My name is Dr. Courtney Brown, and I am Interim Program Director at Wake Forest School of Nurse Anesthesia. It's so nice to discuss this topic today. It's on theoretical models, frameworks, and approaches to cultural competency training. And I'm going to make this as specific to our area as possible. It may start off at first very theoretical, but get down into more nuts and bolts. So with that, here's my disclosure statement. I have no financial relationships with any commercial interests related to the content of this activity, and I will not discuss off-label use during my presentation. So here are our outcomes. The learner will compare and contrast two models for cultural competence that could be incorporated into a nurse anesthesia educational program. And the learner will identify three additional resources that are numerous throughout that you can review on diversity, equity, and inclusion that can be utilized in your design of your programming. So our three main agenda items are to discuss considerations for the selection of a cultural competency theory, an overview of selected theories used in healthcare education, both within and outside of nursing, and pedagogical approaches based on those selected theories. So how do you begin? Where do you even start? You know, when you're thinking about how am I going to put pen to paper, you really want to do a little bit of time to think and also gather some information. In particular, you want to find some source material. Number one, whatever theory you want to choose. It can't be one that you just said, hey, I like that one. In terms of writing accreditation documents and in terms of presenting things to student learners, you really want to have what we call alignment. Alignment is where whatever you review from this institutional mission and vision, your department's mission and vision, and even accreditation standards, there's a flow to it. They all align on the same kind of constructs. And things are not kind of in conflict with what you've stated previously within the institution or within your department. So as you're preparing your meetings, and we'll talk about who you may want on your team of individuals, think about, you know, what did it bring to the table? What is the institutional mission and vision? What are the Department of Schools mission and vision? Bring to the table your department's accreditation standards or even institutional accreditation standards. Also review your faculty or leadership's philosophy of teaching. Some involve where the learner is the recipient of lecture-based discussions. Others are more student-led or student-driven or learner-led or learner-driven, where the learner themselves has to demonstrate competencies and it's less so of a directed approach. Also review your current educational model or framework. Are you front-loaded? Are you integrated? If you're integrated, a fair number of the competencies are likely going to have to fall within your daily clinical evaluations. However, if you are more front-loaded, you may look at your knowledge and attitudes in the very beginning and switch to skills and encounters as your learners enter the clinical setting. You also want to look at your hospital's nursing framework. Is there already an existing philosophy? Most of those, which I'll discuss in a few minutes, are not going to be in conflict and would greatly benefit from adding another theory as a supplement to their actual philosophy as it relates to diversity, equity, inclusion, or cultural competence or humility. So then you want to assemble your team. And this is going to be also looking and taking stock of your organizational values and approaches. Does your organization favor a top-down approach where you'd want to identify an executive team and administrative leadership and work through those channels? Or do you have a lot of buy-in that you're going to need to get in terms of implementing this into the clinical daily eval? If it's going to take a lot more faculty development of your clinical faculty in order to understand the constructs that you're putting onto the daily clinical eval, engage with them early. If they're part of the process, they can become your champions of implementation once things start to launch. And they also would benefit greatly as well as potentially their patients benefit from getting this kind of faculty development as soon as you can. You also want to potentially select a thread director if you're going in that route. And I do recommend a thread director on these activities. They'll make sure that the activities are scaffolded, that they're sequential, developmental, that there's a beginning, middle, and an end, and that there are some staged, potentially objective ways of measuring that people are attaining these throughout the curriculum. Also, you consider creating focus groups or working groups. And again, thinking about making many hands make work light so that you can maybe perhaps have them help develop rubrics or questions for on your clinical evaluations based on your selected theory. And then whether or not to include or not include learners. I can tell you this. Learners are much more further down the road in advancing their knowledge on cultural competency than probably most faculty. And in addition, going forward as we continue to build, a lot of our learners will have partaken in cultural competence education and training in the baccalaureate levels that could only help us grow in the master's and now doctoral level competencies. You can build upon what they already come in knowing rather than having to redo or regroup on what they haven't had yet. So here's just an example of an alignment. So this is my own institution where we reviewed our mission and vision of atrium health. We also put down our mission and vision of our department of academic nursing. And the final piece was looking at our educational model. We didn't find anything in our mission and vision that would not potentially include diversity, equity inclusion language. And we didn't define anything in our mission and vision on either area that we would have to continue to use below the department levels that gave us a little bit more freedom than some other locations may have. Now in terms of our key values, we did define diversity as honor of individuality and protection of the dignity of all. And looking at our own personal educational model, we're integrated. We prefer experiential hands-on active learning approaches. So the theory that we would gravitate towards would be one that would lend itself to simulation, problem-based learning and case-based approaches. And also we look at the learner as a customer and a future colleague and learning is bi-directional. And so theories that involve less of expertise on faculty and more of we're here to learn about these values and ideas and learn from each other would be more in alignment with our own educational philosophical leanings as educators. Then we reviewed AACN definitions and AACN defines culturally sensitive care is the ability to appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share common distinctive racial, national, religious, linguistic, or cultural heritage. And that is straight from the Department of Health and Human Services Office of Minority Health. In addition, they define cultural humility as a lifelong process of self-reflection and self-critique whereby the individual not only learns about another's culture but also examine his or her own beliefs and cultural identities. And then COE accreditation standards are found on the right. In particular to culturally competent, they define cultural competency is demonstrated by effective utilizing various approaches in assessing, planning, implementing, and administering anesthesia care for patients based on culturally relevant information. So in alignment with that definition, it also can lend itself to simulation, problem-based learning, simulated standardized patient assessments, as well as the clinical setting and having rubrics throughout that actually measure that. Now, in terms of those hospital-based programs I said you might want to look at, is your hospital, if your hospital-based program, is your hospital magnet certified? Or do they have a guiding nursing philosophy? But as I mentioned, most of these nursing theories that they may have may not offer much in terms of additional resources for any of your cultural humility or cultural competency training. It's just simply understanding that they are likely not to be in conflict with it and could probably even benefit from an additional theory. So perhaps your hospital administration would be also interested in which theory that you ultimately choose or take apart or actually wouldn't be part of the working groups. So now I'd like to present to you some selected cultural competence or cultural humility theories. And some are, most of these are going to be from nursing. A couple will be from outside of nursing. In terms of the nursing frameworks, of course, we're going to start with Leininger, 2002. Of course, her work predates 2002, but the one in particular actually started in the 1980s. But the theory of transcultural nursing or the Sunrise Model is one that we're going to talk about, as well as Ferranda, Campanha-Picote, Purnell, Shim and Dorenbos. And in terms of other disciplines, the Tervillon-Murray-Garcia, that's a medical model of cultural humility, Betancourt is also a medical model, cultural competence model, and Delgado and Stefancic is also critical race theory. We're going to evaluate all for potential use in a nurse anesthesia program. So in terms of Leininger, again, this is a Sunrise Model. This is actually considered more of a grand theory. She was the first really nurse anthropologist, and she found the discipline of transcultural nursing and ethno-nursing qualitative research methodology. She also found the Council on Nursing and Anthropology with the American Anthropological Association or Society of Applied Anthropology, as well as the Transcultural Nursing Society and the Journal of Transcultural Nursing. A fair number of our cultural humility models you're going to find in that journal. So if there's one journal that your faculty may want to do some more perusal within, it's that one in particular. She first started our theory in 1978 with Transcultural Nursing Concepts, Theories, and Practices, but I have other selected more recent publications as she built upon this original nursing model. Now if you look at the model she has where all of these pieces in terms of the Sunrise Enabler, you have to go into an area of cultural discovery where you work with the patient to identify all these different worldviews and cultural, social, structural dimensions such as religious or philosophical factors, political and legal factors, etc. to define what are the influences on their care expressions and patterns to provide them with holistic health care. So in terms of that, it is a meta-grand theory. It may be already present as a driving mission and vision. It would likely not be present in your curriculum and outlining it. I would say that most nursing programs may take parts and pieces of this, but probably none of them typically would utilize it all together in its whole in terms of because it is so broad and grand. So a great oldie but goodie, but definitely one that you'd probably only be able to use a few pieces of it throughout your curriculum in a holistic way. The next one I'd like to provide you is one that was literally inspired by Leininger's original Sunrise model. This is Faranda's Rainbow Model of Cultural Humility. Cynthia Faranda has held faculty positions in the University of Miami as well as Johns Hopkins University. The thing I like about her approach to developing her model is she did an actual concept analysis of both cultural humility and cultural sensitivity. She also has an instrument that she's tested to measure cultural humility. So if you chose models such as this, you'd already have a reliable validated tool to pull from if you wanted to measure it occasionally throughout your curriculum. Now in terms of her model, the other things that are different from Leininger's then she has different rainbow sections, if you will. She has, of course, a worldview very similar to Leininger, that she has context where you have historical precedents, political climate, personal beliefs, and values. In the bottom there, you're going to see where people have a cultural conflict between discordant perspectives and the imbalance of power. So she in 2020 more so included concepts of power and privilege, which weren't necessarily originally a main focus of Madeline Leininger. The other parts is at the bottom, it gets a little harder to read her model in terms of understanding other than the process, her processes lifelong that produces positive outcomes, and that all decisions and actions must require cultural humility, and that otherwise you'll have negative outcomes if somebody displays cultural ambivalence or destruction. So it's a bit more harder of a model to apply, but it is still kind of a brand new model that people are gravitating towards, especially because of the inclusion of power and privilege within it. Now this was her actual cultural humility concept analysis, and I actually find it a little easier to potentially keep in terms of a curricular approach. So in terms of cultural humility, there she defines it as having the constructs of openness, self-awareness, egoless, supportive interaction, self-reflection, and critique, and that with along with lifelong learning, things that are outcomes would be empowerment, mutual benefit, respect, partnerships, and optimal care. And yes, there still is things that can actually upend it, which would be power imbalance, and things that would promote it, which would be diversity, but I found that this model, just even this concept analysis, might be one that would be more appropriate to potentially, or more amenable to educational endeavors. Now, Kapin Habakote is a really well, very well-known, very well-cited theorist. In terms of on the left is her original model, the process of cultural competence in the delivery of healthcare services. On the right, in 2005, she took her same model, and because she also completed a Master's of Arts in Theology, created the biblically-based model of cultural competence. Created the biblically-based model of cultural competence. So, for example, if your school is monotheistic, her particular theologic approach may be more in alignment, as it includes ideas of religion much more so, and God much more so from a biblical perspective. Now, the author, the reason what inspired her to originally perceive her cultural competence model was that she found herself personally not ethnically fitting into her school of nursing. She was from Cape Verde, so neither black nor white, and that's when she began to explore cultural and ethnic groups. She completed her baccalaureate, master's, and doctoral degrees in nursing. She extended her interest in cultural groups to the fields of transcultural nursing and again, medical anthropology. She also heralds Leininger as one of her main influences as well, and she again, she completed that graduate work in theology in terms of where she used the curriculum of allied health professions as well as seminaries. So, she kind of did a marriage of both of them in her final piece. Now, her assumptions are that cultural competence is a process, not an event. Cultural competence consists of the five seen on the left here of cultural awareness, knowledge, skill, and encounters, and cultural desire. Cultural desire was actually added later it wasn't originally there and is considered somewhat inclusive of cultural skill and awareness. There's also more variation within ethnic groups than across ethnic groups. This is one of her assumptions. Other assumptions, there's a direct relationship between the level of competence of the health care provider and their ability to provide culturally responsive health care services, and cultural competence is an essential component in rendering effective and culturally responsive services. Now, in terms of her, I've got a series of her publications. She also has several tools based on both of her models that actually measure cultural competence, and she also has a website that can help you kind of see if maybe you can parse out some more of her development. She's got some really nice graphics, so just, I'll provide that as one of your references and resources at the end of this presentation in your educator portal. Now, the Pernell model is another grand theory, very, very unwieldy to consider for its use in just strictly at our bedside practice, but it is a very well-cited model that could be actually already in place at your school or department or university. So it's defined also as a grand theory. He, however, cites Campena Bocote, as he also cites sociology and anthropology, as well as Madeline Lanier again. He says that culture is process and not an end point. One progresses from, if you look at the bottom, unconsciously incompetent, not being aware that one is lacking knowledge about another culture. And this is the part of the bottom that I find the most, I gravitate towards the most. You may find different parts and pieces that you find more interesting, but you progress from unconsciously incompetent to conscious incompetence, being aware that you're lacking knowledge about another culture, moving to conscious competence, learning about client's culture, verifying generalizations about the client's culture, and providing culturally specific interventions, and finally to unconscious competence, where you automatically provide culturally competent care to clients of diverse cultures. Now, I would say of all of them, that piece, that last piece, where somebody is automatically completely cultural competent. Now, within the literature, there is a great divide between those that say you can never be truly 100% competent in another's culture, and that even using the words cultural competence may make one to believe that you can learn or study a list of attributes, and that once you've learned those attributes, you no longer have to learn about another's culture that you kind of have checked off your boxes, you're done. And that, what I'd say, would be about the cultural competency training that we saw in the 1990s and 2000s, and is incorporated even in some of our EPIC systems that has a little check box of things to make sure that you're doing for another's culture. In our particular nurse anesthesia program, we found those to be what we would call very essentialist views, and felt that there's no way that culture is a static thing, and we fell on that side of the great divide. So that's why we more or less favored more culturally humble practices, where you have no assumptions whatsoever, but you go into all interactions with questions, with and without assumptions, and without assuming anything of the other's culture. So in that case, on our area, we would never be unconsciously competent. We would always strive to stay consciously competent, but striving really to always ask the right questions. Now, in terms of publications, he does not have a tool that would measure, and he also is very quick to point out that this is what he would call a grand theory, and not necessarily one that may be amenable outside of that. Now, in terms of Shim and Dorenbos, they have a 3D model for cultural competence. And so if you look here on the right, you'll see they have the provider level and the client level. They have the same four jigsaw pieces, jigsaw puzzle. And then somewhere between those interactions, you can lead to culturally congruent care. So what falls in those jigsaw pieces is these four constructs. The four constructs being awareness, competence, sensitivity, and diversity. So Shim attributed influence of Meininger and Pernau. So you see, they're all kind of running in the same kind of literary circles, but they are slightly all different. So again, it is sort of evaluating which one fits your institution best or your program best. But in terms of this one, they do have a cultural competence assessment tool. It's been used in several research projects, and it's one of the few models, as I mentioned, that has one. Again, the main two that I've already made mention of are Shim and Dorenbos, and Campina-Bakote. Now, Stephanie Meyer-Shim was an assistant professor at Wayne State. Unfortunately, she passed away in 2016. Although Ardith Dorenbos is professor Department of Biobehavioral Nursing Science at the University of Illinois, Chicago, she also earned her PhD at Wayne State University. She also frequently researches pain and palliative care in cancer patient populations. In terms of publications, the main publications are this particular model and, of course, the validation and reliability testing of their tool. Now, in terms of Turvalon and Murray-Garcia, this is another great model. Now, this is one that is not in the field of nursing. It was produced originally in 1998. To date, it's been cited almost 3,000 times that I can find in the literature. This figure was from a slide deck at the National Institutes of Health. In terms of who they are, they make mention that the training outcome, perhaps better described as culture humility versus cultural competence, this is what they wrote, actually dovetails several educational initiatives in the US physician workforce training as we approach the 21st century. It is a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. So the biggest thing here, if you see in that first pillar, is lifelong learning, you'll never arrive, and critical self-reflection. You'll never stop checking yourself, so to speak, in terms of how you approach your care. Now, the other piece is that it requires humility in how physicians, this is their words because they are physicians, check the power imbalances that exist in the dynamics of the physician-patient communication and patient-focused interviewing and care, meaning you cannot just approach the patient and direct their care. It needs to be more relationship-centered and where you include their thoughts and their culture into your decision-making. And finally, their final piece is that community-based clinical and advocacy training models where they hold institutions that they work within accountable. So that would be one more activist type of piece of their cultural humility paradigm. Now, Melanie Trevalon is an MD and also a pediatrician, and now she's a cultural humility consultant. You can find her online that she has her own little business for cultural humility. And then Jan Murray-Garcia is an MD and MPH, a full-time faculty member at UC Davis Health and the Betty Irene Moore School of Nursing. So you have an MD with a full-time faculty appointment at UC Davis Health. She developed and directs their anti-racism and cultural humility training program. She also teaches in their doctorate in nursing practice degree program. And that training program, the anti-racism and cultural humility is a three- and four-day immersive experiences for nurse leaders, nursing and medical school faculty and staff, as well as healthcare leaders. She's also, she became a pediatrician from Stanford University. And then with their, in terms of, in terms of their particular publications, very few publications have they actually put out since the seminal article. They've decided to spend more time on creating programming available to us to teach us how to teach cultural humility practices. So here's a quote from an article on self-reflection and multicultural training. Be careful what you ask for. As conceptualized by scholars in the field of psychology, racial identity theory is critical to understanding and planning for the potentially wide range of predictable reactions to provocative activities, including those negative reactions that do not necessarily herald a flaw in programming. As I've made mention, once you begin starting to have conversations on culture, inevitably you will have discussions on race and racism. Those can be uncomfortable. So she's making mention here that any provocative activities could elicit an emotional response. It doesn't mean you have any flaws in your programming. It's just a change in growth. Here is their particular website for their anti-racism and cultural humility fellowship and academy. I would keep abreast. If you are a particular faculty or within a school that has done very little up to date, or you're in a less, very less diverse area of the country where these kinds of experiences are gonna be a little more challenging for you to come by, this may be one particular avenue that can help kind of spur you along the path of helping develop some great activities. They kind of teach you both the racial dialogue, facilitation skills, educational approaches and content, research approaches, including clearly and accurately defining race and research strategies, analyses, and reporting. I mean, it's a shared vocabulary around anti-racism and cultural humility. Betancourt is another MD who's also kind of in the public health domain. He used more of a sociocultural approach and based it on the patient provider discordance. So here's a quote from his article. Sociocultural barriers were identified at the organizational, structural, and clinical levels, a framework for cultural competence interventions, including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials and provider education across cultural issues emerged to categorize strategies to address racial and ethnic disparities in health and healthcare. So his is more of a systems approach where it's much more practical boots on the ground, much less theoretical, and focused specifically on achieving more equitable health outcomes. So in terms of if your faculty would rather focus on the disparities in health outcomes in and of themselves, this particular model would lend itself to those discussions. And finally, Delgado and Stefanichick, I hope I said it right, a critical race theory. It was actually the original envisioners of critical race theory are Derrick Bell, Kimberly Crenshaw, and Richard Delgado, which is one of the authors on this text that I showed you. Now, they're all in the law paradigm, lawyers. So their law or legal scholars, and their theory states that racism is so ingrained in everyday life that white and non-white people both select choices that fuel racism. So with that, even in 2007, the US Supreme Court school assignment case and whether race could be a factor in maintaining diversity in K through 12 schools, there was even differences in opinion on that where the Chief Justice John Roberts opinion famously concluded the way to stop discrimination on the basis of race is to stop discriminating on the basis of race. And then during oral arguments, then Justice Ruth Bader Ginsburg said, it's very hard for me to see how you can have a racial objective by a non-racial means to get there. So it's just one of those theories that is very difficult. You're almost making your argument by making your case at the same time on the way to how not to do it. So I'm not gonna lean one way or the other. I would say that I am seeing an increase in literature in educational pedagogy at higher education institutions that are looking into this as a possible framework. Now, Rachel Delgado and Jean Stefanchik both hail from the discipline of law. They both revised a book to include key material on things such as colorblind jurisprudence, Latino critical scholarship, immigration, and the rollback of affirmative action. This second edition introduces readers to important new voices outside of law, including education, psychology, and offers greatly expanded issues, updated reading lists, and extensive glossary of terms. So it's basically a worldview. If you will, what they're saying in this worldview is you can't look at anything without putting up a lens saying, is this something related to race or ethnicity that's structurally related to our country? And so that is part of the blowback from the actual theory itself. Now, both of them are professors, well, I should say Jean Stefanchik is a professor in climate research affiliate at the University of Alabama School of Law. She has other books such as Must We Defend Nazis? Why the First Amendment Should Not Protect Hate Speech and White Supremacy and Critical Race Theory. So a lot of really what we call controversial types of thoughts. And so again, this might work well for universities such as UAB where they both hail from. It may not work for your program or it might. So it's just one of those things that you have to take stock of your faculty, your institution, your hospital institution, and see, is this something that would work well for us? Are we an institution that really truly believes in re-envisioning the civil rights movements? And is this something that we can take forward? And are our students ready to take up the mantle with us? That'd be my other caveat to this. You also wanna keep in mind that they are gonna be partaking of this and whether or not you can deliver it in an effective way. And that does not cause any kind of racial trauma along the way as well. So in terms of other things, just to let you know, Professor Delgado also went to UA, is also a professor at UAB. And he also taught at UCLA prior to relocating to UAB. And in fact, he has several, he's authored over 200 journal articles and 20 books regarding his work. Just so he's considered a distinguished, he even had a Pulitzer Prize nomination for his work. So these are distinguished writers and thought leaders. And it is considered a model civil rights as opposed to dismantling structural racism. The major tenants, as I mentioned, it's racist so ingrained in our fabric of our society in the United States that you really can't talk about anything at all without including it as a potential lens. Now, in terms of what I found in PubMed, I found a total of seven publications for Richard Delgado, none related to CRT, zero for Gene Stefanchik. But when you Google, I'm sorry, not Google, when you do a PubMed search of CRT in medicine, you will find more. And I will put these references, they're gonna be in the notes of this PowerPoint presentation as well as on, as well as I have other references that you can look at if this is something that you think that you want to take on at your institution or programming. But in particular, there are several writers in medicine that have applied critical race theory as a potential for, as a lens for examining primary care provider responses to persistently elevated hemoglobin A1Cs. Jennifer Tsai, T-S-A-I, is particularly known for writing within this genre. For example, she has articles named A Call for Critical Race Theory in Medical Education in Academic Medicine, which is one of the highest impact factor for medical journals, as well as another article with some other researchers, Race Matters, Examining and Rethinking Race Portrayal in Preclinical Medical Education. And then another author is David Acosta, not that involved with CNN, but an actual physician, Breaking the Silence, Time to Talk About Race and Racism. So there's a lot of good new resources, more timely resources, really everything has been since 2016 regarding CRT in medicine. But that being so new, it's gonna be a little harder to find some good guidance literature to help with applying that. So just be advised that if you're going to apply this particular one, you may need some outside help to do it correctly. And then finally, I found an awesome article that I'm gonna include in your list of resources. This young lady, I assume, well, I shouldn't assume, is Dr. Shen, who created a huge literature review on cultural competence models and cultural competence assessment instruments and nursing. And this individual, this researcher did a lot of the work for us. So please review this article if none of the ones, especially if none of the ones that I have already presented seem to quite fit you. What she found was, and this is an extensive of just nursing at the top, and then below that, she also evaluated counseling psychology and social work, as well as medicine. So she found that basically all of them have the same dimensions somewhat incorporated within them. They have an effective dimension that looks at cultural sensitivity, or in the case of Kapinha-Bakote, cultural desire. They all have cognitive dimensions of awareness, knowledge, and understanding. So you have basically KSAs or KSUs, however you want to call that, as well as skills with skill, practical, or behavioral dimensions. Specifically, it was skills that she separated between skills, things that you can demonstrate that are not an interaction encounter, and then the ones at the top also involve being able to incorporate interactions or encounters with those particular models. So she also went on to demonstrate, in the same article, had it even bigger than what I've provided here, but I only pulled out the ones, the assessment tools of those that are reliable and value to measure cultural competency or cultural care, and a lot of them involve learners. So again, at the end of the day, as any educational writer of curriculum, you want to know that what you're doing is creating a change in your student learners. So my recommendation would be to include a reliable, valid tool to see if your programming has made any measurable changes in the domains that you'd like to see changed in. So for example, Kapina Bakote has inventory assessing cultural competence and health care providers. The ones that have undergone reliability and validity testing are the IAPCC revised, the IAPCC student version. The IABW, BW meaning biblical worldview, has not undergone reliability and validity testing yet. And then in terms of the others, the SHIM model, that 3D model, they have a 25 item that's been tested for reliability and validity called the cultural competence assessment. Being 25 items, that's very appealing as well. It does assess cultural awareness, sensitivity, and cultural behaviors. Jeffrey's has two. One is on transcultural self-efficacy, so based on Bandura's model, as well as her own cultural competence and confidence model, or the CCC. I didn't present that within here, but you can look that up on your own. It has three subscales, cognitive, practical, and effective. And then finally, the cultural competence clinical evaluation tool. But both of Jeffrey's tools are mirror images, except that one relates more to cultural competence than a clinical evaluation. The other is more a self-inventory. So again, there are ways that you can have a student assess themselves, and that would help you not necessarily have to collect all the data and evaluate yourself. So now, you've gone through potential theories. I talked about how you can approach, practically speaking, how you can operationalize some working group teams. I've given you a good overview of some potential, but there's so many more other models out there, so that SHEN articles would be very good to look at. So now the time has come to say, okay, so I'm going to pick one. I'm going to pick one. How do I make it go into an educational offering? So this is where actually the model helps you to identify what would be good. And that's why I'm making a recommendation to potentially choose a model to make your life a little easier, because it helps you narrow down what you want to see changes in, and helps you identify how to stage them throughout the curriculum. So you identified your model. Make sure you, along the way, define the terms based on the model of cultural competence, if you want to go there, or cultural humility, cultural sensitivity, and any KSAs or knowledge, skills, or attitudes as learning outcomes you want to achieve. Try to think of that theory, what are your main outcomes, and align them with your future likely accreditation standards, aka the 2021 AAC and essentials, which they're there, and they'd be easy to map to. Then design the approaches based on the outcomes you're trying to achieve, if they're effective or knowledge, and then as well as faculty expertise. And then also align them with how are you going to assess them. So let's just look at an example. So here's an example of application. So say, for example, I chose Kampenaga-Bokote culturally competent model of care, right? And I already have her definitions. The definitions are based on her theory. I'll include cultural awareness, knowledge, skills, and encounters, and desire. So theoretically defined, she defines cultural awareness as the self-examination and in-depth exploration of one's own cultural and professional background. And it's different from the recognition of one's biases, but that's part of it. It involves the recognitions of one biases, prejudices, and assumptions about individuals who are different. There is within the definition an approach. So, and the other piece is cultural encounter, is to directly engage in cross-cultural interactions from people from culturally diverse backgrounds. So we came up with a couple of learning outcomes within our cultural conversations and cultural humility thread. It is a thread, and it's definitely not, it's still under construction. So I wish I could give you the whole program, but I can't. But I'll give you pieces as we, as we build. So under cultural awareness, we've categorized this learning outcome. The learner will complete a self-examination of their personal culture and professional background in a narrative. And then under cultural encounter, the learner will compare their culture with two individuals from a different background. So those are our two learning objectives, and it's based on the Kapina-Bakote definitions. Again, we're trying to make things easier for ourselves. So now the pedagogical approach, right? So here we go, the learner will complete a self-examination. So we had our learners complete an implicit bias test. It was for their own, nobody had to show anybody their own implicit bias test, but they did have to do a little bit of a self-examination following it. And then completion of a self-cultural narrative essay following prompts. The prompt was, what has or have been your experiences, if any, regarding poverty, race, sexual orientation, bias, et cetera. Describe some of your seminal experiences. And we, we actually define seminal experience as something you experienced as witnesses, a child or an adult that fundamentally changed your worldview in relation to how you personally view these things now. The second was on cultural encounters. The learner will compare their culture with two individuals and the participation and conversations of cultural humility series. And we define participation as completion at 60% of the post-discussion prompts and communities were selected based on our local populations of interest. This is where you can really tailor the kind of approaches you're doing to the types of populations that are present in your local community, which is very impactful. It's in our estimation, very impactful for the student. So under cultural awareness and those personal narratives, we had such beautiful self-reflective accounts. We had people identifying the Asian experiences related to COVID-19 and the so-called China virus. They were powerful accounts. This was a self-examination of how they felt they fit in society and most recent events. We also had people growing up as biracial asked to choose which culture that they want to ascribe to. We also had several mentioning being a white male and how they feel like they're assumed to be rich, privileged, and racist. Being black and always advocating, but being afraid of being labeled an angry black woman or angry black man. Being black and assumed to be the quota learner in the classroom. These were based on those prompts, themes that we saw being identified by the learners, which would indicate an increase in cultural awareness of how they felt that they were being perceived within the world and how they also they had other pieces in there that were also beautiful, how they overcame those feelings of concern. Now in terms of project implicit, they had to click on an implicit bias test and then they had to choose, I believe we had them choose, but they can also do all of the above. We would try, we were trying to pick those particular implicit biases based on the speakers that were going to be coming to us within the next couple of months so that they could say an aha. And as they're taking them, they were supposed to keep a journal to chronicle their thoughts, reactions, and feelings or wow moments. Sort of again, that self-reflection, that self-examination of how they perceive how that came across to them. So in terms of learning responsive, aside from the cultural awareness responses I've already provided you, 100% of our first year master's learners and of course, we're going into our first year DNP on site. So it'll be 100% of them as well going forward, completed and had full participation in the culture building lecture series. In terms of cultural desire, 100% of those that completed those, again, 60% completion rate on their post-encounters indicated they had other types of backgrounds that they were really curious about. So really showing some cultural sensitivity and desire to continue. But again, cultural encounters and awareness and desire are all based on Kapina Lakote's theory. So here's just some examples of prompts that we had them complete. You have participated, thoughtfully answered the following questions with descriptive, honest, transparent answers. Did you take note of any emotional reactions from the speaker in this story shared? What was your emotional action? Why do you think you had that reaction? Again, approaching self with a period of self-inquiry. Why did I feel that way? Why did I react that way? Another one, society goes through periods of turbulence and periods of safety and consistency. What type of period are we in now? Now, I would like to say that this was written before COVID-19 because it was. This was right before the pandemic began, but it was during a period of social unrest at the time. So how do you feel about this? What are the implications? Is it hindering in your journey to become more humble? I mean, how more contemporaneous can we be? Now, in terms of end of semester, so we had an end semester summative kind of moment in time to say where you are now. And as I mentioned about cultural desires, the cultural prompts were, for example, in terms of her desire, she defines cultural desire as the motivation of healthcare provider to want to, rather than have to, engage in the process of becoming more culturally aware, culturally knowledgeable, culturally skillful, and familiar. As I mentioned, we had 100% say they were curious about other cultures after this. So now, say we decided instead of competing up with Bacote to utilize strictly Turvelon and Murray-Garcia. As I mentioned, they have additional constructs that they want us to use. So with those approaches, we could have a maintenance of a self-reflective journal that they continue after this lecture series into the clinical setting, where they themselves document on an iterative process with themselves how they respond to patients in the clinical setting. Also, recognizing and challenging power imbalances, I already discussed how they defined it. We could create simulation-based experience or a set of trigger films that demonstrate discrimination within a hospital setting, and have the learner role-play options for intervention. Have all students complete the active bystander training, which we actually did this year. Learners must keep a log of utilization, or learners must present cases quarterly. That's something we still haven't implemented yet, but these are all ideas based on this model. Incorporate role model for cultural humility and daily clinical evaluation tool, so we can work on a potential clinical learning outcome, where they have to role model cultural humility. In terms of institutional accountability, which is another construct from Tervalon and Marie-Garcia, have learners review the institutional mission and vision in regards to diversity, equity, and inclusion. Have them participate in a root cause analysis of a patient-related event that resulted in error, harm, with roots in access, equity, or disparities of care. These are things that would definitely have a corresponding AAC and DEI essential with them. And then have learners review or write policy changes to address a known disparity of the institution. Again, all things to make them much more activist, which is much so in line with the Tervalon-Marie-Garcia model, in terms of their pillar on institutional accountability. So here's just two more articles I want to make mention of that I think would be great for you to consider, including Coulier Cultural Competence and Undergraduate Nursing Curriculum. There were tons of ideas on how to approach it from a pedagogical perspective, as well as the second article on educational interventions. They looked at actual research studies and employed educational interventions and what their outcomes were. And finally, this was actually from Marie-Garcia, another article, that article about in terms of what they see happen when people start to talk about race and ethnicity in these environments. People start with that pre-encounter and naivety. I have seen this in our own cultural humility series. When you present them with some sort of conflict, they can have a cognitive dissonance. This is a known response. It's very ego-protective and it's part of white racial identity development. So the question then is, is to retreat into white culture more viable than dealing with a conflict? If they choose yes, they may actually espouse four time periods of anti-minority and pro-white idealism. However, over time, if provided additional encounters, the attitudes can become more flexible, then they can redefine their role in the world. And we have seen this happen within our program. We've seen people go back and forth between the, you know, in terms of pro-minority, anti-pro-white, anti-minority until they finally have a redefinition. And then they're able to more closely mimic transcultural care. Now, some students are already coming in very pro-minority with a liberal viewpoint. However, even then, if they experience a conflict within the discussions, they can go into the pro-white, anti-minority mindset, or they can go straight to redefinition. So this is just something that they have found specific to the white student, less so to the black student or the minority student or the underrepresented. So this is just something that you have to be prepared for to see. As I mentioned before, you are going to see some growth and change. It does not mean that you're doing something wrong. And this came from Gian Marie Garcia's article, Self-Reflection and Multicultural Training. Be careful what you ask for. That doesn't mean, and as she mentioned, it doesn't mean that you're doing things wrong. If you're questioning who you are during any kind of facilitated race discussions and multicultural training, you're challenging all your previous preconceptions, things that you've learned since childhood. And you're going to have occasional moments of, oh my gosh, I can't believe I thought that originally. You got to give yourself room to grow and not judge yourself. And that goes for the students as well. So if you approach this with the understanding that this is likely to occur specifically to the white students more so, then just calling it out normalizes that this is a common thing that happens, and you don't need to dwell on it. That you need to just simply learn about being more multicultural and press on. And you're probably going to have this exact same experience when encountering a brand new culture that you've had no experience with, no encounters with, no cultural awareness of, and no cultural knowledge of, that you're bound to potentially have some assumptions once again and have cognitive dissonance once again. So that's just all I have in terms of this discussion. It's very exciting to know that you are embarking on potentially incorporating a lot of this information into your curriculum in terms of where do we go from here. It's also very exciting because it gives you an opportunity to write curriculum that, you know, I know we've been writing curriculum for the new DNP Essentials, but now this curriculum is a little more of the heart. And so it's not a set of boxes that you have to necessarily check off, but it definitely is a change in mindset and a growth that once you start incorporating these kinds of lessons within, I think you'll really appreciate the maturity that you'll see grow within our learners, at least I have thus far. Now in terms of references, I will have all of these along with their links if I can find the links, because some of them I have institutional ability to get to, but I can't copy the link. But they may be available through your institutional search processes as well. And so all of these will also be within a companion document, as well as those two main articles that I said had just an excellent and just bevy of information. And anything that we come up with here at my program will continue to provide you additional mechanisms for how to incorporate in your curriculum too. So I thank you for listening today and I appreciate your time and attention. Thank you.

exam development

blueprint for exam

cognitive level of questions

formative assessment

feedback to students

exam security

Dr. Courtney Brown

Wake Forest School of Nurse Anesthesia

cultural competency training

nursing field

theoretical models

frameworks

cultural awareness

educational programs

cultural humility