Abstract: A Content Analysis of Cultural Competence and Cultural Humility in Nursing Fundamentals Textbooks

◆ Heather J. Carmack, University of Alabama
◆ Khadiza T. Jannat, University of Alabama

Rationale: In 2011, the six US health and medicine educational associations identified four core competencies that should govern interprofessional practitioner training. The first competency, values and ethics, includes cultural competency in three elements: promoting health equity through patient-centered care, appreciating patients’ cultural diversity, and respecting differences in health professions. Nursing is one of the only health professions that has successfully integrated the core competencies into their education materials. The purpose of this study is to examine how cultural competency is presented to future nurses in their introductory textbooks. Method: The authors conducted a directed qualitative content analysis of the 11 nursing fundamentals textbooks published after the introduction of the IPEC’s core competencies. The authors coded for definitions of cultural competence, the IPEC’s value competencies focused on cultural competence, and the six types of cultural competence. Intercoder reliability indicated the coding was reliable (.70-.99 across three waves of coding). Results: Most textbooks (n = 8) included an explicit definition of cultural competence, framing cultural competence as (1) a lifelong process, (2) a commitment to culture and health equity, and (3) an awareness of self and the cultural beliefs of patients. The IPEC core competency elements were unevenly presented in the textbooks. All textbooks (n = 11) identified cultural diversity and difference and most (n = 8) discussed patient-centered care. However, only six textbooks talked about the importance of diversity in healthcare professions. All textbooks identified the importance of the basic elements of cultural competence: cultural awareness, cultural knowledge, and cultural skill. These elements encourage future nurses to learn about their own cultural backgrounds, spend time learning about different cultural groups, and develop the skills necessary to collect important cultural information about patients during assessment and intake. Most (n = 10) also discussed the importance of cultural encounters (engaging directly with diverse patients) and cultural desire (developing the motivation necessary to want to be culturally competent and caring). Finally, nine textbooks discussed cultural humility, which focuses on critiquing patient-provider power imbalances as well as systematic racism, sexism, and discrimination in the healthcare system. These textbooks called for nurses to identify implicit bias and engage in patient advocacy. Implications: First, although all textbooks called for a focus on patient diversity, the examples provided were almost exclusively about race or ethnicity, especially on patients speaking a language other than English. These examples do not highlight the diversity of patient differences, which limits nursing students’ education of diversity. Second, cultural competence focusing on cultural awareness, knowledge, and skill mirrors previous findings about communication competence. It is easier to teach students about knowledge and skill than it is to teach about motivation. Finally, newer textbooks encourage students to be more active in their critique of institutional practices of discrimination and their own implicit biases. Although none of the textbooks actively presented anti-discrimination practices, this may be the first step in finding ways to challenge and change healthcare systems by teaching students how to advocate for healthcare equality.