the literature related to cultural competence, its measurement, and the variables that have been proposed to influence it. Second, we studied those healthcare providers who, during the course of patient care, spend considerable time with their patients, i.e., rehabilitation professionals and registered nurses. Third, ethnocentrism (utilizing the G E N E 5 scale) was used to benchmark cultural competence against a well-established and potentially related variable. One can argue that cultural competence, that is 'the ability to work within the cultural context of an individual, family, or community from a diverse cultural/ethnic background, 4 could be associated with ethnocentrism, that is, a view of things in which one's own group is the center of everything, and all others are scaled and rated with reference to i t . 4 5 To our knowledge, the construct of cultural competence has not previously been benchmarked to ethnocentrism. Further elucidation of the role of ethnocentrism in determining cultural competence of healthcare providers, could augment the evidence-based for the construct of the latter. Finally, we examined attributes related to the cultural competence of healthcare professionals reported in the literature. O f particular interest were international experience, either general or specific to healthcare, and interest in such experience. Understanding the relationship of these variables with cultural competence may have implications for recruitment and professional education. There is preliminary evidence suggesting a relationship between individuals' international experience or interest, and their cultural awareness and sensitivity to other cultures. 6 1 If this could be substantiated, opportunities for clinical fieldwork for student and new graduates, for example, may be a vehicle for enhancing 62 cultural competence in healthcare practitioners when practicing abroad or in their country of origin. Chapter 2 described the critical analysis and its findings, and Chapter 3 reported the findings of a questionnaire study that included the I A P C C - R 4 questionnaire and the G E N E 5 as well as a section on demographic information, international experience, and personal attributes. Wi th respect to the critical analysis (Chapter 2), our primary conclusions were: 1. The current cultural competence assessment tools, such as the I A P C C - R 4 questionnaire do not fully address cultural competence as they do not consider outcomes of care. We believe that cultural competence is more reflective of Suh's construct which includes patient outcomes as well as healthcare provider attributes as components. 1 0 Both prospective and retrospective research is needed to examine the importance of professional's attributes in the improvement of patient and clinical outcomes. These outcomes include patient satisfaction, improved health, reduced illness, and decreased length of hospital stay. Unt i l these tools are combined with an assessment of clinical and patient outcomes, only half, at best of the construct of cultural competence is being considered. 2. The term cultural sensitivity may be a more appropriate designation for the component of cultural competence that the current tools evaluate: the attributes of the healthcare professional that are thought to result in culturally competent care. 3. The transparency of the questions in the I A P C C - R 4 questionnaire was of concern, given the current climate of 'political correctness' and influence of socially desirability of responding. Further, compared with related questionnaires such as established scales of ethnocentrism, the 63 scale did not include distracters, and included few questions that were reversed to minimize perseverance of response. With respect to the questionnaire study (Chapter 3) in which we examined the cultural competence of rehabilitation professions and nurses, and the relationship of selected attributes, our primary conclusions were: 1. Cultural competence of physiotherapists, occupational therapists, and registered nurses were comparable when assessed with the I A P C C - R 4 scale, as were scores across the three hospital sites. Thus, the data were pooled across professional groups to examine the relationships among cultural competence and selected attributes and variables. 2. Cultural competence scores were negatively associated with ethnocentrism which is consistent with the nature of each of these constructs. Further, cultural competence scores were fairly strongly associated with self-reported cultural sensitivity scores. 3. A relationship between international experience and cultural competence supported 62 Campinha-Bacote's 'cultural encounters' domain in her model of cultural competence. This domain is defined as the process which encourages the healthcare professional to directly engage 62 in face-to-face interactions with clients from culturally diverse backgrounds. 4. The absence of associations between healthcare specific international experience and cultural competence scores suggested that exposure to various cultures does not necessarily have to be in healthcare to broaden healthcare professionals' awareness, understanding, and acceptance of alternate views and beliefs held by their patients. 5. Desire to work internationally was associated with cultural competence scores supporting Campinha-Bacote's 6 3 contention that desire is fundamentally important to the construct of 64 cultural competence. In a multiple regression model, when controlling for the variable 'desire to work internationally', the association between international experience and cultural competence disappeared. Therefore, the desire to provide healthcare services in another country and to explore other cultures may be more important than the actual international experience itself. 6. Cultural competence was positively associated with the proportion of a practitioner's caseload that was culturally different from the practitioner. The association between cultural competence scores and culturally diverse caseloads supports that either the experience of treating culturally different patients is related to cultural competence, or that practitioners who score high on cultural competence seek out culturally-diverse practice settings, or both. Based on the former interpretation, practitioners may enhance their cultural competence through exposure to cultural diversity by participating in education programs that expose healthcare professionals to diverse health and healthcare practices, as well as cultural groups or events. 7. The ability to speak more than one language was related to higher cultural competence scores. Abi l i ty to speak multiple languages may be a result of any number of life events. One reason may be that the multilingual healthcare professional is an immigrant, or at least the child of an immigrant. Either of these cases may result in an increased understanding, empathy, and awareness for the difficulties that some patients from minority cultures face when immersed in the Canadian healthcare system. 8 8 Alternatively, the ability to speak more that one language may have stemmed from a desire to learn the additional language(s). This scenario may be in keeping with importance of desire associated with international experience, or the desire to meet the cultural needs of patients in Campinha-Bacote's model. Our study was largely correlational, thus prospective research studies are needed to examine whether, or to what degree, healthcare professionals with certain attributes are attracted to 65 international practice because of their cultural competence (as defined by I A P C C - R scores), or become more cultural competent because of the experience. Some evidence suggests that immersion and exposure can increase people's cultural awareness and sensitivity. 6 1 However, the degree to which this occurs, and whether an effect can be observed in most people, is unknown. It is possible that screening tools could identify those healthcare professionals who would benefit most from such exposure and training. The question remains however, whether with this training and experience, improves patients' satisfaction with care and clinical outcomes. Considerable study is needed to examine these questions. Retrospective studies are needed to define fully the components of culturally competent care. Such studies could examine patient and clinical outcomes, and then retrospectively, examine the attributes of the patient and the healthcare provider, and their interaction. One could argue that a significant interaction exists between the two individuals to effect optimal patient and clinical outcomes. Based on cultural theory, 6 5 some healthcare providers may have a more authoritarian style, in which the patient's perspective is not sought after. For patients from some cultures, this may be the expected style of treatment and communication. Others, however, such as those patients from western cultures, may respond more favorably to a healthcare provider with whom they have personal rapport and can ask questions. In addition, based on their culture, some patients may be more comfortable with power distance between themselves and healthcare providers, 6 5 and would be less comfortable i f the relationship was informal. Researching the relationship between the healthcare professional and the patient are challenging due to the potential confounding variables influencing the relationship. For example, the effect of other healthcare providers, or restraints within the health system would need to be controlled for. 66 Finally, until a link is established between the attributes of healthcare professionals theorized to improve clinical outcomes, and actual improved clinical outcomes, these two constructs should remain distinct. We propose the use of 'cultural sensitivity' when referring to such attributes in that their impact on patient and clinical outcomes is unknown. 4.1.2 I M P L I C A T I O N S Research Based on theory and evidence, to what extent does the construct of cultural competence in healthcare actually exist? We would argue that the construct needs to be grounded based on the outcomes and deliverables of care, namely, patient and clinical outcomes, such as patient satisfaction, improved health, reduced impairment, illness, or disability, and improved participation. The superiority of culturally competent care over usual care needs to be established. Wi th grounding of the construct based on outcomes, we question whether culturally competent care is a function of the healthcare provider (Canpinhe-Bacote's model), or the interaction between the healthcare provider and the patient, (Suh's model). In addition, as our understanding of this construct deepens, the effects of cultural competence at the level of the healthcare professional, the approach taken in this thesis, w i l l need to be amalgamated with organization- or system-level cultural competence, a separate stream of research at present. Finally, prospective and retrospective studies to elucidate the construct of cultural competence with respect to its validity and its primary components should be supported. Retrospective 67 studies in particular w i l l be useful to characterize the attributes of healthcare providers and patients based on patient and clinical outcomes (positive, no change, and negative outcomes). Clinical One of the underlying purposes for studying and assessing the cultural competence of healthcare professionals is to determine how to improve cultural competence in clinicians. The challenge of proposing effective methods o f improving clinicians ability to adapt their clinical behavior to meet the culture-based needs of their patients warrants a discussion of social cognitive models of social change. 9 1 These models propose theoretical foundations predicting why humans make changes in their behavior. In the context of improving cultural competence, questioning how and why a healthcare professional would choose make changes to her/his clinical practice that w i l l enhance their ability to provide culturally sensitive care is relevant. Several theories, including the social cognitive theory, 9 2 the transtheoretical model , 9 3 and the theory of planned behavior, 8 7 suggest that outcome expectancy, or the expectation that an outcome w i l l follow a given behavior, is an important factor in behavioral change. 9 1 Both the likelihood and the importance of the expected outcome play a role in motivating change. ' ' Thus, validating the relationship between the attributes and behavior of a healthcare professional and improved clinical outcomes may facilitate behavioral changes in the clinician. Without knowledge of how improved cultural sensitivity of healthcare providers impacts their professional behavior and their patient's outcomes, a basis for cultural awareness and immersion remains intuitive. The precise relationship between international exposure and cultural competence as assessed with the I A P C C - R , 4 and based on Campinhe-Bacote's model, warrants elucidation before recommendations regarding the role of international experience in cultural 68 competence can be made. Prospective studies are needed to establish whether individuals who pursue international experiences have attributes consistent with cultural competence, or whether this attribute is fostered by such experiences. Education Recommendations to include cultural content to increase cultural sensitivity in healthcare professional programs are not yet evidence-based methods of maximizing patient and clinical outcomes. However, the impact of culture on health and ill health beliefs and behaviors has been well established, which supports the integration of such content. Based on the responses of participants, methods of disseminating cultural information to healthcare professionals should vary from formal education, both during and post professional training, to in-services and workshops within the hospital or clinic setting. Further validation is needed to determine the most effective type of information: either cultural-general, based on cultural theories,65'94 or culture specific, describing cultural beliefs and practices of the most populous minority cultures in the region, needs. 4.1.3 F U T U R E D I R E C T I O N S The inclusion of clinical outcomes in conjunction with the cultural domains or qualities of the healthcare professional, as proposed by Suh,10 provides a foundation from which future research in the field should advance. Agreement needs to be established between high scores on cultural competence assessment tools and patients' perceptions of culturally competent care by their healthcare providers. In addition, evidence to support associations between high cultural competence scores and outcomes related to the patient or the health system would further progress the field of cultural competence. Literature is slowly emerging in this area. Saha, 69 Arbelaez, and Cooper, have reported that when surveyed, non-white respondents were less satisfied with their healthcare than white respondents. Previous studies have reported similar findings, but Saha and colleagues provide a critical link to cultural competent care. They report that the quality of patient-physician interactions (as reported by the patient) were lower among Hispanic and Asian patients than among Black or White respondents. Further, Asians, and to a lesser degree Hispanics, reported lower levels of cultural sensitivity among their physicians. Future research within one minority population assessing the relationship between outcomes such as patient satisfaction and level of cultural competence demonstrated by their healthcare provider would be beneficial. Similarly, correlations between healthcare professionals who achieve high scores on both cultural competence evaluation tools and on other clinical outcomes, such as treatment or cost effectiveness, would also aid in the advancement of the field. A major practical challenge with such studies is the multiple factors that influence a patient's clinical outcomes, including the variety of different healthcare professionals with whom a patient may interact with daily. The critique, the study, and the discussion of cultural competence in this thesis have focused on the cultural competence of the healthcare professional. A parallel field is the study of the cultural competence of healthcare organizations and systems. 9 6" 9 8 Within this framework, the adaptability of organizations, such as hospitals or health regions, as well as the managerial support for cultural training, programs, and resources are addressed. It is clear that the healthcare professional and the system within which she/he works are intimately related, making evaluation of one without the other challenging. Future studies may address the construct and assessment of cultural competence by combining these related spheres. 70 4.2 SUMMARY This thesis was designed to critically evaluate the cultural competence with respect to existing models and tools related to cultural competence in rehabilitation professionals and nurses, and then to examine the association between cultural competence scores and selected attributes. Wi th respect to the critique, we introduced models and tools of cultural competence including those of Campinha-Bacote 4 and Suh. 1 0 Both models describe attributes of the healthcare professional that are purported to result in culturally competent care. Suh's model, on a theoretical basis, can be argued to be more grounded than that of Campinha-Bacote, because she also includes clinical and patient outcomes in her model. Unlike Suh's, however, Campinha-Bacote has developed a tool for assessing cultural competence based on her model. The limitations of the tool are described; the most fundamental criticisms are that it reflects practitioner attributes only, and that the questions are biased toward answering in a politically-correct or socially-desirable way. Nonetheless, because it was deemed the best tool available, we incorporated it into a questionnaire study to examine the relationship between cultural competence and selected variables including international experience, and cultural characteristics such as language. In addition, we benchmarked this scale against an established scale of ethnocentrism - an attribute one could argue should be reflected in an index of cultural competence. Based on the critique, we surveyed a sample of convenience of physiotherapists, occupational therapists, and registered nurses, practicing in three hospitals in the Lower Mainland of British Columbia. We had 71 respondents including 33 with and 38 without international experience respectively. The results supported that cultural competence scores were comparable for the three professional groups and three hospitals surveyed. We observed associations between cultural competence scores and the following variables: ethnocentrism scores, self-reported 71 cultural sensitivity, international experience, and desire to gain this experience, ability to speak more than one language, and the exposure to a clinical caseload consisting o f culturally diverse patients. Finally the study shed light on healthcare providers' perceptions of cultural competence and the influence of international experience on this competence. The questions of what cultural competence is and how best to assess it remain. The term cultural sensitivity may be more appropriate rather than competence when referring to healthcare professional attributes as assessed by the Campinhe-Bacote's model, and tool, the I A P C C - R 4 . 4.3 CONCLUSION The mandates of the Canadian Romanow Report and Kirby Commission, as well as the United States Health and Human Services Initiative 8 included the improvement of the quality o f care for immigrant populations. The field of cultural competence strives to achieve this. However, the construct of cultural competence needs to be firmly grounded in clinical outcomes, before being systematically integrated into the mandates of health ministries, organizations, policy makers, educators, and clinicians. In this century in which Canada's health priorities include the -y elimination of healthcare disparities and optimal health education to facilitate health and wellness, it is timely for researchers and clinicians to critically examine the construct of cultural competence and its definition. If a definitive case can be made for such a construct, then assessment tools that are valid and reliable warrant further development. The association between international experience and cultural competence strengthens previous research findings, but contradicts those studies finding a relationship between international 72 healthcare experience and improved cultural competence. Two new contributions to the field were the determination of an association between cultural competence and both ethnocentrism and desire to gain international experience. This may impact the nature of training, continuing education, and immersion programs, enhancing awareness of the role that culture plays in health and healthcare, and facilitating in healthcare professionals, a stronger desire and motivation to consider the influence of culture in their interactions with patients. Further, the association between cultural competence scores and ethnocentrism, international experience, and experience treating diverse patient caseloads support that increased exposure to different cultures and world views increase healthcare professionals' scores on cultural competence assessment tools, and possibly their ability to meet the culture-related health needs of their patients - an outcome that may facilitate improved patient care for cross cultural groups. Finally, we argue that practitioner attributes which likely reflect attributes more correctly classified as cultural sensitivity, patient attributes, and their interaction, determine management outcome that reflect cultural competence. We conclude that the construct of cultural competence and its assessment is in its infancy. M u c h work remains to validate the construct and the methodology for assessing its presence in healthcare professionals. This second component should emanate from the elucidation of the construct. This thesis has identified some of the limitations of the work to date in this field. We argue that grounding the construct in patient and clinical outcomes may better clarify the constructs of the model, and in turn, the methodology and components of tools to evaluate cultural competence. 73 Table 1 Summary table of current evaluation tools to measure cultural competence in health care professionals Tool Authors Questions: number, length, type Purpose Domains Covered Reliability (Cronbach's a) Construct Validity Cross-Cultural Adaptability Inventory (CCAI) Kelley C and Meyers J ( 1 9 9 ? ) 23,28,29 50 questions (15-30 min) (4 sub-scales) 6 point Likert scale cross-cultural training, research, assess potential for cross-cultural adaptability, multi-disciplinary emotional resilience flexibility/openness perceptual acuity personal autonomy 0.9 (Total) 0.82 0.8 0.78 0.68 (each domain) rigorous statistical analysis to clarify the meaning of construct of cross-cultural adaptability Inventory for Assessing the Process of Cultural Competence -revised (IAPCC-R) Campinha-Bacote (2002) 4,17,24,30-35,61,62 25 questions (15 min) 4 point Likert scale cultural competence in healthcare providers (for educational, clinical and research purposes) cultural awareness, cultural knowledge, cultural skill cultural encounters, and cultural desire (5 items per domain) 0.87 (mean from 3 authors) 0.83 (Guttman Split-half) based on Campinha-Bacote's (1998) 1 7 conceptual model of cultural competence Cultural Competence Assessment (CCA) Schim SM, Doorenbos AZ, Miller J, Benkert R (2003) 2 4 25 questions (2 sub-scales) 5 point Likert scale provide evidence of cultural competence among health care providers and staff cultural diversity awareness and sensitivity (subscale A, 8 items), cultural competence behaviors (sub-scale B, 17 items) 0.92 (0.75 for sub-scale A, 0.93 for sub-scale B) based on Schim and Miller's 2 4 model of cultural competence Cultural Self-Efficacy Scale (CSES) Bernal H, Froman R (1993) 3 6 58 questions (4 sub-scales: general cultural skills, caring for 3 specific groups) 5 point Likert scale determine the level of confidence that nurses have in caring for diverse cultural groups knowledge of cultural concepts, cultural patterns, skills in performing transcultural nursing functions 0.97; multiple regression to predict overall score was not statistically significant based on the concept of self-efficacy as developed by Bandura 3 7 74 Table 1 continued Summary table of current evaluation tools to measure cultural competence in health care professionals Tool Cross-Cultural Adaptability Inventory (CCAI) Inventory for Assessing the Process of Cultural Competence -revised (IAPCC-R) Cultural Competence Assessment (CCA) Cultural Self-Efficacy Scale (CSES) Content Validity Discriminant Validity Initial Population Used Use in Rehabilitation Notes Limitations identified most consistently cited traits and skills associated with cultural adaptability; expert opinion; field testing reviewed by national transcultural health care experts school principals with higher CCAI scores were more heterogeneous in ethnicity, spoke more languages, and had more cross-cultural training known groups technique (pre- and post testing of 200 nurses at a one day diversity training day) psychology patients, professionals working or wanting to work with individuals of other cultures 15 nurses in an acute care hospital (30% at a Master's level, 30% at a bachelor's level) significant correlation to significant differences IAPCC; expert b/w individuals with 125 hospice panel review; different educational employees and subjective levels and prior volunteers feedback; field diversity training testing congruent with the score influenced by: Giger and diversity-related Davidhizar continuing ed., cultural community Transcultural heritage, % of health nurses Assessment Model culturally different and Theory 1 8 clients PT students Cronbach a = 0.9 (subscale ranges: 0.59 to 0.83) unclear culture general, not designed to predict success or failure in cross-cultural interaction process oriented; notes that "with modifications", the tool can be used with allied health professionals 5th grade reading level; tested in a variety of healthcare workers (does not specify rehabilitation) self-efficacy in general cultural skills and in caring for clients from 3 groups (Black, Hispanic, Asian) not specific to healthcare; transparent questions designed by nurses for nurses; requires high level of literacy 1 4 limited testing and use (new tool); uneven number of items in sub-scales; only tested on White Americans specific to certain ethnic groups of clients 75 Table 2a General demographic and personal characteristics (n =71) Frequency (%) Mean (SD) Range Age (in years) 40.62(10.60). 22 to 61 Gender Male Female Profession: Physiotherapist Occupational therapist Registered nurse Years of clinical practice Hospital of work Richmond Lion ' s Gate V H H S C - U B C Site 5 (7%) 66 (93%) 27 (38%) 18 (25%) 26 (37%) 23 (32%) 29 (41%) 19(27%) 13.57 (10.77) < l t o 4 1 Canadian trained Yes N o 46 (65%) 25 (35%) Speak more than one language Yes N o 27 (38%) 44 (62%) International health care experience Yes 33 (46%) N o 38 (54%) Cultural identity European Asian Central or South American, or Caribbean African 58 (82%) 10(14%) 2 (3%) 0 (0%) Table 2b Demographic and personal characteristics stratified by international experience (mean, standard deviation, and range) Mean (SD) Range International Yes No Total Yes No Total experience n = 33 n = 38 n = 71 n = 33 n = 38 n = 71 Age (in years) 41.70 39.69 40.62 22 to 61 23 to 61 22 to 61 r (10.93) (10.36) (10.60) Years of 14.52 12.74 13.57 .08 to 40 .33 to 41 .08 to 41 clinical practice (11.53) (10.13) (10.77) Desire to work 8.13 6.29 7.14 1 to 10 Oto 10 Oto 10 internationally (2.30) (3.35) (3.07) 77 Table 2c Demographic and personal characteristics stratified by international experience (frequencies and percentages) Frequency (or %) Yes No Total International experience n = 33 n = 38 n=71 Gender Male 2 (40%) 3 (60%) 5 Female 31 (46%) 35 (54%) 66 Profession Physiotherapist 12 (44%) 15 (56%) 27 Occupational therapist 8 (44%) 10 (56%) 18 Registered nurse 13 (50%) 13 (50%) 26 Hospital of work Richmond 11 (48%) 12 (52%) 23 Lion 's Gate 15 (52%) 14 (48%) 29 V H H S C - U B C Site 7 (37%) 12 (63%) 19 Canadian trained Yes 10 (22%) 36 (88%) 46 N o 23 (92%) 2 (8%) 25 Speak more than one language Yes 16 (59%) 11 (41%) 27 N o 17(39%) 27 (61%) 44 Cultural identity European descent 25 (43%) 33 (57%) 58 Asian (including Middle East) 8 (80%) 2 (20%) 10 Central / South American or Caribbean 0 (0%) 2 (100%) 2 Native American 0 (0%) 0 (0%) 0 African 0 (0%) 0 (0%) 0 78 Table 3a Scale reliability: item-total statistics for the IAPCC-R Question Number Scale Mean Scale Corrected Alpha if if Item Variance if Item-Total Item Deleted Item Deleted Correlation Deleted 21 65.28 50.91 -.09 .81 22 63.93 47.10 .33 .79 23 64.24 46.95 .28 .80 24 63.98 46.36 .40 .79 25 63.92 48.25 .26 .80 26 65.75 47.46 .28 .80 27 63.93 46.30 .45 .79 28 64.79 43.08 .70 .77 29 64.83 41.04 .65 .77 30 65.39 46.71 .39 .79 31 64.53 49.54 .02 .81 32 64.80 46.23 .42 .79 33 63.75 48.12 .31 .80 34 64.29 47.28 .38 .79 35 64.72 42.05 .63 .77 36 64.22 48.70 .26 .80 37 64.62 49.15 .11 .80 38 64.54 47.80 .31 .80 39 64.58 47.04 .36 .79 40 65.70 46.84 .28 .80 41 64.62 49.53 .06 .81 42 64.70 47.26 .30 .80 43 65.42 44.84 .42 .79 44 64.28 46.21 .49 .79 45 64.93 48.86 .19 .80 Table 3b Scale reliability: item-total statistics for the G E N E Question Number Scale Mean Scale Corrected Alpha if if Item Variance if Item-Total Item Deleted Item Deleted Correlation Deleted 46 22.82 36.74 .57 .75 47 22.82 37.00 .63 .75 49 22.74 38.40 .30 .78 50 22.87 37.90 .50 .76 52 22.49 37.44 .36 .77 53 23.01 38.28 .48 .76 54 22.72 39.02 .36 .77 55 22.48 35.77 .58 .75 56 22.66 35.76 .69 .74 58 21.84 40.29 .18 .79 59 22.86 39.28 .28 .78 63 22.92 39.78 .41 .77 65 22.84 39.35 .46 .77 66 22.86 43.05 -.03 .81 67 23.18 41.54 .40 .78 Note: Questions 48, 51, 57, 60, 61, 62, and 64 are distracters and were removed Table 4a Comparison of mean IAPCC-R scores by profession and hospital Mean (SD) N F-value (p) Professions (all) 67.32 (7.11) 71 2.97 (.058) Physiotherapist 65.24 (5.68) 27 Occupational therapist 70.38 (7.84) 18 Registered nurse 67.37 (7.40) 26 Hospitals (all) 67.32 (7.11) 71 7.62 (.001) V H H S C - U B C Site 71.78 (7.06) 19 Lion's Gate Hospital 64.27 (6.79) 29 Richmond Hospital 67.49 (5.64) 23 Table 4b Comparing IAPCC-R mean differences between hospitals (Post hoc Scheffe Test) (I) Hospital (J) Hospital Mean Difference (I-J) P V H H S C - U B C Site Lion's Gate hospital 7.50 * .001 Richmond hospital 4.29 .113 Lion's Gate hospital V H H S C - U B C Site -7.50 * .001 Richmond hospital -3.22 . .217 Richmond hospital V H H S C - U B C Site -4.29 .113 Lion's Gate hospital 3.22 .217 * The mean difference is significant at the .05 level. 81 Table 5 Outcomes believed to be most important in culturally competent care (mean rankings stratified by international experience) Participants with international experience n = 33 Participants without international experience n = 38 Mean (SD) Rank Mean (SD) Rank Improved patient health 2.06(1.71) 1 2.06 (1.50) 1 Patient satisfaction with patient-provider interaction 2.55 (1.50) 2 2.46(1.27) 2 Provider is able to enhance the patient's understanding of what the provider assesses the patient's medical problem is 2.91(1.72) 3* 3.88(2.14) 5* Patient and provider have equal responsibility/power in their relationship with each other 3.09 (2.13) 4 * 3.79(1.94) 3* Patient compliance with treatment 3.41(1.81) 5* 3.86(1.97) 4 * Provider satisfaction with the patient-provider interaction 4.70 (2.02) 6 4.89(1.73) 6 Patient and provider end the interaction with more similar world views than they began with 5.27 (2.43) 7 6.24(1.92) 7 ranking difference between groups 82 Table 6a Relationship between international experience or desire to gain this experience and cultural competence (Spearman's rs correlations) Cultural competence scores (IAPCC- R 4) n = 71 .18 (.141) .24 (.043)* 37 (.002)** * Correlation is significant at the 0.05 level (2-tailed) ** Correlation is significant at the 0.01 level (2-tailed) Months spent working internationally Months spent l iving / traveling internationally Desire to work internationally Table 6b Predicting cultural competence scores from the variables 'months spent working internationally' and 'desire to work internationally' (Multiple regression model) Dependent variable = cultural competence scores using the I A P C C - R Model summary v t v 71 .43 .19 7.90 (.001)** Coefficients Significance B Beta U P ) (Constant) 1.79 141.43 (<.001) Desire to work internationally .001 .30 2.72 (.008)* Months spent l iving / traveling internationally .001 .28 2.54 (.013)* * Correlation is significant at the 0.05 level (2-tailed) ** Correlation is significant at the 0.01 level (2-tailed) 83 Table 7 Relationship between specific attributes and cultural competence scores (Pearson's r, Spearman's rs, or r\ correlations) Cultural Ethnocentrism Cultural competence scores scores on the sensitivity on the IAPCC- R 4 G E N E 5 scores r P r P r P Age -.15 .205 .26 .032* -.06 .650 Years lived in Canada -.18 .139 .09 .469 -.12 .308 Years of clinical practice -.12 .323 .25 .036 -.09 .442 Percent of caseload culturally different from the participant .37 .002** -.07 .543 .11 .382 Number of continents traveled to .26 .027* -.02 .893 .20 .089 rs P rs P rs P Months spent working internationally .18 .141 -.10 .704 .38 .001** Months spent l iving / traveling internationally .24 .043* -.05 .704 .41 .000** Desire to work internationally .37 .002** -.18 .132 .35 .003** n P n P P Gender (female, male) .18 .143 .09 .479 .09 .456 Speak more than one language (no, yes) .34 a .007* a .03 a .831 a .18 a .134 a Minority (non-European) descent (no, yes) .033 .786 .01 .936 .01 .966 Canadian trained? .030 .807 .09 .461 .17 .162 (no, yes) * Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed), a = Equal variances not assumed and appropriate t-test performed instead 84 Table 8a Select immigrant populations (IP) in Vancouver, North Vancouver, and Richmond Total Municipality population Total IP IP as a % of total population Chinese population (%ofIP) South Asian population (%ofIP) West Asian population (% of IP) Japanese population (%ofIP) Vancouver 545,671 264,495 48% 161,110(61%) 30,655 (12%) 3,160(1%) 8280 (3%) Richmond 164,345 96,385 59% 64,270 (67%) 12,120 (13%) 1,155(1%) 3615 (4%) North Vancouver 44,303 9,955 22% 1,900(19%) 980 (10%) 2,830 (28%) 670 (7%) Table 8b Health care professionals' place of birth Hospital (Municipality) n % born in Canada IP as a % of healthcare professionals % born in high-income countries3 % born in China % born in South Asia % born in South or Central America, Asia b , or Africa V H H S C - U B C Site (Vancouver) 19 63% 37% 16% 0% 5% 16% Richmond (Richmond) 23 65% 35% 17% 0% 4% 13% Lion 's Gate (North Vancouver) 29 59% 41% 31% 0% 3% 7% IP = immigrant population a = Europe, U S A , Australia, or New Zealand b = excluding South Asia , China, or West As ia 85 Figure 1 Leininger's Sunrise Model to Depict Dimensions of the Theory of Culture Care Diversity and Universality C U L T U R E C A R E Focus: Individuals, Families, Groups, Communities or Institutions in Diverse Health Contexts of IVofassianai Care— Oiru Practice Transcultural Care Decisions & Actions Culture Care Preservation/Maintenance Culture Care Accommodation/NegotiatioB Culture Care Repatteming/Restrucraring t Cul tura l ly Congruent Care for Health, Well-being o r Dying Code Acute viral disease caused by tie ftymari From: Leininger M . 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J Nurs Care Qua! 1998;13(1):41-51. 95 Contact for concerns about the rights of research subjects: If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the U B C Office of Research Services at 604-822-8598. Consent: Your participation in this study is entirely voluntary, and you may refuse to participate or withdraw from the study at any time without jeopardy to your employment. B y returning the completed questionnaire, you are consenting to participate in the study. Please keep this letter for your own records. Thank you. Best regards, Dr. Elizabeth Dean and Jen Capell 97 Section I: All participants please fill out pages 1 to 5 ('ode:, 1. Gender: Male • Female • 2. In what year were you born? 3. Country of birth: 4. Number of years lived in Canada: 5. Profession: Physiotherapist • Occupational Therapist • Registered Nurse • 6. Highest educational level: Diploma • Bachelor's degree • Master's • PhD • 7. In what country did you obtain your professional qualification? If you obtained this qualification in Canada, at which university did you receive it?_ 9. For how long have you practiced as a PT, OT or nurse? (If you have worked part-time in this capacity, please answer in terms of total number of full-time years and months. For example, 2 years at 0.5 F T E represents 1 year in total.) Years: Months: 10. How many months/years have you spent living outside Canada since you began your therapy/nursing training? Years: Months: 11. If you have lived outside of Canada after beginning your therapy/nursing training, in what countries have you lived? Please also circle the countries in which you practiced health care. Countries: 12. What language do you generally speak at home? 13. What other languages do you speak proficiently? 14. How would you define your cultural identity?: • European descent • Native American • Asian (including Middle East) • Caribbean, Central or South American • African • Other 15. What percentage of your current patient case load belong to a cultural identity different than your own, in your opinion? % 16. Approximately how many months in total have you spent traveling (including those months spent volunteering/working) outside Canada since you were 18 years of age? months 17. How many of these months have been spent volunteering or working in health care (including practicums during your professional training)? months 18. How many times have you travelled for a length of time that was longer than 1 month? 19. If you have traveled for longer than 1 month at a time, to which countries to you go during this (these) long trips? 20. To which continents have you traveled, including working experiences (since age 18)? Please check all that apply. North America (outside Canada) • South America • Africa • Australia /Oceania • Europe • Asia • Please answer the following questions by circling the answer that you feel is most appropriate for you (in a health care setting). 21. Cultural competence mainly refers to one's competency concerning different ethnic groups. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 22. I feel that cultural competence is an ongoing process. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 23. Factors such as geographical location, gender, religious affiliation, sexual orientation, and occupation are not considered areas of concern when seeking cultural competence. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 24. I have a personal commitment to care for clients from ethnically/culturally diverse groups. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 25. I feel that there is a relationship between culture and health. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 26. I am knowledgeable in the area of ethnic pharmacology. VERY KNOWLEDGEABLE KNOWLEDGEABLE SOMEWHAT KNOWLEDGEABLE NOT KNOWLEDGEABLE 27. I am motivated to care for clients from culturally/ethnically diverse groups. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 28. I am knowledgeable about the worldview, beliefs, practices and/or life ways of at least two cultural groups. VERY KNOWLEDGEABLE KNOWLEDGEABLE SOMEWHAT KNOWLEDGEABLE NOT KNOWLEDGEABLE 29. I am aware of the cultural limitations of existing assessment tools that are used with ethnic groups. VERY AWARE AWARE SOMEWHAT AWARE NOT AWARE 30. I am knowledgeable in the area of biological variations among different ethnic groups. VERY KNOWLEDGEABLE KNOWLEDGEABLE SOMEWHAT KNOWLEDGEABLE NOT KNOWLEDGEABLE 31. Anatomical and physiological variations do not exist in different ethnic groups. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 32. I am aware of specific diseases common among different ethnic groups. VERY AWARE AWARE SOMEWHAT AWARE NOT AWARE 33. I am willing to learn from others as cultural informants. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 34. I seek out education, consultation, and/or training experiences to enhance my understanding and effectiveness with culturally and ethnically diverse clients. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 35. I am aware of at least 2 institutional barriers that prevent cultural/ethnic groups from seeking healthcare services. VERY AWARE AWARE SOMEWHAT AWARE NOT AWARE 36. I recognize the limits of my competence when interacting with culturally/ethnically diverse clients. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 37. When my values and beliefs "clash" with my client's values and beliefs I become frustrated. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 38. I am aware of some of the stereotyping attitudes, preconceived notions and feelings that I have toward members of other ethnic/cultural groups. VERY AWARE AWARE SOMEWHAT AWARE NOT AWARE 39. I have a passion for caring for clients from culturally/ethnically diverse groups. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 40. I am aware of at least 2 cultural assessment tools to be used when assessing clients in a healthcare setting. VERY AWARE AWARE SOMEWHAT AWARE NOT AWARE 41. It is more important to conduct a cultural assessment on ethnically diverse clients than with other clients. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 42. I feel comfortable asking questions that relate to the client's ethnic / cultural background. VERY COMFORTABLE COMFORTABLE SOMEWHAT COMFORTABLE NOT COMFORTABLE 43. I am involved with cultural/ethnic groups outside of my healthcare setting role. VERY INVOLVED INVOLVED SOMEWHAT INVOLVED NOT INVOLVED 44. I believe that one must "want to" become culturally competent if cultural competence is to be achieved. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 45. I believe that there are more differences within cultural groups than across cultural groups. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE The following items refer to the cultures of different parts of the world. Work quickly and record your first reaction to each item. There are no right or wrong answers. Please indicate the degree to which you agree or disagree with each item, using the following five-point scale Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5 46. Most other cultures are backward compared to my culture. 47. My culture should be the role model for other cultures. 48. People from other cultures act strangely when they come to my culture. 49. Lifestyles in other cultures are just as valid as those in my culture. 50. Other cultures should try to be more like my culture. 51. I am not interested in the values and customs of other cultures. Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5 52. People in my culture could learn a lot from people in other cultures. 53. Most people from other cultures just don't know what's good for them. 54. I respect the values and customs of other cultures. 55. Other cultures are smart to look up to our culture. 56. Most people would be happier if they lived like people in my culture. 57. I have many friends from different cultures. 58. People in my culture have just about the best lifestyles of anywhere. 59. Lifestyles in other cultures are not as valid as those in my culture. 60. I am very interested in the values and customs of other cultures. 61. I apply my values when judging people who are different. 62. I see people who are similar to me as virtuous. 63. I do not like to co-operate with people who are different. 64. Most people in my culture just don't know what is good for them. 65. I do not trust people who are different. 66. I dislike interacting with people from different cultures. 67. I have little respect for the values and customs of other cultures. 68. How would Y O U define culturally competent health care? 69. In what order would you rank the following outcomes in terms of their importance to cultural competence? Please rank the outcomes from 1 to 8 (1 = most important, 8 = least important) improved patient health patient compliance with treatment patient satisfaction with the patient-provider interaction provider is able to enhance the patient's understanding of what the provider assesses to be the patient's medical problem provider satisfaction with the patient-provider interaction patient and provider end the interaction with more similar world views than they began with provider and patient have equal responsibility/power in their relationship with each other other (please add any additional factors you think are important) 70. How important is it that Canadian health care professionals are culturally competent when practicing in Canada and internationally? Please comment. In Canada I Internationally 71. In what ways do you think a therapist or nurse could improve her or his ability to effectively treat patients from diverse cultural backgrounds? 72. What factors do you think have the greatest influence on a health care professional's ability to provide culturally competent care? 73. Are there any experiences or circumstances that you feel have increased Y O U R ability to effectively treat patients from cultures other than your own? If so, please describe them. 74. Do you think that volunteering in health care overseas would improve a therapist's ability to work with patients of diverse cultural backgrounds here in Canada? Why or why not? 75. How would you rate your desire to volunteer internationally in healthcare? (Please assume that financial, family, or other commitments would not interfere with international volunteering) 0 1 2 3 4 5 6 7 8 9 10 Would not want to go Neutral Would love to go - 5 -102 Section II. Questions for those participants who have NOT had the opportunity to volunteer or work overseas in health care: 76. How sensitive do you perceive yourself to be to cultural differences? (circle one) 0 1 2 3 4 5 6 7 8 9 10 Not at all sensitive Average Very sensitive 11. If you A R E interested in volunteering overseas, what sparked this interest? 78. For what reasons have you N O T volunteered overseas in health care in the past? 79. Do you think that in the future you will volunteer overseas? Why or why not? Section III. These questions apply to you ifyou H A V E volunteered/worked overseas in health care (including those who received their training abroad). 80. Please describe your international volunteering/work experience. (If you have had more that one international experience, please list each one as a separate occasion.) Experience (doing what, where) # of consecutive months Countrv Year . 81. How sensitive do you perceive yourself to be to cultural differences T O D A Y ? (circle one) 0 1 2 3 4 5 6 7 8 9 10 Not at all sensitive Average Very sensitive 82. How sensitive do you believe you were PRIOR to your volunteer experience? (circle one) 0 1 2 3 4 5 6 7 8 9 10 Not at all sensitive Average Very sensitive 83. In what ways (if any) has your international experience in health care influenced your practice as a therapist in Canada? 84. If your experience was as a volunteer, did you use a volunteer agency? Yes • No • 85. Were you oriented to the new culture before or upon your arrival? Please describe. 86. How could you have been better prepared for your international experience? Thank you very much for taking the time to participate with this research. Do you have any other comments or feedback? (please use the space below and/or the reverse side) - 7 -104 

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