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Health care disparities and the influence of nurse leader cultural competency: an evaluation study

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Health care disparities and the influence of nurse leader cultural competency: an evaluation study

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Content Running head: HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

1

HEALTH CARE DISPARITIES AND THE INFLUENCE OF NURSE LEADER
CULTURAL COMPETENCY: AN EVALUATION STUDY

by

Susan Williamson Gergely

________________________________________________________________________

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

December 2017

Copyright 2017 Susan Williamson Gergely

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DEDICATION
This dissertation is dedicated to nurse leaders and the nurses they lead. Nurses work
tirelessly to care for their patients and are the heart and soul of patient care. I would also like to
dedicate this work to the many professionals who strive to make health care delivery in the
United States accessible, equitable, and inclusive to all individuals.

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ACKNOWLEDGEMENTS
I would like to acknowledge and thank my family, Kacey, Alex, and especially Tim for
the support, encouragement, and breathing space that allowed me to fully lean into this
experience. A special thanks to my mother, Shirley, who throughout this journey encouraged me
to take care of myself and not feel guilty about missed obligations. Thank you to her, as well as
my dad, who left us far too early, for instilling the value of education, lifelong learning, and
independence. To my sisters, Kathleen and Annette, thank you for modeling the way. Also,
thank you to all of my extended family members and friends who willed me to the finish line.
To my dissertation committee, Dr. Kimberly Hirabayashi, Dr. Monique Datta, and Dr.
Karen Embrey, thank you for guiding me through the process. Dr. Hirabayashi, you helped me
see the forest through the trees. Dr. Datta, I will always be grateful that you were my first USC
professor and helped “frame” my entire doctoral experience. Dr. Embrey, thank you for
providing your nursing leadership perspective to my study and for your contributions to nursing
and health care.
To my colleagues at the AHA and AONE, a heartfelt thank you. I am so appreciative to
the powerhouse of nurse leaders, including Pam Thompson, Michelle Janney, and Linda Burnes
Bolton, who early on convinced me I could contribute to the critical work of diversity and
inclusion in health care. To Maureen Swick, thank you for supporting me to the finish line.
Thank you as well to the AONE members who participated in my research and shared your
valuable insights. To my colleagues, Beverly Hancock and M.T. Meadows, your encouragement,
listening, and understanding literally kept me going.
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Finally, to my inaugural class of 2017 classmates, I am honored to have taken this
journey with you. You are a remarkable bunch, from whom I have learned so much about
endurance, life, and compassion. I hope we all remain lifelong friends.

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TABLE OF CONTENTS
Dedication 2
Acknowledgements 3
List of Tables 7
List of Figures 8
Abstract 10
Chapter 1: Introduction 11
Introduction of the Problem of Practice 11
Role of Cultural Competence 12
Organizational Context and Mission 13
Organizational Goal 14
Importance of Addressing the Problem 15
Description of Stakeholder Groups 16
Stakeholder Group for the Study 19
Purpose of the Study and Questions 19
Methodological Framework 20
Organization of the Dissertation 20
Chapter 2: Review of the Literature 22
Overview of the Literature 22
Health Care Disparities 22
The Role of Cultural Competence 28
Stakeholder Knowledge, Motivation, and Organizational Influences 33
Summary of Chapter 53
Chapter 3: Methodology 54
Purpose of the Study and Research Questions 54
Conceptual Framework 54
Participating Stakeholders 57
Data Collection and Instrumentation 59
Data Analysis 62
Credibility and Trustworthiness 64
Validity and Reliability 64
Ethics 65
Chapter 4: Results and Findings 67
Study Participants 67
Findings for Research Question 1 71
Summary of Findings 110
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Chapter 5: Recommendations 112
Recommendations for Practice to Address KMO Influences 112
Integrated Implementation and Evaluation Plan 129
Strengths and Weaknesses of the Approach 149
Limitations 150
Future Research 150
Conclusion 151
References 154
Appendices 164
Appendix A: Recruitment Letter 164
Appendix B: Informed Consent/Information Sheet 165
Appendix C: Survey Items 167
Appendix D: Interview Protocol 170

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LIST OF TABLES
Table 1. Organizational Mission and Goals 18
Table 2. Stakeholder Knowledge Influences 40
Table 3. Stakeholder Motivation Influences 46
Table 4. Stakeholder Organizational Influences 52
Table 5. Respondent Level of Responsibility 68
Table 6. Respondent Level of Years in a Nursing Leadership Role 69
Table 7. Respondents’ Hospital Licensed Bed Count 70
Table 8. Summary of Knowledge Influences and Recommendations 114
Table 9. Summary of Motivation Influences and Recommendations 122
Table 10. Summary of Organization Influences and Recommendations 126
Table 11. Outcomes, Metrics, and Methods for External and Internal Outcomes 132
Table 12. Critical Behaviors, Metrics, Methods, and Timing for New Reviewers 134
Table 13. Required Drivers to Support Nurse Leaders’ Ability to Identify and Apply 136
Evidence-based Practices in Providing Culturally Competent Care
Table 14. Components of Learning for the Program 141
Table 15. Components to Measure Reactions to the Program 142
Table 16. Sample: Evaluation Tool Immediately After Training 145
Table 17. Sample Monthly Dashboard: May 147

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LIST OF FIGURES
Figure 1. Study conceptual framework: Modified Clark and Estes gap analysis 56
Figure 2. Racial and ethnic minority patients in the United States receive lower 72
quality of care, which results in reduced health outcomes
Figure 3. The cultural context of each patient’s treatment is influenced by the 80
individual, family, and community
Figure 4. Health care disparities that stem from language barriers can be reduced 84
through improved procedural knowledge of the nurses on how to effectively
communicate with patients for which English is not their primary language
Figure 5. It is important that nurses dedicate time to reflect on their own knowledge 88
and level of cultural competence in providing care to patients of all races
and ethnic minorities
Figure 6. Prejudice and bias, including both conscious and unconscious bias, impact 89
the quality of care that patients receive
Figure 7. It is important for me to lead my nursing staff in providing culturally 93
competent care
Figure 8. I am confident in my ability to lead my nursing staff in providing culturally 95
competent care
Figure 9. My organization’s strategic plan includes guidelines for incorporating 97
cultural and linguistic competence into nursing operations
Figure 10. I receive clearly defined goals and objectives from my organization’s senior 100
leadership and governance body to improve the level of cultural competence
of my nursing staff
Figure 11. My organization’s chief executive officer and governance body holds 100
leaders accountable for improving the level of cultural competence of
their staff
Figure 12. My organization values and places importance on improving the level of 104
cultural competence in delivering care through the allocation of resources
and education to the nursing staff
Figure 13. Quality improvement projects that are aimed at improving the quality of care 104
provided to diverse patient populations are in place at my organization

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Figure 14. Cultural competency training is required at my organization for new staff 105
orientation
Figure 15. Cultural content areas are included as a required component of annual 106
nursing education at my organization
Figure 16. My staff has adequate access to language assistance services, to aid in such 109
functions as interpreting for patients for which English is not their first
language

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ABSTRACT
Health care disparities for racial and ethnic minority patients are a serious issue in the United
States. Although socio-economic status affects access to care, even when socio-economic status
is constant, disparities of care prevail. Many factors contribute to these disparities, including
patient-related, system-related, and provider-related factors. A key strategy identified to address
provider-related factors is to address the cultural competence of caregivers. This evaluation study
explored the knowledge, motivation, and organizational influences that affect nurse leaders being
able to lead their teams in providing culturally competent care to patients of all ethnic and racial
backgrounds. Using a modified gap analysis as the conceptual framework, this mixed method
study included a review of the literature, as well as a survey and interviews with the primary
stakeholder group of the study, nurse leaders. The study showed that nurse leaders believe in the
critical importance of leading their teams in providing culturally competent care, have strong
self-efficacy in their abilities to do so, and are strong mentors to their teams. Despite these
positive attributes, key study findings also revealed that nurse leaders need a deeper
understanding of the presence of health care disparities for racial and ethnic minority patients,
more formalized and frequent training to increase their cultural competence knowledge and
skills, and increased opportunities to self-reflect on their own abilities and potential for bias.
Further, organizations need to demonstrate support by ensuring that improving caregiver cultural
competence is a strategic priority, providing resources to support, and by holding leaders
accountable to improve the level of cultural competence of their teams. The study provided
recommended solutions to close the knowledge, motivation, and organizational influences and an
integrated implementation and evaluation plan to assess program outcomes.
Keywords: nurse leader, cultural competence, health care disparities
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CHAPTER 1
INTRODUCTION
Introduction of the Problem of Practice
The problem addressed in this study is the variance in the quality of health care provided
to racial and ethnic minorities, in comparison to the quality of health care provided to non-
minorities. This variance is a problem because race, ethnicity, and language preference often
affect the level of care a patient receives regardless of socioeconomic status (Smedley, Stith, &
Nelson, 2003; Ross et al., 2010; Rowland, Jones, Hines-Martin, & Lewis, 2013). This problem is
important to address because health care disparities result in lower quality of patient care,
suboptimal health outcomes, and overall increased health care costs (LaVeist, Gaskin, &
Richard, 2009).
In April 2013, the U.S. Department of Health and Human Services (HHS) released the
National Standards for Culturally Linguistically Appropriate Service (CLAS) in Health and
Health Care (U.S. Department of Health and Human Services [HHS], 2013). Developed by the
HHS Office of Minority Health, the purpose of the standards is to provide resources to health
care organizations to aid in reducing disparities of care. Updated from a report published in
2001, the new standards provide an expanded list of cultural factors that currently contribute to
health care disparities, including race, ethnicity, language, spirituality, disability status, sexual
orientation, gender identity, and geography (HHS, 2013). Although there are many influences
that contribute to disparities in health care, this study specifically focuses on the role of cultural
competence and the influence of race, ethnicity, and language.
The quality of care received by racial and ethnic minorities in the United States is lower
than the quality of care received by non-minorities, resulting in health care disparities. Compared
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to the quality of care received by Whites, Blacks and Hispanics receive lower quality of care in
approximately 40% of quality measures, American Indians and Alaska Natives receive lower
quality of care in approximately 33% of quality measures, and Asians receive lower quality in
approximately 30% of quality measures (Agency for Healthcare Research and Quality [AHRQ],
2013). Although a limited number of quality metrics showed marginal improvements from the
prior year, the 2013 AHRQ report noted no significant improvements for racial and ethnic
minority health outcomes. To demonstrate these disparities further, the prevalence of chronic
diseases in minority populations is higher, compared to the prevalence of chronic diseases in
non-minority populations. Further, Black women are more likely to have heart failure, coronary
heart disease, hypertension, and stroke, compared to White women (Mead et al., 2008). Blacks
also have a higher occurrence of chronic health conditions, even at higher income levels (Doty &
Holmgren, 2006). The mortality rate of population groups is another measure utilized to assess
quality of care. Mortality rates are approximately 1.6 times higher for Blacks compared to
Whites (Smedley et al., 2003). This differentiating ratio between White and Black mortality rates
has not improved since 1950 (Smedley et al., 2003). Blacks, American Indians, and Alaska
Native babies also have significantly higher mortality rates, in comparison to the non-minority
population (Mead et al., 2008).
Role of Cultural Competence
Although U.S. laws and regulations prohibit discrimination based on race and ethnicity,
health care disparities still exist for minority patients. One contributing factor to health care
disparities is a lack of cultural competence in delivering care to patients from diverse
backgrounds. Cultural competence in the delivery of health care is “valuing diversity, conducting
self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and
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institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in
communities” (HHS, 2013, p. 139). From a broader perspective and lens of the provider, cultural
competence is the “ability of health care systems and providers to deliver care to patients with
varied and diverse values, beliefs, and behaviors, while meeting the patients’ social, cultural, and
linguistic needs” (Health Research & Educational Trust [HRET], 2011). Contributing factors to
health care disparities, stemming from a lack of cultural competence, include bias (or prejudice),
stereotyping, and clinical uncertainty in interacting with racial and ethnic minority patients
(Engebretson, Mahoney, & Carlson, 2008; Rowland et al., 2013).
Organizational Context and Mission
The American Organization of Nurse Executives (AONE) is the national professional
organization for nurse leaders. Since 1967, AONE has provided leadership, professional
development, advocacy, and research to advance nursing practice and patient care, promote
nursing leadership excellence, and shape national health care policy. The mission of AONE is to
shape health care through innovative and expert nursing leadership. Through this mission,
AONE supports nurse leaders in their efforts to help individuals and communities reach optimal
health. With approximately 10,000 members, AONE is the voice of nursing leadership in health
care. The AONE vision of “global nursing leadership—one voice advancing health,” inspires the
organizational stakeholders to improve the delivery of health care throughout the world
(American Organization of Nurse Executives [AONE], 2015).
AONE members serve in nursing leadership roles in hospitals and other health care
settings. Nearly one-third (33%) of members serve in director positions, 21% serve in executive-
level roles, and 17% serve in manager roles. The remaining members serve in academia, vendor-
support, other leadership positions, or emerging leadership roles. The largest percentage (60%)
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of AONE members are employed in acute care hospitals, followed by health care systems (16%),
and academia (8%). AONE members have extensive nursing experience, with 83% of members
having more than 20 years of nursing experience; only 3% have 10 years or less experience
(AONE, 2014).
As a subsidiary of the American Hospital Association (AHA), the mission, vision, and
key strategic priorities of AONE directly support the AHA vision of a society of healthy
communities, where all individuals reach their highest potential for health. The AHA formed in
1899, originally as a small gathering of eight hospital superintendents. Today, the organization
represents and supports nearly all of the nation’s approximately 5,000 hospitals through
advocacy and legislative support, thought leadership, knowledge transfer, and professional
development opportunities. The AHA/AONE offices are located in Washington, D.C. and
Chicago, IL and the organization employs approximately 450 team members (American Hospital
Association [AHA], 2015).
Organizational Goal
The defined organizational goal for this study is that by May 2020, all nurses led by
AONE-member nurse leaders will provide culturally competent care to patients of all ethnic and
racial backgrounds. This goal evolved from the National Call to Action to Eliminate Health Care
Disparities initiative, launched in 2011. The initiative focuses on increasing the level of cultural
competency of clinicians and the collection of patient race, ethnic, and language preference data,
as well as the implementation of strategies to increase diversity in hospital-based governance and
leadership (AHA, 2015). This study focuses on the goal targeted to increase clinician,
specifically nursing, cultural competence in delivering care.
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Importance of Addressing the Problem
The problem of health care disparities is important to address to improve individual
quality of care and life, minimize economic impact, and reduce health care costs in the United
States. According to the U.S. Census Bureau (2010), racial and ethnic minorities will account for
a majority of the U.S. population by 2043. As a result, the importance of reducing health care
disparities will continue to increase. In addition to contributing to a lower individual quality of
life, health care disparities cause an economic burden to the U.S. economy, resulting in lower
productivity, lost wages, and increased health care expenditures (LaVeist et al., 2009; Smedley et
al., 2003). In a study commissioned by the Joint Center for Political and Economic Studies,
LaVeist et al. (2009) estimated that over a three-year-period (2003 to 2006) unnecessary direct
medical costs related to health care disparities exceeded $230 million. During this same period,
indirect costs associated with disparities exceeded $1.0 trillion. Indirect costs associated with
health care disparities include premature death, lost worker productivity, lost or lower wages,
and increased absenteeism from the workplace due to personal illness or caring for an ill family
member (LaVeist et al., 2009). The problem of health care disparities for racial and ethnic
minorities is also critical to address from a moral perspective, which supports the belief of equal
opportunities for all people, including the opportunity for good health (Ornelas, 2008).
In addition to the broader economic and societal factors, reducing health care disparities
for racial and ethnic minority patients is also critical to U.S. hospitals and health care systems.
Reducing disparities results in improved quality outcomes, lower costs, and improved
reimbursement, which all affect the success and viability of health care organizations (Wilson-
Stronks & Mutha, 2010). As hospital reimbursement has shifted from a fee-for-service model to
value-based care and population health models, since the initial implementation of the
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Affordable Care Act, it is imperative that quality and outcome measures improve to support the
financial viability of hospitals (AHA, 2014). Reducing health care disparities also results in a
higher level of patient satisfaction and a stronger connection between hospitals and their local
communities, which are key performance metrics for hospitals (AHA, 2014). Despite the
financial and performance impact of providing equitable care, there are also other mission-driven
factors for reducing health care disparities. In a survey of hospital chief executive officers
(CEOs), conducted by Wilson-Stronks and Mutha (2010), leaders identified achieving the
organization’s mission as the number one reason to improve equity of care, outranking financial
savings and benefits. To achieve the AHA mission of advancing the health of individuals and
communities, AHA and AONE must support U.S. hospitals in reducing and eventually
eliminating health care disparities (AHA, 2015).
Description of Stakeholder Groups
There are four primary stakeholder groups, who directly contribute to achieving the
organizational goal of this study, including AONE-member nurse leaders, hospital and health
care system CEOs, AONE staff, and AONE governance. Nurses constitute the largest percentage
of hospital staff and serve as the primary provider of patient care in the United States (U.S.
Bureau of Labor Statistics [BLS], 2015). The role of the nurse leader is critical to meet the
organizational goal that all nurses led by AONE-member nurse leaders will provide culturally
competent care to patients of all ethnic and racial backgrounds. To achieve the organization goal,
nurse leaders, who provide leadership oversight to the nursing staff, need to be able to identify
and apply evidence-based practices in providing culturally competent care to patients of all
ethnic and racial backgrounds.
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To achieve the organizational goal, hospital and health care organization CEOs have to
incorporate the goal into the key priorities of the organization, from both a strategic and financial
perspective. Further, hospital and health care organization CEOs have to obtain an understanding
and commitment to the critical role that providing culturally competent care plays in closing the
gap in disparities of care for racial and ethnic minorities. The agreement of hospital and health
care system CEOs to sign the national Pledge to Act to Eliminate Health Care Disparities, in
support of their commitment to make the goal an organizational priority, demonstrates their
understanding and commitment to reducing disparities.
To assist nurses in their ability to provide culturally competent care, another identified
stakeholder is the AONE staff. Supported by the AONE governance body, AONE team members
have to identify gaps in the existing knowledge and motivation of nurse leaders regarding
overseeing the delivery of culturally competent care. AONE team members also have to identify
organizational factors that are impeding nursing from achieving cultural competence and share
evidence-based practices with the AONE membership. Further, AONE staff have to obtain the
proficiencies needed to utilize effective education modalities to develop and deliver appropriate
educational resources.
To provide the financial and strategic support required for the AONE staff to identify
gaps, share evidence-based practices, and develop cultural competency resources for nurse
leaders, AONE governance also needs to provide support. To support the organizational goal,
members of the AONE board of directors have to embrace and understand the critical role that
nurses play in the delivery of culturally competent care. Board members also need to have the
knowledge and proficiencies required to utilize health care disparity data to justify the allocation
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of AONE resources. Table 1 provides an overview of the study’s organizational performance
goal, as well as the key stakeholder goals.

Table 1
Organizational Mission and Goals
Organizational Mission
The mission of AONE is to shape health care through innovative and expert nursing leadership
(AONE, 2015).
Organizational Performance Goal
By May 2020, all nurses led by AONE-member nurse leaders will provide culturally
competent care to patients of all ethnic and racial backgrounds.
AONE-member
Nurse Leaders
Hospital and Health
Care Organization
Chief Executive
Officers AONE Staff AONE Governance
By October 2018, all
AONE-member
nurse leaders will be
able to identify and
apply evidence-
based practices in
providing culturally
competent care to
patients of all ethnic
and racial
backgrounds.
By July 2017, all
hospital and health care
organization CEOs will
sign the national Pledge
to Act to Eliminate
Health Care Disparities
in support of their
commitment to make
the goal of reducing
health care disparities
an organizational
priority.
By October 2017,
AONE staff will
create an educational
program aimed at
increasing the level
of cultural
competence of nurses
based on identified
knowledge,
motivation, and
organizational gaps.
By August 2017, the
AONE board of
directors will
approve the
allocation of funds
and other resources
to identify gaps,
share evidence-based
practices, and
develop resources
aimed at increasing
the cultural
competency of
nursing.

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Stakeholder Group for the Study
While the joint efforts of all stakeholders will contribute to the achievement of the
organizational goal that all nurses led by AONE-member nurse leaders will provide culturally
competent care to patients of all ethnic and racial backgrounds, the primary stakeholder group
for the purpose of this study is AONE-member nurse leaders. Aligned with the organizational
goal, the stakeholder goal supports that by October 2018, all AONE-member nurse leaders will
be able to identify and apply evidence-based practices in providing culturally competent care to
patients of all ethnic and racial backgrounds. Achieving this goal will expand the ability of nurse
leaders to lead their teams in treating patients with varied cultural and linguistic needs, and will
contribute to the reduction of disparities of care for racial and ethnic minorities.
Purpose of the Study and Questions
The purpose of this study is to evaluate the degree to which AONE is meeting its
organizational goal that by May 2020, all nurses led by AONE-member nurse leaders will
provide culturally competent care to patients of all ethnic and racial backgrounds. Although a
complete performance evaluation would focus on all stakeholders, for practical purposes the
stakeholder group focused on in this study is AONE-member nurse leaders. The stakeholder goal
is that by October 2018, all AONE-member nurse leaders will be able to identify and apply
evidence-based practices in providing culturally competent care to patients of all ethnic and
racial backgrounds. The analysis focuses on the knowledge, motivation, and organizational
barriers related to achieving the stakeholder goal.
The following research questions guide this study:
1. What are the knowledge, motivation, and organizational elements related to achieving
the stakeholder goal that by October 2018, all AONE-member nurse leaders will be
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able to identify and apply evidence-based practices in providing culturally competent
care to patients of all ethnic and racial backgrounds?
2. What are the recommendations for organizational practice in the areas of stakeholder
knowledge, stakeholder motivation, and organizational influences?
Methodological Framework
To close performance gaps and achieve organizational and stakeholder goals, it is
necessary to accurately identify causes of the gaps and apply the appropriate solution (Clark &
Estes, 2008). The Clark and Estes’ (2008) gap analysis model is a systematic, analytical method
utilized to assist in the clarification of goals and the identification of gaps between actual
performance levels and preferred performance levels within organizations. The framework
includes an analysis of three key areas critical to achieving organizational goals, including
knowledge, motivation, and organizational influences (Clark & Estes, 2008). To reach targeted
goals, all three of these components must be present and aligned.
A modified version of the Clark and Estes’ (2008) gap analysis model is used as the
framework for this study. Although the Clark and Estes’ (2008) gap analysis model helps to
identify causes of performance gaps, for the purpose of this study a modified version of the
model is used to evaluate and identify the presence of gaps, versus the causes of gaps, in the key
areas of knowledge, motivation, and organizational influences. A mixed methodology is used for
this study, utilizing both quantitative (survey) and qualitative (interviews) approaches. Research-
based solutions and a plan to evaluate the recommendations are provided.
Organization of the Dissertation
This dissertation is organized into five chapters. This chapter provided an overview of the
study problem of practice, research questions, and methodological framework. Also included in
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Chapter 1 was a framing of the organizational context, mission, and goals, as well as the key
stakeholder goal. Chapter 2 includes a review of relevant literature related to the problem of
practice, including a review of the knowledge, motivation, and organizational factors that affect
achieving the stakeholder goal. Chapter 3 provides an overview of the conceptual and
methodological framework of the study, including strategies to address sampling, data analysis,
validity, and reliability. In Chapter 4, findings from the data collection are provided and
analyzed, including the identification of key study themes. The study concludes with research-
based solutions and an integrated implementation and evaluation plan in Chapter 5.

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CHAPTER 2
REVIEW OF THE LITERATURE
Overview of the Literature
This chapter includes a review of the literature related to the relationship between health
care disparities for racial and ethnic minorities and cultural competence in delivering care. The
first section focuses on the prevalence of health care disparities and the factors that contribute to
their occurrence. The second section reviews the role that cultural competence plays in health
care disparities, various cultural competency models applied in health care, and models used to
evaluate cultural competence. The chapter ends with a review of the knowledge, motivation, and
organizational factors that affect the delivery of culturally competent care to patients of all racial
and ethnic backgrounds.
Health Care Disparities
Despite the advancement of treatment options and improved health outcomes, health care
disparities are still present among varying population groups. Health disparities is a term used to
describe a higher occurrence of illness, injury, disability, or mortality for one population group,
in comparison to other population groups (Kaiser Family Foundation [KFF], 2012). In contrast,
health care disparities represent differences in health outcomes among various population
groups, due to factors such as access to care, health insurance coverage, and variances in care
delivery (KFF, 2012). Historically, health care disparities were reflective of inequities present in
the broader society, due to the prevalence of segregation and discrimination (Weisfeld &
Perlman, 2005). These disparities in care, stemming from segregation and discrimination,
resulted in disparities in health outcomes (Smedley et al., 2003; Weisfeld & Perlman, 2005).
Although the presences of health care disparities have been associated with many demographic
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variables, including age, geography, gender, disability status, and sexual orientation, this study
focused on the impact of race and ethnicity on health care outcomes.
A heightened focus on reducing health care disparities for racial and ethnic minorities
began with the passing of the Minority Health and Health Disparities Research and Education
Act of 2000. This act also formed the National Center for Minority Health and Health Disparities
and granted the AHRQ authority to monitor the presence of health care disparities (KFF, 2012).
In 2010, the Department of Health and Human Services (HHS) launched an action plan that
focused on reducing health care disparities for racial and ethnic minorities (HHS, 2010). The
plan identified key determinants to achieving equity in care aligned with social, economic, and
environmental disadvantages.
Role of Socioeconomic Factors
The race and ethnicity of individuals often contribute to their socio-economic status.
According to a study conducted by the Pew Research Center, White households have a median
wealth of approximately 20 times higher than black households and 18 times higher than
Hispanic households (Kochhar, Fry, & Taylor, 2011). These wealth gaps are the largest noted
over the last fifty years (Kochhar et al., 2011). Due to the prevalence of wealth gaps, minorities
are more likely to live in poverty. Blacks and Hispanics are more than twice as likely to live
below the federal poverty level as Whites and Asians (Mead et al., 2008).
The most prevalent determinant of health care disparities is attributed to socioeconomic
status and related factors. Primary attributes, related to socioeconomic status, include lower
educational attainment and income, poorer housing options, reduced nutrition, higher
environmental risks, and restricted access to health care treatment (Fiscella, Franks, Gold, &
Clancy, 2000; Geiger, 2006). Due to a larger representation in lower socioeconomic groups,
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Blacks have lower access to health care and more exposure to unhealthy behaviors (Weisfeld &
Perlman, 2005). Lower socioeconomic status results in individuals in this group receiving fewer
preventative health screenings, including mammograms, immunizations, eye exams, and prenatal
care (Fiscella et al., 2000). This lack of health care access results in reduced health outcomes.
Limited access to health insurance is another critical socioeconomic factor contributing to
health care disparities (Smedley et al., 2003). Individuals with health care insurance are more
likely to seek care, especially in the early stage of an illness (Weisfeld & Perlman, 2005). In a
study of survival rates for cancer patients, the three-year survival rate was 98% for insured
prostate cancer patients compared to 83% for uninsured prostate cancer patients; 91% for insured
breast cancer patients compared to 78% for uninsured breast cancer patients; 71% for insured
colorectal cancer patients compared to 53% for uninsured colorectal cancer patients; and 23% for
insured lung cancer patients compared to 13% for uninsured lung cancer patients (McDavid,
Tucker, Sloggett, & Coleman, 2003). Although the Affordable Care Act, passed in 2010, has
reduced the number of uninsured individuals in the United States by nearly 20 million,
approximately 13 million Americans remain without health care insurance coverage (AHA,
2015). These uninsured individuals are more likely to receive lower quality of care compared to
individuals with health insurance.
Non-Socioeconomic Factors that Contribute to Health Care Disparities
Although socioeconomic status is a key influence on the presence of health care
disparities, research supports that racial and ethnic minorities receive lower quality of care, even
when socio-economic factors are held constant (Geiger, 2006; Smedley et al., 2003). With the
exception of Asians, members of minority groups are more likely to report that their health status
is fair or poor, compared to Whites (Mead et al., 2008). The factors that contribute to these
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25
disparities typically group into three primary areas, including patient-related factors, system-
related factors, and provider-related factors.
Patient-related factors. Various patient-level factors contribute to health care disparities
for racial and ethnic minorities, including refusal of treatment, adherence to treatment
recommendations, low health care literacy, and other cultural factors (Smedley et al., 2003).
Although these patient-related factors play a role in the presence of health care disparities, it is
unclear in the literature as to what levels these patient-related factors contribute (Smedley et al.,
2003). One explanation for the variance between refusal of treatment between minority and non-
minority patients, is that non-minority patients over-utilize medical care, creating a gap in usage
between minority and non-minority patients (Hannan et al., 1999). This difference in treatment
usage is largest for non-life threatening discretionary procedures. These optional procedures are
often not viable for patients who are challenged by certain socio-economic factors, such as
reduced income and limited access to health insurance (Hannan et al., 1999).
Another key patient-related variable tied to health care disparities is a poor cultural match
between patients and providers that results in reduced health outcomes (Cooper-Patrick et al.,
1999). Studies have shown that minority patients are more likely to have better relationships with
their physicians if they are of the same race, which affects the level of patient involvement in
their treatments and health outcomes (Cooper-Patrick et al., 1999). Recent studies attribute this
gap to a communication deficit between the provider and patient. To narrow the gap, cultural
humility training for clinicians improves the ability to communicate with patients of all
ethnicities and cultures (Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012). Cultural
humility is a process that involves incorporating clinician humility into the need for self-
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26
reflection and self-examination, awareness of any power imbalances, and mutual respect
between the clinician and the patient (Tervalon & Murray-Garcia, 1998).
System-related factors. The structure and organization of hospitals and health care
systems, as well as the financing of services, also contribute to health care disparities. These
system-related factors include limited organizational resources dedicated to providing unique
care to patients from varying cultures. For example, in some organizations there are limited
resources allocated to interpretation and translation services, which create communication
barriers between the patient and provider (Diamond & Jacobs, 2009). Although Title VI of the
Civil Rights Act of 1964 requires that providers meet the language need of their patients, some
organizations find it challenging to achieve this goal due to the broad diversity of their patients
and communities. The presence of language barriers can result in medical errors, reduced patient
engagement, and medication errors (Delphin-Rittmon, Andres-Hyman, Flanagan, & Davidson,
2013; Diamond & Jacobs, 2009). Although risks decline with the use of professional interpreters,
clinicians sometimes under-utilize interpreters by relying on their own limited non-English
language knowledge and skills. Reducing language barriers has a positive influence on patients
and their understanding of their treatment and care, and as a result improves clinical outcomes
(Diamond & Jacobs, 2009; Zabar et al., 2006).
Other system-related factors that affect health care disparities include limited access to
care, due to geographic and payor constraints. Often provider availability is limited in
geographic areas with high minority populations. This reduces access to these vulnerable
population groups. In addition, ethnic and racial minority patients often have a higher percentage
of Medicaid and Medicare coverage, in comparison to private pay insurance, which can also
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27
limit access to available providers (Smedley et al., 2003). These additional system-related factors
create access barriers for minorities to receive care.
Provider-related factors. Stereotyping, bias, and clinical uncertainty in treating patients
of diverse backgrounds also contribute to health care disparities for racial and ethnic minorities.
These factors contribute to lower quality outcomes for racial and ethnic minorities, in part, due to
the formed behaviors of physicians, nurses, and other treatment providers, which impact
decision-making and results in variations of medical treatment (Chapman, Kaatz, & Carnes,
2013).
Stereotyping is the social process in which people use categories, such as race, ethnicity,
gender, and religion, to obtain, process, and recall information about individuals (Smedley et al.,
2003). Stereotyping can also affect the decision-making process of health care providers. To
improve efficiency, physicians are trained to assess risk factors for population groups and
associate certain diseases with these groups for diagnostic purposes (Chapman et al., 2013). This
segmentation of various demographic groups can result in the use of unconscious cognitive
shortcuts in the decision-making process, which results in stereotyping (Smedley et al., 2003).
While stereotyping is used as a social process to sort people into categories, bias is rooted
in the core beliefs and attitudes of individuals (Smedley et al., 2003). Conscious bias often
manifests in acts of prejudice. In contrast, unconscious bias is unintentional and displayed
without the awareness of individuals, often in sharp contrast with their defined personal beliefs
(Chapman et al., 2013; Dovidio, Kawakami, & Gaertner, 2002). Unconscious bias has been
documented in children as early as three-years-old (Chapman et al., 2013). In addition to the
influence of stereotyping on unconscious bias, other identified contributing factors include
cognitive overload of the health care provider and the response of patients to medical treatment.
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Cognition research supports that clinicians are more likely to be influenced by unconscious bias
when their cognitive capacity is challenged, for example, when they are tired, ill, or under stress.
During these times, clinicians are more likely to rely on information that is stored in their
memories and reinforced by stereotypes, rather than on unique information related to specific
patients (Van Ryn & Saha, 2011).
Provider-related factors also include greater clinical uncertainty in treating patients from
diverse cultural backgrounds (Geiger, 2006). Clinical uncertainty can result in clinicians
cognitively relying on prior beliefs, which can sometimes be incorrect (Smedley et al., 2003). To
provide optimal care, clinicians have to be able to be aware of and utilize various cultural clues
that can influence a patient’s treatment (Engebretson et al., 2008). This creates a proficiency in
providing care for individual patients based on their unique cultural and linguistic attributes.
The Role of Cultural Competence
To reduce the level of health disparities for racial and ethnic minorities, key strategies
have been identified to improve the quality of care for all patients. Grouped into three categories,
these strategies include: (1) data collection on patient race, ethnicity, and primary language, (2)
partnerships to develop and execute solutions, and (3) training of health care staff to provide
culturally competent care for patients of all racial and ethnic backgrounds (AHRQ, 2013).
According to a 2015 study, 80% of hospitals provide cultural competence training during
employee orientation, 79% provide cultural competence continuing education, and 40% include
cultural competence as a priority in their organizational strategic plan (Institute for Diversity in
Health Care Management [IFD], 2015). Although a high percentage of hospitals provide cultural
competency training, there is little research on the effectiveness of the training to improve patient
outcomes and to reduce health care disparities.
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29
Providing Culturally Competent Care
Increasing the cultural competence of health care providers has contributed to improving
the health status of racial and ethnic minorities and reducing disparities of care. Cultural
competence is the ability of health care systems and providers to deliver care to patients with
varied and diverse values, beliefs, and behaviors, while meeting the patients’ social, cultural, and
linguistic needs (HRET, 2011). Cultural competence requires an in-depth understanding of the
sociocultural background of patients’ families, background, and environments (Betancourt,
Green, & Carillo, 2002). To provide culturally competent care, it is important for health care
providers to identify, educate and train staff who can effectively communicate with patients from
various ethnic and racial backgrounds (HRET, 2011). This education and training includes an
understanding of changing demographics in the U.S., the impact that these changes have on
clinical care, and the development of skills needed to become culturally competent. Increasing
the ability of clinical staff to interact effectively with patients of all ethnic and racial
backgrounds increases patient engagement, resulting in increased patient treatment compliance
and health outcomes (HRET, 2011). To reduce disparities of care for racial and ethnic minorities,
health care providers need to expand their level of understanding and proficiency in delivering
care to patients from all cultural backgrounds.
Models Used to Develop Cultural Competence
To improve the level of cultural competence in delivering health care, several care
delivery and assessment models, developed within the nursing field, are utilized in the health
care setting as frameworks to improve the quality of care provided to all patients, regardless of
race, ethnicity, or varied culture. Four key models include the Campinha-Bacote’s Model of
Cultural Competence in Health Care Delivery, Transcultural Assessment Model, Leininger’s
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30
Cultural Care Diversity and Universality Theory/Sunrise Model, and Purnell’s Model of
Transcultural Health Care (American Association of Colleges of Nursing [AACN], 2008).
Campinha-Bacote ’s Model of Cultural Competence in Health Care Delivery. One of
the most utilized cultural competence models within nursing is the Campinha-Bacote’s Model of
Cultural Competence in Health Care Delivery (Campinha-Bacote, 2002). This model views
cultural competence as an ongoing process in which the provider continually strives to gain
knowledge and skills within the cultural context of the individual, family, and patient. The model
is structured around five key pillars, including cultural awareness, knowledge, skills, encounters,
and desires (Campinha-Bacote, 2002). To achieve cultural competence, all five areas must be
addressed. Competence increases as the intersection of the five constructs becomes larger.
Individuals and organizations begin the journey to cultural competence by demonstrating an
intrinsic motivation to engage in a cultural competence process. The Campinha-Bacote model is
grounded in the clinicians’ intrinsic motivation to become fully engaged in the cultural
competence process, which is addressed in the desire component (Campinha-Bacote, 2002).
Transcultural Assessment Model. Developed by Giger and Davidhizar (2008), the
Transcultural Assessment Model defines each person as a unique individual, influenced by
culture, ethnicity, and religion. The model proposes that individuals should be assessed in the
areas of communication, space, social orientation, time, environmental control, and biological
variations to ensure that their unique needs are met in each of these areas. Under each category, a
set of questions is developed to increase the understanding of the patients’ cultural needs. The
model supports that the patient should play an active role in their cultural assessment (Giger &
Davidhizar, 2008).
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31
Leininger ’s Cultural Care Diversity and Universality Theory/Sunrise Model. Based
on anthropological observations and the study of various cultures, Leininger’s Cultural Care
Diversity and Universality Theory is grounded in a set of general assumptions regarding
providing culturally competent care, as well as beliefs and behaviors that are specific to unique
contexts (Leininger & McFarland, 2006). The theory supports the belief that culture manifests
into specific patterns of behaviors, which create differences between societies. The model
provides guidance on how to deliver culturally competent care through a care delivery process
that includes assessment, planning, implementing, and evaluating the unique needs of all patients
(Leininger & McFarland, 2006).
Purnell ’s Model of Transcultural Health Care. The Purnell Model of Transcultural
Health Care is based on clinicians, through education and application, moving through four
stages of cultural competence, including unconscious incompetence, conscious incompetence,
conscious competence, and unconscious competence (Purnell & Paulanka, 2008). The model
transitions from a macro environment to microenvironment, evaluating the area of global society,
community, family, person, and health. Within each area, domains tie to unique cultures; each of
the domains are interconnected.
Although there are numerous other models utilized to advance cultural competence
within health care organizations, most of the models consistently place an emphasis on
expanding the awareness, knowledge, and skill set of health care providers, including the nursing
staff. This increased competency is essential to affect positively the overall quality of care
provided to all patients and resulting health outcomes.
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32
Evaluating Cultural Competence
To improve the level of cultural competence within an organization, and to expand the
awareness, knowledge, and skills of the clinical staff, it is important to have the ability to
measure and evaluate the current competency level of the health care professionals within the
organization. One of the most utilized tools to assess cultural competence in the nursing field is
the Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals
(IAPCC). Developed by nurse researcher, Josepha Campinha-Bacote, the 20-item tool measures
cultural awareness, knowledge, skill, and encounter (Campinha-Bacote, 2002). The tool, based
on Campinha-Bacote’s model of cultural competence in health care delivery, views cultural
competence as an ongoing process in which the provider is continually striving to deliver
culturally competent care. The model includes five constructs, including cultural awareness,
cultural knowledge, cultural skill, cultural encounters, and cultural desire. The assessment tool
measures all of the defined constructs, with the exception of cultural desire (Campinha-Bacote,
2002).
In addition to the Campinha-Bacote model, numerous other tools are used to assess
cultural competence in health care providers. A study published in 2007 in Academic Medicine
evaluated 54 tools currently used to measure cultural competence (Kumaş-Tan, Beagan, Loppie,
MacLeod, & Frank, 2007). According to the study findings, there is little consistency between
the numerous cultural competence evaluation tools. Further, according to the study the reliability
of measurement tools is questionable. A common weakness of the reviewed evaluation tools was
that many of the evaluation tools were developed without patient input, rely on clinician self-
evaluation, and oversimplify the impact of culture and the successful achievement of cultural
competence. All of the evaluated tools utilize quantitative survey instruments, with the number
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33
of survey items ranging from 20 to 35 questions and Likert scales ranging from four-point to
seven-point scales. According to the study, the four most cited tools include the Cultural Self-
efficacy Scale (CSES); Multicultural Awareness, Knowledge, and Skills Survey (MAKSS);
Cross-cultural Counseling Inventory (CCCI); and the Kumaş-Tan et al. (2007) Multicultural
Counseling Knowledge and Awareness Scale (MSKAS).
Stakeholder Knowledge, Motivation, and Organizational Influences
Knowledge and Skills
In addition to motivation and organizational influences, knowledge influences are a key
contributor to performance gaps (Clark & Estes, 2008). When assessing gaps in performance, it
is important to examine if people know how to achieve a set performance goal. This section
focuses on a review of the literature of knowledge-related influences that are pertinent to
achieving the stakeholder goal that by October 2018, all AONE-member nurse leaders will be
able to identify and apply evidence-based practices in providing culturally competent care to
patients of all ethnic and racial backgrounds. The review includes an analysis of various
knowledge types and their respective influence on achieving the stakeholder goal.
Knowledge types. Understanding the influence of the various types of knowledge on
stakeholders is a critical component of improving performance outcomes and measures. Four
primary knowledge types contribute to learning and performance, including factual, conceptual,
procedural, and metacognitive knowledge (Krathwohl, 2002; Rueda, 2011). The least complex,
factual knowledge, involves a basic understanding of terminology, details, and elements related
to a specific discipline. Conceptual knowledge is more complex than factual knowledge and
involves a broader understanding of connecting patterns and relationships. Both factual and
conceptual knowledge are declarative knowledge types. The next level of knowledge,
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34
procedural, enables learners to understand how to do something. Procedural knowledge involves
a deeper understanding of the criteria for using skills, techniques, and methods (Krathwohl,
2002). In addition to these three types of learning, a fourth type, metacognition, supports that
learning is elevated when students have control over their own cognitive abilities (Baker, 1989).
Two components of metacognition include knowledge of one’s own thinking and self-regulation.
Metacognition is also a key factor in the successful transfer of learning, or the application of
learned knowledge to new situations (Krathwohl, 2002). Factual, conceptual, procedural, and
metacognition knowledge all have an influence on achieving the defined stakeholder goal and
are analyzed in this study.
Influences of stakeholder knowledge. This section provides a review of the literature
relevant to the stakeholder goal that by October 2018, all AONE-member nurse leaders will be
able to identify and apply evidence-based practices in providing culturally competent care to
patients of all ethnic and racial backgrounds. Included is an overview of the declarative,
procedural, and metacognitive knowledge influences that affect the achievement of the
stakeholder goal.
Declarative knowledge influences. Declarative knowledge includes both factual
knowledge, which includes understanding basic terminology, and conceptual knowledge, which
includes connecting patterns and relationships (Clark & Estes, 2008). To be successful in
providing culturally competent care, nurse leaders need to know the impact that disparities of
care have on health outcomes for racial and ethnic minorities. The Agency for Healthcare
Research and Quality (AHRQ, 2013) estimates that Blacks and Hispanics receive lower care,
compared to Whites, in approximately 40% of quality measures. In addition to data that
documents disparities in health care between various racial and ethnic groups, clinicians also
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35
self-report, based on their own knowledge, that patients are sometimes treated differently and
receive varied care due to their race or ethnicity (Mallinger & Lamberti, 2010; Sabin, Nosek,
Greenwald, & Rivara, 2009). To illustrate, the Kaiser Family Foundation (2002) National Survey
of Physicians reported that 26% of female physicians and 39% of male physicians agreed that
disparities in treatment for racial and ethnic minority patients occur “very” or “somewhat often.”
Segmented by race, the study reported that 25% of White physicians, 52% of Latino physicians,
33% of Asian physicians, and 77% of Black physicians acknowledged disparities in treatment
due to race or ethnicity occur “very” or “somewhat often.” An understanding of the evidence-
based research, which documents the prevalence and impact of disparities of care for racial and
ethnic minorities, is an important component of the knowledge base that nurse leaders need to
embrace to improve the care provided to these population groups.
Another key declarative knowledge requirement for nurse leaders, to enable them to
provide culturally competent care, is to understand the definition or meaning of providing
culturally competent care. This knowledge includes an understanding that the individual, family,
and community influence the cultural context of each patient’s treatment (Campinha-Bacote,
2002). Cultural knowledge also requires an understanding of the prevalence of diseases among
racial and ethnic groups, and treatment efficacy (Campinha-Bacote, 2002; Smedley et al., 2003).
Obtaining cultural knowledge can be impaired because patients and health care providers each
have their own unique set of cultural backgrounds and assumptions. To provide culturally
competent care, nurse leaders need to be aware of these varied cultural influences and attributes
that influence patients (Ornelas, 2008; Smith, 2014).
To aid in gaining this knowledge within the framework of their own cultural attributes,
nurse leaders need to focus continually on advancing their learning and education, and the
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36
knowledge and learning of their staff, to improve the delivery of care for patients of all racial and
ethnic backgrounds (Smith, 2014). To demonstrate the connection between education and a
resulting increased knowledge of definitions and terminology associated with providing
culturally competent care, a study conducted by Khanna, Cheyney, and Engle (2009), showed
that the cultural knowledge and skills of clinicians improves after education and training. The
study, which measured the respondents’ understanding of the terms culture, race, and ethnicity,
pre- and post-training, showed a statistically relevant improvement in cultural competency
knowledge after training. Due to the varied cultural influences and attributes of patients, a solid
foundation in the meaning, terminology, and definitions associated with cultural competence, as
well as the relationship to quality of care, is needed for nurse leaders and the nurses they manage
to increase their level of cultural competence.
Procedural knowledge influences. Procedural knowledge enables learners to understand
how to do something (Clark & Estes, 2008). To be able to identify and apply evidence-based
practices in providing cultural competent care, nurse leaders need to know how to implement and
assess successful strategies and practices of providing culturally competent care.
To illustrate an application of procedural knowledge, to provide culturally competent
care, clinicians must have the knowledge and ability to communicate effectively with patients
who do not speak English as their primary language and have limited English proficiency. To
provide optimal care, nurse leaders must have knowledge of the language preference of
individual patients and ensure use of the patients’ preferred language in communications
(Diamond & Jacobs, 2009). Approximately 20% of all people residing in the United States use a
language other than English as the primary language in their home, which creates a challenge to
communicate effectively by only using the English language (U.S. Census Bureau, 2010).
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Further, the number of people in the United States who identified their ability to speak English as
“not well” or “not at all” doubled from 4.8% in 1980 to 8.1% in 2000 (Diamond & Jacobs,
2009). As an added barrier, in addition to the language barriers in communicating with patients,
many family members, who often serve as the advocate or interpreter for the patient, also speak a
primary language other than English (Diamond & Jacobs, 2009; Smedley et al., 2003). Family
members play an important role in facilitating the exchange of information between clinicians
and patients and this role is hindered when family members have limited English language skills.
Strategies that address the impact of these language barriers can improve the knowledge,
attitudes, and skills of health care providers related to the importance of effectively
communicating with patients (Zabar et al., 2006). In support, in its report, Unequal Treatment —
Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (Smedley et
al., 2003) recommended that education aimed at overcoming language barriers be included in
clinical and practice education. Health care disparities, which stem from language barriers,
decline when the procedural knowledge of clinicians, regarding how to communicate effectively
with patients for which English is not their primary language improves. A common application
of procedural knowledge is the use of translation services or language lines, used by clinicians as
a tool to communicate with patients for which English is not their primary language.
Metacognitive knowledge influences. Metacognition influences one’s own thinking and
self-regulation, as well as the successful transfer of learning to new situations (Krathwohl, 2002).
To be able to identify and apply evidence-based practices in providing culturally competent care,
nurse leaders need to know how to reflect on their own knowledge and level of competence in
providing care, be aware of their own cultural self-biases, and understand how to utilize their
own cultural competency knowledge in clinical decision-making. Because patient demographics
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38
and the cultural environment continue to change, fully understanding how to provide culturally
competent care requires a commitment to life-long learning to remain current with environmental
changes (Smith, 2014). Although cultural competency education and training can build the
knowledge, skills, and awareness of nurse leaders, self-awareness and lived experiences increase
the ability of nurses to achieve cultural proficiency in the practice environment. Reaching this
level of proficiency involves more than mastering a body of knowledge, it involves internalizing
the concepts of cultural competence and using the concepts to build a level of mutual respect for
all patients (Musolino et al., 2010). This internalization, supported with self-reflection of one’s
own knowledge strengths and limitations, assists in the expansion of the ability of nurse leaders
to lead their teams in providing culturally competent care.
As part of the self-evaluation, reflection, and learning process, another component of the
metacognitive knowledge influence on nurse leaders is the awareness of their own cultural self-
biases. Prejudice and bias, including both conscious and unconscious bias, affect the quality of
care that patients receive (Ornelas, 2008). These factors contribute to lower quality measures, in
part, due to the formed behaviors of nurses, physicians, and other treatment providers, which
impact clinical decision-making and result in variations of medical treatment (Chapman et al.,
2013; Sabin et al., 2009). Prejudice, or conscious bias, is grounded in the beliefs and attitudes of
individuals. In contrast, unconscious bias is unintentional and manifests without the awareness of
individuals, often in sharp contrast with their defined personal beliefs (Chapman et al., 2013;
Dovidio et al., 2002). Clinicians are more likely influenced by unconscious bias when they are
experiencing cognitive overload or their cognitive capacity is challenged, for example, when
they are tired, ill, or under stress (Dovidio et al., 2002). During these times, such as care
provided in hospital emergency rooms, clinicians are more likely to rely on information that is
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39
stored in their memories and reinforced by stereotypes, rather than on knowledge related to
specific patients (Van Ryn & Saha, 2011). By thoroughly understanding their own personal
biases and potential triggers, nurse leaders can begin to understand the impact that these
attributes have on health care disparities.
The understanding of nurse leaders, on how to utilize their own cultural competency
knowledge in clinical decision-making, is another metacognitive knowledge influence that
affects the stakeholder goal. The successful transfer and application of prior learning to new
situations or practice is an important part of metacognition (Krathwohl, 2002). Nursing education
and higher education curricula, which includes evidence-based principles, aid in the transfer of
knowledge that focuses on improving the level of cultural competency knowledge of clinicians
(Musolino et al., 2010; Ross et al., 2010). Yet, curricula that include cultural competence
content, at both the undergraduate and graduate levels, are limited in formal nursing education
(Ross et al., 2010). Most programs that include cultural competency content in the curricula
focus on declarative knowledge, including terminology and obstacles to providing culturally
competent care. Although these programs include terminology and information on obstacles to
providing culturally competent care, the programs typically do not include evidence-based
principles to assist nurses and other clinicians to make meaningful clinical decisions to address
disparities (Ross et al., 2010). Mastering a body of knowledge requires not only acquiring the
needed skills, but also developing the skills to transfer that knowledge in practice (Schraw &
McCrudden, 2006; Sealey, Burnett, & Johnson, 2006). The combination of foundational
knowledge, provided in nursing education, and the transfer of that knowledge to clinical
decision-making and application to practice can increase the level of cultural competency of
nurse leaders.
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40
In summary, various knowledge influencers affect the stakeholder goal of all AONE-
member nurse leaders’ ability to identify and apply evidence-based practices in providing
culturally competent care to patients of all ethnic and racial backgrounds. Table 2 highlights the
assumed knowledge influences and potential knowledge influence assessments framed within the
declarative, procedural, and metacognitive knowledge types.

Table 2
Stakeholder Knowledge Influences
Assumed Knowledge Influence Knowledge Influence Assessment
Declarative
(Factual) Nurse leaders need to know the
impact that disparities of care have on health
outcomes for racial and ethnic minorities.
Racial and ethnic minority patients in the United
States receive lower quality of care, which results in
reduced health outcomes. (5-point Likert scale)
(Conceptual) Nurse leaders need to have an
understanding of the meaning of providing
culturally competent care.
The cultural context of each patient’s treatment is
influenced by the individual, family, and community.
(5-point Likert scale)
Procedural
Nurse leaders need to know how to implement
and assess successful strategies and practices
of providing culturally competent care.
Health care disparities that stem from language
barriers can be reduced through improved procedural
knowledge of nurses on how to effectively
communicate with patients for which English is not
their primary language. (5-point Likert scale)
Metacognitive
Nurse leaders need to know how to reflect on
their own knowledge and level of cultural
competence in providing care, be aware of
their own cultural self-biases, and understand
how to utilize their own cultural competency
knowledge in clinical decision-making.
It is important that nurses dedicate time to reflect on
their own knowledge and level of cultural competence
in providing care to patients of all racial and ethnic
minorities. (5-point Likert scale)
Prejudice and bias, including both conscious and
unconscious bias, affect the quality of care that
patients receive. (5-point Likert scale).

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41
Motivation
Motivation influences, in addition to knowledge influences and organizational influences,
are a key contributor to performance gaps (Clark & Estes, 2008). This section focuses on a
review of the literature of motivation-related influences that are pertinent to achieving the
stakeholder goal that by October 2018, all AONE-member nurses will be able identify and apply
evidence-based practices in providing culturally competent care to patients of all ethnic and
racial backgrounds. Motivation is an internal behavioral state that helps to facilitate the
completion of goals (Mayer, 2011). The processes involved in motivation impact our abilities to
start a task, continue to persist until the task or goal is completed, and dedicate ample mental
effort to be successful (Clark & Estes, 2008; Pintrich, 2003). Engagement and persistence in a
task are strongly impacted by an individual’s interest in the particular task, initiative, or subject
area (Schraw & Lehman, 2009). To understand the impact of motivation on nurse leaders and
their staff in providing culturally competent care, this section of the literature review includes an
analysis of the influence of the expectancy value motivation theory and the self-efficacy theory.
Expectancy value theory. The expectancy value theory frames the first assumed
motivational influence for reaching the stakeholder goal. The theory, based on two sets of beliefs
that affect motivation, includes first the individual’s expectation of his or her ability to
successfully reach a goal, and second, the value the individual places on the goal (Eccles, 2006).
Once an active choice to complete a task is made, the value of the task plays an important role in
regulating motivation (Eccles, 2006). Primary types of values include intrinsic value, or
enjoyment an individual expects to receive, attainment value, which ties closely to an
individual’s self-schema, and utility value, which aligns with how well the task fits with an
individual’s overall goals (Eccles, 2006). The value of a task ties closely to its perceived cost,
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42
which includes the time and resources needed to complete the task, in consideration of the same
amount of time and resources that could be used to complete other tasks. Choosing to participate
in a given task results in less time and resources to participate in other goals or activities (Eccles,
2006). Placing value on the task, trusting that the individual has the ability to meet a goal
successfully, and willingness to incur the perceived cost of the task are important criterion for
individuals to meet objectives successfully.
Expectancy value theory influence on nurse leaders. To be able to identify and apply
evidence-based practices in providing culturally competent care to patients of all ethnic and
racial backgrounds, nurse leaders need to see the value in their staff providing culturally
competent care and believe that they can be successful in doing so. This assumed motivational
influence requires making an active choice to provide culturally competent care, as well as
placing a value on the goal. Once a choice has been made to reach a goal, persistence and mental
effort are needed to achieve the goal (Shraw & Lehman, 2009). To illustrate, using a clinical
application, providing culturally competent care requires conducting patient assessments and
developing a treatment plan based on a discovery and understanding of patients’ cultural
traditions, perceptions, practices, beliefs, and values. Delivery of care, grounded in this type of
cultural assessment, improves patient satisfaction and clinical outcomes (Smith, 2014). Yet,
completing thorough assessments, grounded in cultural competence, requires dedicating ample
time and mental effort to gather necessary knowledge and information (Smedley et al., 2003;
Smith, 2014). Therefore, utilizing a cost-benefit analysis framework, there is a perceived cost
associated with the completion of these assessments, related to the time spent away from other
tasks and fear of failure, which can create barriers to completing the goal.
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43
Due to the many pressures and time constraints placed on nurses, finding ample time to
conduct cultural assessments can be challenging and nurses may make a decision not to
complete. Nurses may not make an active choice to fully understand and assess the cultural
traditions, perceptions, practices, beliefs, and values of patients, which could be attributed to the
value that nurse leaders, and the nursing staffs they manage, place on this task. The goal of
achieving a higher level of cultural competency is not valued equally among all clinicians
(Jeffreys, Bertone, Douglas, Li, & Newman, 2007). Making an active choice, persisting, and
dedicating ample effort to providing culturally competent care compete with many other interest
areas, including the mastery of nursing specialty areas and general clinical competencies
(Jeffreys et al., 2007). These competing influencers may result in less active choice and value
placed on achieving a higher level of cultural competence and can create tensions between what
nurse leaders want to do, and what they can realistically do, in clinical practice.
To achieve culturally competent care, in addition to making an active choice to pursue,
persisting to completing the task, and applying ample mental effort, nurse leaders must also be
motivated to obtain the skills, knowledge, and lived experiences required to be successful. The
Campinha-Bacote’s Model of Cultural Competence in Health Care Delivery discussed earlier in
this chapter describes this process as a cultural desire or motivation of the health care provider to
achieve a higher level of proficiency, versus only meeting the level of proficiency that is required
to be adequate (Campinha-Bacote, 2002). The model describes the process of cultural
competence as the intersection between cultural knowledge, awareness, skill, encounters, and
desire. The desire portion of the model addresses the motivational component needed to provide
culturally responsive care and requires both active choice and value of the task by nurse leaders
(Campinha-Bacote, 2002). Due to the daily pressures and competing tasks required of nurse
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leaders and the nurses they manage, they may lack the needed motivation to achieve a higher
level of cultural competency proficiency.
Self-efficacy theory. Self-efficacy theory is the second assumed motivational framework
that influences reaching the stakeholder goal. Self-efficacy theory, grounded in the work of
psychologist Albert Bandura, identifies self-beliefs as a critical component of motivation.
Supported in social cognitive theory, self-efficacy reflects an individual’s belief of their ability to
achieve a task as an individual or part of a group (Pajares, 2006). This self-belief is a critical
component of motivation and achieving goals and improving performance. Only by believing
that they have the needed ability and that their actions will result in achieving a desired goal, will
individuals make a choice to accomplish and persist to achieve a goal (Pajares, 2006).
Self-efficacy forms in individuals through four primary influencers, including mastery
experience, vicarious experience, social persuasions, and physiological reactions (Pajares, 2006).
Mastery experience is based on self-confidence obtained by successfully mastering a task.
Vicarious experience is obtained by observing others being successful in a like task. Social
persuasions are the result of influence or messaging one receives from others, including
appraisals from others. Physiological reactions include the influence of emotional states and
moods on one’s self-efficacy (Pajares, 2006).
Self-efficacy theory influence on nurse leaders. To be able to identify and apply
evidence-based practices in providing culturally competent care to patients of all ethnic and
racial backgrounds, nurse leaders need to believe that they are capable of leading their staff in
providing culturally competent care. Although this belief in their ability partially stems from
their exposure to patients from varying cultures in clinical practice, it also needs to be grounded
in formal nursing education. The role of nursing faculty to prepare future nurse leaders is an
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45
important part of this preparation (Lowe & Archibald, 2009). A study conducted by Sealey et al.
(2006) evaluated the self-ratings of a group of nurse faculty regarding their ability and
motivation to prepare nurses to provide culturally competent care. The study showed that faculty
were more confident that they had strong cultural competency awareness, compared to their
confidence or self-efficacy in their actual clinical skills in treating patients from diverse cultural
backgrounds (Sealey et al., 2006). Cultural awareness, viewed typically as the first step of the
cultural competency continuum, involves a general level of acceptance, respect, and valuing of
cultural differences (Sealey et al., 2006). The decreased level of faculty self-efficacy could result
in a reduced transfer of knowledge from faculty to student and could influence the self-efficacy
of nurse leaders once they are in practice.
Increasing self-efficacy is important because nurses who have a higher degree of cultural
knowledge are more likely to be more secure treating patients from diverse cultures. Self-
efficacy theory supports that mastery of a body of knowledge increases an individual’s success,
which in turn increases the individual’s self-efficacy (Pajares, 2006). In a review of 26 studies,
which utilized the cultural self-efficacy scale rating tool, Coffman, Shellman, and Bernal (2004)
found that respondent nurses reported their levels of self-efficacy in treating patients from
diverse cultures as merely average. Further, the study showed a variance in the self-efficacy of
nurses based on the race of the patients. Using a 5-point Likert scale, respondent nurses reported
a mean score of 3.1 for confidence in treating African Americans, a 3.1 for Hispanics, and a 2.4
for Asians (Coffman et al., 2004). This compilation of studies demonstrates a gap in the level of
self-efficacy among nurses. The gap in self-efficacy in treating patients from varied cultures is
often present regardless of the age, experience level, or education of the clinician (Bernal &
Froman, 1987; Kulwicki & Boloink, 1996). In addition to feeling more secure in their roles,
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46
increased self-efficacy can also increase the motivation of nurse leaders to stay and be successful
in their roles due to increased job satisfaction (Lee, Anderson, & Hill, 2006). Both increased
confidence and job satisfaction, resulting from increased self-efficacy, could result in a higher
level of cultural competence.
To summarize, various motivation influences impact the stakeholder goal of all AONE-
member nurse leaders being able to apply evidence-based practices in providing culturally
competent care to patients of all ethnic and racial backgrounds, Table 3 highlights the assumed
influences and potential assessments framed within the expectancy value theory and self-efficacy
theory.

Table 3
Stakeholder Motivation Influences
Assumed Motivation Influence Motivation Influence Assessment
Expectancy Value Theory:
Nurse leaders need to see the value in their staff
providing cultural competent care and believe that
they can be successful in leading them to achieve this
goal.
It is important for me to lead my staff
in providing culturally competent care.
(5-point Likert scale)
Self-Efficacy Theory:
Nurse leaders need to believe that they are capable of
leading their staff in providing cultural competent
care.
I am confident in my ability to lead
my staff in providing culturally
competent care. (5-point Likert scale)

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Organizational Influences
In addition to knowledge and motivation influences, another contributing factor to
performance gaps is organizational influences. This section focuses on a review of the literature
of organizational-related influences that are pertinent to achieving the stakeholder goal that by
October 2018, all AONE-member nurse leaders will be able to identify and apply evidence-based
practices in providing culturally competent care to patients of all ethnic and racial backgrounds.
The review focuses on the influences of clearly defined goals and objectives and the allocation of
needed resources.
Ineffective and inefficient organizational processes, as well as a lack of resources, often
create organizational barriers to achieve performance goals (Clark & Estes, 2008). Both the
climate and culture of an organization influences these barriers. The organizational climate,
driven by policies, practices, and procedures, as well as the expected behaviors of the rewarded
group members, reflect what employees believe their organizations value (Schneider, Brief, &
Guzzo, 1996). These beliefs and values mold to shape the organizational culture (Schneider et
al., 1996). An organization’s culture forms from the values, goals, and beliefs that develop over
an extended period within the organization (Clark & Estes, 2008). Both the climate and the
culture of an organization have an impact on the achievement of organizational goals.
Organizational support is needed within organizations to ensure that employees feel
supported, to narrow identified performance gaps, and to reach targeted goals. Within hospitals
and health care systems, organizational support is needed to build the cultural competence of
nurse leaders and the nursing staff they manage (Maddalena, 2009). Although current research is
limited regarding the impact of organizational barriers to achieving a culturally competent health
care workforce, a limited number of studies show that clinicians often do not feel supported by
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48
their organizations to achieve cultural competence in treating racial and ethnic minority patients
(Reese, Melton, & Ciaravino, 2004; Taylor & Alfred, 2010). This perceived lack of
organizational support reflects in both cultural and climate influences, through policies and
procedures, and the belief of nurse leaders that their organizations do not value improving
cultural competence, due to the limited allocation of resources.
Organizational goals and objectives. To be able to identify and apply evidence-based
practices in providing culturally competent care to patients of all ethnic and racial backgrounds,
nurse leaders need to receive clearly defined goals and objectives from the leaders of their
organizations to improve the level of cultural competence of their staff, as well as hold the
leaders within the organization accountable to achieve this goal. Hospitals and health care
systems are responsible for proving the infrastructure necessary to support providing culturally
competent care (Douglas et al., 2014). Establishing a clear vision and specific goals, in addition
to defined metrics, is a critical component of effective organizational change and performance
improvement initiatives (Clark & Estes, 2008). As part of this framework, the mission, vision,
and strategic plan of a hospital should include statements regarding the importance of diversity
and inclusion to the organization and should reflect the needs of the served patient population
(Purnell et al., 2011). The board of directors typically drives the support for this structure by
including goals in the hospital’s strategic plan to improve organizational diversity, provide
culturally competent care, and reduce disparities (AHRQ, 2013). The hospital’s strategic plan
guides the organization and demonstrates the value that the organization places on its key
priorities, including cultural competence and the reduction of health care disparities (Douglas et
al., 2014; Purnell et al., 2011).
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49
Nurse leaders also need to see that their organizations hold leaders within their hospitals
accountable for improving the level of cultural competence of their staff, by clearly defining this
accountability in the organizational goals and objectives. In health care organizations, the board
of directors and senior leaders are ultimately responsible for ensuring that the organization
provides culturally competent care (Purnell et al., 2011). As part of this leadership
accountability, the hospital board should be inclusive and represent the diversity of the
community the board serves (Purnell et al., 2011). The board of directors and leaders within the
hospital should hold themselves and their staffs accountable through reporting structures and
annual reports that outline progress to achieving goals (Delphin-Rittmon et al., 2013).
Leadership accountability also includes ensuring that there is policy and fiscal alignment within
the organization to support successful achievement of targeted goals (Delphin-Rittmon et al.,
2013). To monitor the achievement of these goals, patient outcome data should be collected and
analyzed to identify improvement areas, current inequities, and performance gaps (HRET, 2011).
Patient satisfaction data should be used to evaluate the effectiveness of services for patients of all
cultures (Douglas et al., 2014).
Clearly defined goals and objectives are further demonstrated through the inclusion of
goals to improve staff cultural competence within organizational performance objectives. These
objectives should include specific goals for improving cultural competence into employee
position descriptions and performance evaluations, to ensure that staff has clearly defined
expectations for their roles (Purnell et al., 2011). To be successful, defined cultural competency
goals, strategies, and employee performance expectations should be realistic based on each
organization’s ability to support staff members to achieve the defined targets (Delphin-Rittmon,
et al., 2013). To further demonstrate that the hospital values and places importance on improving
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50
the level of cultural competence in delivering care, specific goals and objectives should also be
identified to broaden the diversity of the hospital’s workforce. It is important to incorporate into
recruiting practices the hiring of individuals who represent the population served by the hospital
(Taylor & Alfred, 2010). Achievement of a more diverse workforce increases staff exposure to
other cultures, provides support to advance their knowledge and improve patient care, and
demonstrates the value the hospital places on diversity.
Allocation of education and resources. Nurse leaders also need to see that their
organizations value and place importance on improving the level of cultural competence in
delivering care through the allocation of education and other resources. To demonstrate the value
of cultural competence, the organizational culture should support the reduction of health care
disparities through resources dedicated to training the broader health care staff, including
nursing, to deliver culturally and linguistically competent care for patients of all ethnic and
cultural backgrounds (Reese & Beckwith, 2015). In a qualitative study conducted by Taylor and
Alfred (2010), nurses identified key organizational barriers to providing cultural competent care
within hospitals attributed to a lack of dedicated resources, such as insufficient training and
education, as well as limited rewards and recognition tied to cultural competence. Even when
training was provided, the nurses in the study said that staff were often not required to attend, nor
required to modify their performance because of the training. Another study found that the most
highly identified organizational barriers to obtaining cultural competency include lack of funding
for staff training and insufficient priority placed on improvements by the organization (Reese &
Beckwith, 2015).
To be effective, diversity and cultural competency training is needed at all levels of an
organization, including the board of directors, leadership, and volunteers (AHRQ, 2013; HRET,
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51
2011). Further, cultural competency training should be included in new employee orientation and
continuing education, as well as mentoring programs for diverse staff members (Purnell et al.,
2011). Clinical simulation, which allows clinicians to rehearse behaviors and treatments without
the use of patients, has proven to be an effective tool to expand the cultural competence of the
nursing staff by providing a safe environment to advance skills (Ozkara San, 2015).
Incorporating clinical simulation opportunities, within organizational training, further
demonstrates the value organizations place on improving cultural competence.
In addition to dedicating resources to employee education and hiring, to demonstrate the
value organizations place on improving the cultural competence of their staff, organizations must
also dedicate resources to other needed areas. One area of support includes the physical
environment of the hospital, including resources dedicated to ensuring the placement of
culturally and linguistically appropriate signs and the availability of culturally appropriate meal
options for both employees and patients (Ornelas, 2008). Another identified resource to improve
cultural competent care is the availability of translation services to support staff in providing care
to patients of limited English proficiency (Ornelas, 2008). Language barriers are a key obstacle,
identified by nurses, to providing culturally competent care due to decreased rapport and
ineffective communication with patients who are not proficient in the English language (Taylor
& Alfred, 2010). Dedicating resources reinforces to the staff that the organization places value
on cultural competence and its resulting impact on patient care.
To summarize, various organizational influences affect the stakeholder goal that all
AONE-member nurse leaders will be able to identify and apply evidence-based practices in
providing culturally competent care. Table 4 provides an overview of the assumed organizational
influences and potential organizational influence assessments.
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52

Table 4
Stakeholder Organizational Influences
Assumed Organizational Influence Organizational Influence Assessment
Nurse leaders need to receive
clearly defined goals and objectives
from the leaders of their
organizations to improve the level
of cultural competence of their
staff, as well as hold the leaders
within the organization accountable
to achieve this goal.
I receive clearly defined goals and objectives from my
organization’s senior leadership and governance body to
improve the level of cultural competence of my nursing
staff. (5-point Likert scale)
My organization’s strategic plan includes guidelines for
incorporating cultural and linguistic competence into
nursing operations. (5-point Likert scale)
My organization’s chief executive officer and
governance body holds leaders accountable for
improving the level of cultural competence of their staff.
(5-point Likert scale)
Nurse leaders need to see that their
organizations value and place
importance on improving the level
of cultural competence in delivering
care through the allocation of
education and resources.
My organizations values and places importance on
improving the level of cultural competence in delivering
care through the allocation of resources and education to
the nursing staff. (5-point Likert scale)
Cultural competency training is required at my
organization for new staff orientation and as a required
component of annual nursing education. (5-point Likert
scale)
Quality improvement projects that are aimed at
improving the quality of care provided to diverse patient
populations are in place at my organization. (5-point
Likert scale)
My staff has adequate access to language assistance
services, to aid in such functions as interpreting for
patients for which English is not their first language. (5-
point Likert scale)

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Summary of Chapter
In summary, Chapter 2 provides an outline of the literature related to the relationship
between health disparities for racial and ethnic minorities and cultural competence in delivering
care. The first section focused on the prevalence of health disparities and the factors, both
cultural and non-cultural, that contribute to their occurrence. The second section reviewed the
role that cultural competence plays in health disparities, the various cultural competency models
applied in health care, and the methods used to evaluate cultural competence. The chapter ended
with a review of the knowledge, motivation, and organizational factors that affect the delivery of
culturally competent care to patients of all racial and ethnic backgrounds.

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54
CHAPTER 3
METHODOLOGY
Purpose of the Study and Research Questions
The purpose of this study was to evaluate the degree to which the stakeholder goal is
being met that by October 2018, all AONE-member nurse leaders will be able to identify and
apply evidence-based practices in providing culturally competent care to patients of all ethnic
and racial backgrounds. The analysis focused on the knowledge, motivation, and organizational
elements related to achieving the stakeholder goal.
To evaluate the influences and potential solutions to achieving the stakeholder goal, the
following research questions guided this study:
1. What are the knowledge, motivation, and organizational elements related to achieving
the stakeholder goal that by October 2018, all AONE-member nurse leaders will be
able to identify and apply evidence-based practices in providing culturally competent
care to patients of all ethnic and racial backgrounds?
2. What are the recommendations for organizational practice in the areas of stakeholder
knowledge, stakeholder motivation, and organizational influences?
Conceptual Framework
A conceptual framework helps to align perceptions of a problem of practice, theories,
prior research findings, and previous literature addressing the issue (Maxwell, 2013). This study
utilized a modified version of the Clark and Estes’ (2008) gap analysis model as the conceptual
framework to identify the knowledge, motivation, and organizational influences of AONE-
member nurse leaders, related to their ability to identify and apply evidence-based practices in
providing culturally competent care to patients of all racial and ethnic backgrounds. The ability
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55
to provide culturally competent care is a provider-related factor that affects disparities of care for
racial and ethnic minorities (Geiger, 2006). To close performance gaps and achieve
organizational and stakeholder goals, it is necessary to identify gaps, so that appropriate
solutions can be applied (Clark & Estes, 2008). The Clark and Estes’ (2008) gap analysis model
is an analytical method used to assist in the clarification of goals and the identification of gaps
between actual performance levels and preferred performance levels within organizations.
Although the Clark and Estes’ (2008) gap analysis model helps to identify causes of performance
gaps, for the purpose of this study a modified version of the model was used to evaluate and
identify the presence of gaps, versus causes of gaps, in the key areas of knowledge, motivation,
and organizational barriers.
It is important to explore thoroughly each of the key factors of knowledge, motivation,
and organizational influences. All three must be present and aligned to reach targeted goals
successfully. Identifying gaps in knowledge requires understanding whether people have the
knowledge needed to reach a set performance goal. Four primary knowledge types that
contribute to learning and performance gaps include factual, conceptual, procedural, and
metacognition (Krathwohl, 2002; Rueda, 2011). Gaps in performance related to motivation
impact one’s ability to start a task, continue to persist until a task or goal is completed, and
dedicate ample mental effort to be successful (Clark & Estes, 2008; Pintrich, 2003). The third
factor affecting the achievement of performance goals, organizational barriers, are present when
organizational processes and resources are either limited or ineffective (Clark & Estes, 2008).
All three of these factors, knowledge, motivation, and organizational influences,
contribute to nurse leaders being able to identify and apply evidence-based practices in providing
culturally competent care. To illustrate, to provide culturally competent care, nurse leaders need
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56
to have the knowledge to define the impact that disparities of care have on health outcomes for
racial and ethnic minority patients (Campinha-Bacote, 2002). Nurse leaders must also be
motivated to see the value in leading their staff to provide culturally competent care and that they
can be successful in doing so (Campinha-Bacote, 2002). In addition, nurse leaders must receive
clearly defined goals and objectives from their organizations to improve their level of cultural
competence (Purnell et al., 2011).
Figure 1 provides a visual representation of the framework used for this study. As shown
in the figure, knowledge, motivation, and organizational elements affect the achievement of
nurse leaders leading their teams to provide culturally competent care. Achieving the stakeholder
goal directly affects the achievement of the organizational goal that all nurses will provide
culturally competent care to patients of all races and ethnicities.

Figure 1. Study conceptual framework: Modified Clark and Estes gap analysis
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57
Participating Stakeholders
The primary stakeholder group for this study was AONE-member nurse leaders. A
random sample of AONE-member hospital-based nurse leaders was solicited to participate in the
survey. Using a random sample ensured that research findings could be generalized to the
broader nurse leader population. Survey respondents were asked to volunteer to potentially also
participate in an individual interview. The list of volunteers was randomly sorted and then six
nurse leaders were purposefully selected from the randomized list to be interviewed. The first
two nurse leaders from the randomized list were selected for each of the three job roles,
including chief nurse executive or vice president, nurse director, and nurse manager. The use of a
purposeful sample was useful to provide a deeper understanding of the knowledge, motivation,
and organizational influences that affect the stakeholder goal (Merriam & Tisdell, 2009).
Survey Sampling Criteria and Rationale
Criterion 1. The first criterion for the sample was that participants were AONE-member
nurse leaders. This criterion aligned with the stakeholder goal that by October 2018, all AONE-
member nurse leaders will be able to identify and apply evidence-based practices in providing
culturally competent care to patients of all ethnic and racial backgrounds. Survey participants
acknowledged that they met this criterion before gaining access to the survey.
Criterion 2. The second criterion for the sample was that participants were hospital-
based nurse leaders who were responsible for overseeing or leading nursing care teams in their
organizations. Survey participants acknowledged that they met this criterion before gaining
access to the survey.
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58
Survey Sampling Strategy and Rationale
A random sample method was used which included AONE-member nurse leaders as
potential respondents. Utilizing a random sample method provides an equal opportunity for each
member of the population to participate (Fink, 2013). Using this sampling method, each AONE-
member had an equal probability of participating. Further, the findings of the study could be
generalized to the broader nurse leader population. AONE-member nurse leaders were invited to
complete an online survey, which assessed the knowledge, motivation, and organizational
influences affecting leading their nursing teams to provide culturally competent care to patients
of all racial and ethnic backgrounds. Potential nurse leader participants received survey
information and a request to participate in the online survey via announcements in the online
AONE-member newsletter over a four-week period.
The survey data collection served as the first stage of this study, followed by individual
interviews. To volunteer to participate in an individual interview, respondents were directed to a
second survey, not connected to the initial survey, to ensure that their survey responses remained
anonymous.
Interview Sampling Criteria and Rationale
Criterion 1. The first criterion for the sample was that participants were AONE-member
leaders. This criterion aligned with the stakeholder that by October 2018, all AONE-member
nurse leaders will be able to identify and apply evidence-based practices in providing culturally
competent care to patients of all ethnic and racial backgrounds.
Criterion 2. The second criterion for the sample was that participants were hospital-
based nurse leaders who were responsible for overseeing or leading nursing care teams in their
organizations.
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59
Criterion 3. The third criterion for the sample was that participants were nurse leaders
who completed the survey and volunteered to participate in an interview.
Interview Sampling Strategy and Rationale
The interview component of the study was utilized to better understand the influences
that contribute to nurse leaders leading their teams in providing culturally competent care. In
qualitative research, interviews focus on the meaning the research participants make of the
problem of practice, versus the researcher’s perspective or findings from the literature (Creswell,
2014). The names of survey participants who volunteered to participate in an interview were
sorted randomly. The sample group was purposefully selected from the randomized list to
include two chief nurse executives or vice presidents, two nurse directors, and two nurse
managers. Purposeful sampling requires the selection of respondents who align with the study
purpose and meet specific criteria (Merriam & Tisdell, 2009). The geographic locations of the
interview volunteers were reviewed to ensure there was geographic representation from various
parts of the U.S. The use of a purposeful sample enabled the selection of participants who were
best able to address the research questions and represent various levels of leadership, years of
experience, and geographic location. The six identified nurse leaders were solicited to participate
in an interview via an email from the researcher.
Data Collection and Instrumentation
This study was based on a mixed method approach, using both quantitative and
qualitative data collections. The research design was explanatory, meaning quantitative data was
collected and analyzed first, followed by qualitative data collection and analysis. Using an
explanatory method allows the researcher to use the qualitative data to explain further the
findings of the quantitative data (Creswell, 2014). For this study, the qualitative interview and
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60
observation data were used to build upon the data and findings of the quantitative survey,
regarding influences that contribute to being able to identify and apply evidence-based practices
in providing culturally competent care. A mixed method study supports data triangulation, or the
ability of multiple data collection methods to support each other’s strengths and weaknesses
(Maxwell, 2013). A mixed method study also provides an opportunity to develop further the
qualitative questions based on the findings of the quantitative survey (Creswell, 2014). In this
study, the qualitative questions were reviewed after the survey data were collected to ensure that
no adjustments were needed.
Quantitative research allows the researcher to numerically identify trends, attitudes, and
opinions of a sample that can be projected to the broader population (Creswell, 2014). The goal
of the quantitative survey in this study was to collect data on the participants’ perceptions of the
knowledge, motivation, and organizational elements, which affect the stakeholder goal of all
AONE-member nurse leaders being able to identify and apply evidence-based practices in
providing culturally competent care to patients of all ethnic and racial backgrounds. The
quantitative data were also used to inform the qualitative interview questions. Qualitative
research helps to provide an understanding of how people make sense or meaning out of their
environments and experiences (Merriam & Tisdell, 2009). The qualitative interviews for this
study probed deeper into how the stakeholders interpret or understand the influences that affect
providing culturally competent care.
Prior to collecting data, approval for the study was obtained through the University of
Southern California Institutional Review Board. A recruitment letter, included in the AONE
member newsletter, was used to invite nurse leaders from the defined sample to participate in the
study. The letter included a brief overview of the goal of the research, as well as a description of
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61
the sampling criteria (Appendix A). Prior to participation, research volunteers received an
informed consent document, which outlined the purpose of the study, participant involvement,
payment/compensation for participants, confidentiality, and investigator contact information
(Appendix B). Permission was obtained to record the individual interviews.
Survey
A link to the survey was included in an electronic newsletter distributed to the AONE
membership; 132 surveys were completed. The survey instrument included 15 questions that
addressed various influences to providing culturally competent care to patients of all racial and
ethnic backgrounds and six demographic questions (Appendix C). The survey responses were
based on a five-point Likert scale for level of agreement, including strongly disagree, disagree,
neither agree or disagree, agree, or strongly agree. Aligned with the conceptual framework of the
study, the questions explored the knowledge, motivation, and organizational influences that
affect nurse leaders being able to identify and apply evidence-based practices in applying
culturally competent care. The survey reliability and validity was tested by piloting the survey
instrument with a sample group of five nurse leaders prior to distributing the survey.
Interviews
Respondents of the survey were asked to volunteer to potentially participate in an
individual interview. Randomly sorting the list of volunteers, six nurse leaders were selected to
be interviewed including the first two chief nurse executives, first two nurse directors, and first
two nurse managers. Contacted by email, all invited interviewees participated; no alternate
interviewees were needed. The individual interviews lasted between 32 and 45 minutes and were
conducted using Skype or phone, due to geographical constraints. The interviews included 10
open-ended questions in a semi-structured format, which enabled probes and follow-up questions
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62
when appropriate (Appendix D). Open-ended questions allow respondents to express themselves
in their own words (Fink, 2013). A semi-structured format provides consistency between
interviews, but still allows flexibility for the researcher to probe into emerging insights (Merriam
& Tisdell, 2009). Aligned with the conceptual framework of the study, the interview questions
for this study explored the knowledge, motivation, and organizational influences that affect nurse
leaders being able to identify and apply evidence-based practices in applying culturally
competent care. To increase the validity of the survey, member checking was used in which key
findings and themes were reviewed with the participants during the data analysis stage. Member
checking is a key strategy to reduce interviewer bias and misinterpretations (Maxwell, 2013).
Peer review and examination are other strategies to improve validity and reliability by reviewing
emerging findings with colleagues (Merriam & Tisdell, 2009). For this study, preliminary
findings were shared with nurse leader colleagues at the AHA to allow adjustments to the data
collection process if needed.
Data Analysis
For this study, an analysis was conducted that synthesized data collected from the online
survey and the nurse leader interviews. Prior to analyzing the survey data, the survey analysis
plan developed during the study development stage was updated. A survey analysis plan allows
the researcher to map survey questions to a study’s research questions, as well as provide
strategies for statistical calculations and data presentation (Pazzaglia, Stafford, & Rodriguez,
2016). After the survey analysis plan was updated, the data was cleaned by looking for missing
data and data entry errors. Data cleaning improves data quality by eliminating errors and
inconsistencies (Rahm & Hong, 2000). Since the survey questions were based on a five-point
Likert scale, and entered electronically, data entry error was minimal. Any question with a
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63
response rate less than 85% was examined to determine viability in projecting to the broader
nurse leader population. Only completed responses were included in the data analysis; non-
responses were not included in the evaluation. Descriptive statistics were calculated after all
survey data were collected.
Interview data were collected after the survey data collection and initial data analysis
phases were completed. Data analysis of the interviews began during interview data collection.
After each interview, an analytic memo was drafted that documented the researcher’s reflections,
observations, and initial themes tied to the research questions and conceptual framework of the
study. Analytic memos are useful to synthesize data to begin to make meaning of the data (Miles,
Huberman, & Saldaña, 2014). In addition to analytic memos, self-reflection memos were utilized
to explore limitations and potential biases of the researcher. After each interview, analysis began
by transcribing the interviews and then coding the transcripts using a three-phase process. In the
first phase, the transcripts were open coded, followed by the identification of empirical codes
that tied to the study’s conceptual framework and addressed the knowledge, motivation, and
organizational influences. According to Harding (2013), empirical codes emerge as part of the
data analysis process. A second phase of coding was conducted to aggregate the identified
empirical codes into analytical/axial codes. In the final phase, these analytical/axial codes were
used to identify pattern codes and themes that related to the conceptual framework of the study.
Throughout the interview analysis, a codebook was maintained, which summarized emerging
codes and themes. A variety of tools were used in the analysis phase to aid in the analytic
process, including asking questions when experiencing writer’s block, drawing on personal
experiences, and exploring the “so what?” to gain further meaning of the responses (Corbin &
Strauss, 2008). Gaps in knowledge, motivation, or organizational influences were considered
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64
validated if they were present in both the survey and interview data. The findings from the
collected data are analyzed and presented in Chapter 4.
Credibility and Trustworthiness
The credibility of a research study’s data is closely associated with the ethics of the
researcher (Merriam & Tisdell, 2009). It is the responsibility of the researcher to produce data
and resulting findings that are credible and trustworthy (Maxwell, 2013). Internal validity, or the
accuracy of the study findings to the external environment, is one way to measure the study’s
credibility (Maxwell, 2013). One strategy to improve credibility, implemented in the study, was
the use of triangulation, or multiple methods of data collection, including survey and interviews.
This triangulation allowed for validation of the findings across multiple methodologies. A
second strategy to increase credibility is member checking. Also called respondent validation,
this strategy involves sharing initial findings with the survey respondents to reduce the
occurrence of potential misinterpretation (Maxwell, 2013). Peer review was also used by sharing
the research framework with nurse leader colleagues at the AHA to allow adjustments to the
survey design, data collection procedures, and research analysis.
Validity and Reliability
To improve credibility, research studies must demonstrate validity and reliability.
Validity is the extent to which the survey findings can be generalized to the broader population,
while reliability aims to improve the consistency of the study findings (Merriam & Tisdell,
2009). A random sample method used for the quantitative survey, included AONE members who
met the defined criteria. To increase the validity of the research findings, a purposeful sample for
the qualitative interviews was used to select two chief nurse executives or vice presidents, two
nurse directors, and two nurse managers from the randomly sorted list of volunteers who
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65
completed the survey. To improve reliability, the triangulation of data methodologies for this
study helped validate the reliability and consistency of the data. Further, an audit trail was
developed by logging detailed projects notes throughout the study. An audit trail helps improve
the reliability of a study through the ability to follow the study development and execution
(Merriam & Tisdell, 2009). Non-response bias was addressed in the qualitative interviews by
being prepared to select an alternative if the selected respondent was unwilling or unable to
participate. All selected respondents agreed to participate, no alternates were needed.
Ethics
To ensure high ethical principles were upheld related to this study, a number of principles
were applied. First, the study proposal was approved by the Institutional Review Board (IRB) of
the Office for Protection of Research Subjects (OPRS) at the University of Southern California.
To comply with IRB requirements, informed consent was obtained from all participants prior to
the start of the study through signed consent forms. Research consent forms must include
notification that participation in the study is voluntary, review any potential risks, and
acknowledge that participants may stop involvement in the study at any time without penalty
(Glesne, 2011; Rubin & Rubin, 2012).
The individual qualitative interviews for this study were audio recorded and a permission
form was obtained from respondents, as well as a verbal consent prior to the interview, granting
permission to record. The confidentiality and privacy of the respondents was critical during the
interviews. Participants in any research study should be protected and ensured that the
information they provide is held in the highest level of confidentiality (Glesne, 2011). To protect
the privacy of the respondents, the quantitative data is reported in aggregate form. The
qualitative data is presented with no unique identifiers tied to the respondents. Pseudonyms for
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66
the interviewed nurse leaders were also used to protect the confidentiality and privacy of the
interviewees. When using pseudonyms, it is important to ensure that the identity of the
respondents is not evident through the organizational description and other information provided
(Rubin & Rubin, 2012). A legend of the participants was documented and stored. A separate
legend of the participants should be maintained and held confidentially in a place separate from
the interview notes, to allow the researcher to identify a participant if needed (Maxwell, 2013).
It is also important that participation in the survey cause no harm to the respondents,
which would include not publishing information that could be detrimental to the respondents’
professional lives, including the loss of their jobs (Rubin & Rubin, 2012). To protect further the
privacy of the respondents, the survey data for this study is being stored on a password-protected
computer in a secure office. The data files will be destroyed two years after the completion of the
survey. The researcher facilitated the individual interviews and the interview transcripts are
being stored on a password-protected computer in a secure office of the researcher. Only the
researcher and professional transcriber had access to the audio recordings, which were destroyed
after they were transcribed.
Reciprocity, or the exchange of favors, is used often in research studies to encourage
participation (Glesne, 2011). In the survey communications for this study, potential respondents
were notified that they would not receive compensation for completing the survey. All
participants who completed the survey and provided their contact information received a thank
you note and were entered into a drawing to receive a $50 Amazon gift card. Five gift cards were
awarded. Participants were not coerced to complete the survey in any manner, but rather were
encouraged to participate as a means of contributing to the issue of reducing disparities of care, a
critical issue for the health care field.
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CHAPTER 4
RESULTS AND FINDINGS
The purpose of this study was to evaluate the degree to which AONE is meeting its
organizational goal that by May 2020, all nurses led by AONE-member nurse leaders will
provide culturally competent care to patients of all ethnic and racial backgrounds. Although
multiple stakeholder groups contribute to this goal, the primary stakeholder group for this study
was AONE-member nurse leaders. The stakeholder goal is that by October 2018, all AONE-
member nurse leaders will be able to identify and apply evidence-based practices in providing
culturally competent care to patients of all ethnic and racial backgrounds. This problem of
practice is important to address because race, ethnicity, and language preference affect the health
outcomes of patients regardless of socio-economic status.
This study focused on the knowledge, motivation, and organizational influencers related
to achieving the stakeholder goal. The following research questions guided this study:
1. What are the knowledge, motivation, and organizational elements related to achieving
the stakeholder goal that by October 2018, all AONE-member nurse leaders will be
able to identify and apply evidence-based practices in providing culturally competent
care to patients of all ethnic and racial backgrounds?
2. What are the recommendations for organizational practice in the areas of stakeholder
knowledge, stakeholder motivation, and organizational influences?
Study Participants
The primary stakeholder group for this study was AONE-member nurse leaders who met
the sampling criteria outlined in Chapter 3. Survey criteria included that participants be AONE-
member nurse leaders, who were hospital-based and responsible for overseeing or leading
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68
nursing care teams in their organizations. Interview criteria included survey participants, who
met the survey criteria, and volunteered to be interviewed.
Survey
A random sample of 132 nurse leaders, who met the study criteria and provided written
consent, completed the survey. The participants included 109 females (82.6%) and 23 males
(17.4%). The respondents were predominately White (85.7%), followed by African American
(5.3%), Asian (4.5%), Hispanic or Latino (3.0%), or other (1.5%). The largest percentage of
respondents had master’s degrees (70.2%), while 18.3% had attained doctoral degrees, followed
by 11.5% with bachelor’s degrees. As shown in Table 5, the largest percentage of respondents
were directors (37.9%), followed by managers (36.4%), CNOs/CNEs/vice presidents (18.9%),
and other (6.8%).

Table 5
Respondent Level of Responsibility
Nursing Responsibility
Percentage of
Respondents
Number of
Respondents
Director 37.9% 50
Manager 36.4% 48
Chief Nursing Officer/ Chief Nursing Executive/ Vice
Presidents
18.9% 25
Other 6.8% 9

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The respondent level of years in a nursing leadership role ranged from one year or less to
more than 20 years. As shown in Table 6, more than half of the respondents (55.3%) had 11 or
more years of experience. Just over a quarter (25.8%) had six to 10 years of experience, 15.9%
had two to five years of experience, and the remaining 3.0% had one year or less of experience.

Table 6
Respondent Level of Years in a Nursing Leadership Role
Years in Nursing Leadership Role Percentage of Respondents Number of Respondents
0 to 1 years 3.0% 4
2 to 5 years 15.9% 21
6 to 10 years 25.8% 34
11 to 15 years 12.1% 16
16 to 20 years 19.7% 26
Over 20 years 23.5% 31

Of the total respondents, 60.1% (79) were employed at hospitals in urban settings,
compared to 21.8% (29) employed in suburban settings, and 18.1% (24) employed in rural
settings. As shown in Table 7, the largest percentage of respondents (38.6%) worked in hospitals
with 500 to 999 licensed beds, followed by 100 to 300 beds (23.5%), 301 to 499 beds (22.0%),
1000 to 4,999 beds (8.3%), less than 100 beds (6.8%), and more than 5,000 beds (.8%).

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Table 7
Respondents ’ Hospital Licensed Bed Count
Hospital Licensed Bed Count Percentage of Respondents Number of Respondents
Less than 100 6.8% 9
100 to 300 23.5% 31
301 to 499 22.0% 29
500 to 999 38.6% 51
1000 to 4,999 8.3% 11
More than 5,000 .8% 1

Interviews
Six interviews were conducted with nurse leaders who met the study criteria defined in
Chapter 3. Four interviews were conducted via Skype and two interviews were conducted via
telephone, at the request of the interviewees. The length of the interviews ranged from 32 to 45
minutes. Below is a summary of the interview participants, using pseudonyms as identifiers.
Cheryl. A chief nursing officer with more than 20 years of experience, who works for a
hospital with 301 to 499 beds in an urban setting. Cheryl is a White female who has a master’s
degree.
Kathy. A vice president with 11 to 15 years of experience, who works for a hospital with
100 to 300 beds in a suburban setting. Kathy is a White female who has a master’s degree.
Sharon. A director with two to five years of experience, who works for a hospital with
100 to 300 beds in a rural setting. Sharon is a Black female who has a master’s degree.
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71
David. A director with two to five years of experience, who works for a hospital with 100
beds or less in an urban setting. David is a White male who has a master’s degree.
Lori. A manager with six to 10 years of experience, who works for a hospital with 300 to
499 beds in a suburban setting. Lori is a White female who has a master’s degree.
Meg. A manager with 16 to 20 years of experience, who works for a hospital with 500 to
999 beds in a suburban setting. Meg is a White female who has a master’s degree.
Findings for Research Question 1
Summarized in this chapter are the findings of the survey and interviews related to
research question 1. The second research question, which addresses the recommendations for
organizational practice in the areas of stakeholder knowledge, stakeholder motivation, and
organizational influences, is addressed in the recommendations section of Chapter 5.
This section addresses the study’s first research question: What are the knowledge,
motivation, and organizational elements related to achieving the stakeholder goal that by October
2018, all AONE-member nurse leaders will be able to identify and apply evidence-based
practices in providing culturally competent care to patients of all ethnic and racial backgrounds?
The section is organized by key stakeholder influences, including knowledge, motivation, and
organizational causes.
Results for Knowledge Causes
Factual knowledge. Nurse leaders need to have increased factual knowledge of the
prevalence of health care disparities for racial and ethnic minorities and the resulting reduced
health outcomes for this population group. To be successful in providing culturally competent
care, nurse leaders need to be able to define the impact that disparities of care have on health
outcomes for racial and ethnic minorities. Figure 2 shows that only 58.3% of survey respondents
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72
agreed (strongly or somewhat) that racial and ethnic minority patients in the U.S. receive lower
quality of care, resulting in reduced health outcomes. Nearly one-third (30.3%) of respondents
disagreed (either strongly or somewhat) that racial and ethnic minority patients receive lower
quality of care, resulting in reduced health outcomes.

Figure 2. Racial and ethnic minority patients in the United States receive lower quality of care,
which results in reduced health outcomes

The interview data provided insight to support the lack of factual knowledge of health
care disparities for racial and ethnic minority patients by nurse leaders, noted in the survey. A
common theme that emerged in the interviews was the perception of the nurse leaders that all
patients within their hospitals receive equal care, regardless of their race or ethnicity. The nurse
leaders discussed that nurses objectively treat patients by diagnosis, so patient race and ethnicity
is not a factor in providing care. Further, there was a general perception that because the nurse
10.6%
19.7%
11.4%
38.6%
19.7%
0%
10%
20%
30%
40%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
Racial and ethnic minority patients in the United States receive lower
quality of care, which results in reduced health outcomes (n = 132)
HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

73
leaders feel all patients have access to care in their hospitals, there are limited disparities for
racial and ethnic minority patients. These two themes, including nurses objectively treat patients
by diagnosis and the perception that all patients have access to care in their hospitals, are
explored further in the section below.
Although the interviewed nurse leaders felt patients received equal care in their
organizations, two nurse leaders articulated a broader understanding of the presence of
disparities for racial and ethnic minorities. One of the interviewed senior leaders, Cheryl, who
has more than 20 years of experience in leadership, expressed her understanding of health care
disparities for racial and ethnic minority patients as,
The research is very clear about the differences in race, ethnic, even social economics for
patients, and that they don’t get access to the same care, and this is not always driven by
their insurance . . . . I don’t know how anybody could not be aware of the data.
When asked if she thought that the nurses who reported to her had the same understanding of
health care disparities for racial and ethnic minority patients, she said she was not certain. She
expressed concern about the potential gap in health care disparity knowledge by saying,
I’m going to ask some of my leaders, but we have talked about cultural competency and
disparities for a long time. So, I don’t know how people can’t know, unless they are just
not reading the literature. But there’s all of those unknown biases that are inherent. So, I
wonder if that is why they just don’t want to even dream about the fact that perhaps they
were giving different care. Not intentionally in any way, but simply because it was there,
and so I wonder if that skews how you look at it, versus the data is the data and you can’t
argue with the data and research.
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74
Another interviewed nurse leader, Sharon, who self-identified as a racial minority and
serves in a nurse director role appeared to have a higher knowledge and awareness of the
presence of health care disparities. She shared that she is more aware of disparities, partly
because she is a Black female. When asked about the lack of health care disparity knowledge of
other nurses, she said that in her organization some nurses have had little exposure to open
dialogue about the presence of disparities. She said, “A lot of these nurses haven’t seen some of
the things that I have seen, so their vision is like blinders on a horse. They sometimes don’t see
the things around them.”
Although these two nurse leaders, at different levels of leadership, were aware of the
presence of disparities, other interviewed nurse leaders did not have the same level of
understanding. For example, one of the interviewed nurse leaders, Lori, a nurse manager with six
to 10 years of experience, said that disparities are not a result of “one’s race, creed, or color, it
has to do with choices in life.” She said, “Risk factors have nothing to do with racial disparity. It
has to do with people’s choices in the way they live . . . . I am not supposed to start enabling you
so you don’t have to take personal responsibility.” She questioned if “people on entitlement
programs deserve to get the same care as people who are working for a living.”
Trained to teach by diagnosis. As noted, a common theme in the interviews was the
belief of the nurse leaders that nurses are trained to treat all patients according to their diagnosis,
regardless of race or ethnicity. As a result, the interviewed nurse leaders felt that all patients
received equal care, with the exception of patients who had reduced access to health care due to
socio-economic factors, such as income limitations and poor housing and community
environments. Meg, a nurse manager working in a suburban environment explained, “You
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75
always have the diagnosis. You always come back to that one equalizing factor and everyone can
be on the same playing field.”
In contrast, Lori felt strongly that patients should take responsibility for overcoming their
personal adversities and managing their own health care.
My obligation is to provide evidence-based care. I don’t know of any nurse or doctor that
would not provide evidence-based care. I don’t see disparities, and I think a lot of times
when I’m looking at all of the numbers, the numbers are about the fact that a population
didn’t get care until late in the stage or they’re having a higher mortality rate because
they never went to the doctor. That’s not the hospital’s fault.
Sharon, who self-identified as a minority, disagreed with the belief that all patients
receive equal care and shared that her knowledge of this perception comes from her own
experience as a minority patient.
Minority patients don’t feel safe in our health care environment because they don’t feel
like they are going to get the treatment that they need to get, like they are always going to
be treated less than other cultures and races.
Sharon shared a story of a Hispanic male patient who said to her, “I should have come sooner but
I didn’t think you guys would take care of me.” Sharon responded to the patient by saying, “Of
course we’ll take care of you. You could be an alien in green skin and if you walked in here, I’m
going to take care of you.”
Throughout the interviews, the nurse leaders placed an emphasis on the training nurses
and other clinicians receive to treat patients by diagnosis, regardless of race, ethnicity, and other
unique patient factors. This training appears to create a potential blind spot for looking at each
HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

76
patient holistically, taking into account the unique attributes that a patient’s race, ethnicity, and
culture contributes to their whole person.
Perception that access to care equates limited disparities. The assumption that access to
care and equitable health outcomes are the same also emerged in the interviews. Several of the
interviewees associated equal access to care with equitable health outcomes because they
perceive that their hospitals provide care regardless of the ability of the patient to pay. When
asked about the presence of health disparities and lower quality outcomes for racial and ethnic
minority patients, Meg, a nurse manager working in a large suburban hospital shared:
We’ve always taken care of our non-paying patients either through state pay programs or
state aid of some sort. When patients come into our emergency room and they don’t have
a payer, we find a way to be able to provide them with care.
Kathy, an assistant vice president from a mid-sized suburban hospital shared a similar view
saying, “If we’re looking at socioeconomic status and disparities, I don’t see a lot of disparities.”
David, a nursing director who works in a small urban hospital, said:
Perhaps certain population groups feel they have a disparity before seeking treatment
because they are poor and feel others believe they do not deserve as good of quality of
care as those with private insurance or come from better jobs or better lives.
Lori also agreed that she does not see disparities for racial and ethnic minority patients in
her hospital and questioned the validity of data that supported the disparities existed.
I do not see disparities, except for patients that don’t understand that there is a safety net
in the community and don’t utilize those available services. I don’t know of any nurse or
physician that would not provide care. I think a lot of times when I’m looking at all of the
numbers, the numbers are about the fact that a population didn’t get care until late in the
HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

77
stage or they’re having a higher mortality rate because they never went to the doctor.
That’s not the hospital’s fault. I think we have to get away away from the disparities
based on race, color, creed or sexual orientation . . . it has to do with his choices in life.
Because nurse leaders see patients of all races and ethnicities receiving care in their
organizations, regardless of ability to pay and other limited socio-economic factors, they believe
the presence of health care disparities and reduced quality outcomes for racial and ethnic
minority patients is minimized.
Conceptual knowledge. Although nurse leaders understand the meaning of providing
culturally competent care, the depth of their understanding varies. To be able to identify and
apply evidence-based practices in providing culturally competent care, nurse leaders need to
have an understanding of the meaning of providing culturally competent care. The level of
understanding of the meaning of providing culturally competent care varied across the nurse
leaders interviewed and did not seem related to their role within the organization. Some of the
nurse leaders described culturally competent care from a broad holistic view, others focused
more narrowly on treating patients all the same, attributing cultural competence specifically to
race, or challenges to providing cultural competent care.
To illustrate the varied descriptions of providing culturally competent care, Sharon
described her understanding as awareness of other cultures:
Cultural competence for me is the nurses being aware of other cultures that they care for,
not just their own culture, and how their background and experiences affect them, how
their own experience affects them and being more open to other cultures, whether the
religion, its people, and really understanding how that affects their nursing care. How
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78
their preconceived notions on culture, on different things can effect and can impede on a
patients’ care, not that the nurse means to, but it certainly can.
Kathy described providing culturally competent care similarly, focusing on treating individuals
the same, while still having an understanding of various cultural influences:
Culturally competent care to me means that we treat all people, no matter what their race
or ethnic background, or beliefs may be, the same, and that we have an understanding of
all of those cultures and what they mean or may not believe in. In order to be able to do
that we have to promote cultural competence and education of that subject throughout our
nursing care.
Liz described providing culturally competent care as care that is holistic and based on the
perceived need of the patient:
It’s providing care that is holistic and is based on where the patient is at, and based on
where the patient perception of that they want and need are. So, wherever the patient is
at, that’s where we come from. It’s more than just individualized, it’s more than just
person centered, but it really is holding each and every human being as a sacred trust, and
really trying to be as non-judgmental as possible, in approaching patients where they are
at.
In the interviews, other nurse leaders articulated a more narrow view of the meaning of
providing culturally competent care. David equated cultural competency more specifically with
race by stating, “My view of race and culture might be different them most of us because I
served in the military. In the military, you are taught one color, one race, one organization. Race
has never been a big deal to me.”
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79
Lori shared her frustration about her understanding of what providing culturally
competent care is by saying, “I feel like I’m responsible to meet everyone’s cultural desires or
I’m incompetent.” She added that she felt that being responsible to meet the broad range of
individual cultural needs was an “unrealistic expectation.” She said these high expectations
create challenges in providing care by saying,
If you’re wanting a Navajo witch doctor to take care of you, you might be deeply
disappointed because we don’t have a Navajo witch doctor at my hospital. I’m a
Christian and I’m an American, so if people are foreigners and they come to our country,
I don’t know that I could be culturally competent and meet all of their desires.
The understanding of the meaning of providing culturally competent care varied considerably
among the interviewed nurse leaders ranging from broad holistic views, to more narrow and rigid
perspectives.
Nurse leaders understand that numerous factors, including the individual, family, and
community influence the cultural context of each patient ’s treatment and the importance of
modeling that understanding to the nurses they lead. To be able to identify and apply evidence-
based practices in providing culturally competent care, nurse leaders need to have an
understanding of the meaning of providing culturally competent care. Nurse leaders understand
that the individual, family, and community influence the cultural context of each patient’s
treatment. As shown in Figure 3, 91.6% of the survey respondents agreed (strongly or somewhat)
that the individual, family, and community influence the cultural context of each patient’s
treatment; only 4.6% disagreed (strongly or somewhat). Understanding the connection between
providing cultural competent care and the cultural context of each patient’s treatment
demonstrates conceptual knowledge of the meaning of providing culturally competent care.
HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

80

Figure 3. The cultural context of each patient’s treatment is influenced by the individual, family,
and community

Influence of individual, family, and community. The interviews supported the survey data
that nurse leaders understand the influence of the individual, family, and community in providing
culturally competent care to patients of all racial and ethnic backgrounds. To illustrate, Sharon
reflected on caring for an Indian patient, whose daughters were highly involved in his care while
he was in the hospital. This involvement caused stress for the nursing staff at her hospital
because they felt the daughters were hovering and being intrusive on his care. Sharon shared that
she used this situation as a teaching moment with her nurses, by telling her team,
Well, let’s talk about that. Why are they so hovering? What are they worried about? How
can we help them? This is a culture where their dad is the head of the family. Their mom
has passed away a couple of years ago. They are going to support their dad in any way
2.3%
2.3%
3.8%
43.9%
47.7%
0%
10%
20%
30%
40%
50%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
The cultural context of each patient's treatment is influenced by the
individual, family, and community (n = 132)
HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

81
they can. In their culture, it is not being overbearing and asking too many questions. They
truly want to understand.
She added that an Indian co-worker shared with the other nurses, “I’m surprised they are not
staying here, bathing him, and doing everything.” Sharon said that this situation was a good
opportunity to teach the nurses about the many cultural attributes that impact the care patients
receive.
Sharon also shared another story about her team treating a Hispanic male patient who did
not want to comply with taking his medication. Through a culture day at the local university’s
school of nursing, one of the nurses learned about the perception of pain in the Hispanic culture.
Sharon shared, “It really helped them when they were talking about the Hispanic community and
their culture of dealing with pain. In their culture, pain is almost a good thing.” She said that the
treating nurse said, “It makes sense now why my patient wouldn’t take any pain medication.” In
these examples, Sharon demonstrated an understanding of the influencers that impacts providing
culturally competent care to patients and was able to model that learning to their nursing staff.
Addressing the unique cultural needs of patients. A general theme of the interviews,
noted under the factual knowledge section of this chapter, was that the nurse leaders perceived
that all patients are treated the same by diagnosis, and as a result, there are limited health care
disparities. Despite this perception, there were several examples provided that illustrated
treatment plans based on the unique cultural needs of the patient. Sharon shared a story about
caring for an Asian male patient who required that his food be served warm. She said, “That was
part of his culture and was very important to his healing because in his culture the comfort of
warm food supports healing.” She said that the nursing team worked with the dietary staff to
meet his needs because, “When we respect a patient’s culture and understand more about their
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82
culture, it helps us take better care of them and be better health care workers.” Meg shared the
importance of incorporating access to places of worship, including meditation and prayer rooms
for patients with varied religious faiths, to facilitate healing. She said, “We have all different
services provided, Catholic, Presbyterian. At sunset, we do prayers in the meditation room for
different religions. We just try to make sure that the staff is aware of those services.” Further,
Kathy described how her hospital uses patient notes to help meet the cultural needs of patients:
We use a folder with a notes page for the patient to write things that they want us as a
care team to know about. Things they prefer, things that bother them, how they would
like to be treated . . . so their care is tailored to them rather than tailored to the hospital.
Although there were several examples provided by the interviewed nurse leaders of care
delivered to meet patients’ unique cultural needs, Lori provided feedback on the difficulty of
doing so. Lori said that providing care that is unique to the cultural needs of each patient is “an
unrealistic expectation.” She said,
I don’t know all the rules of being a Muslim and I don’t know all the rules of being a
Buddhist. Unless I’m a robot and have all that stuff downloaded, like on the Matrix, to
meet everybody’s needs, I am going to fail.
Although the interviewed nurse leaders state that all patients are treated the same regardless of
race or ethnicity, there were several example provided, which support the presence of treatment
plans tailored to meet the unique cultural needs of each patient. The interview data supported that
patients are not always treated the same, but rather often treated to meet their cultural needs.
Procedural knowledge. Although nurses understand the importance of knowing how to
implement practices to provide culturally competent care, there is sometimes a gap in
implementation. To be able to identify and apply evidence-based practices in providing culturally
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competent care to patients of all ethnic and racial backgrounds, nurse leaders need to know how
to measure and assess successful strategies and practices for providing culturally competent care.
One practice used to reduce health care disparities is to minimize language barriers between the
clinician and the patient. As shown in Figure 4, 90.8% of the survey respondents agreed
(strongly or somewhat) that health care disparities that stem from language barriers can be
reduced through improved procedural knowledge of the nurses on how to effectively
communicate with patients for which English is not their primary language. Only 5.4% disagreed
(strongly or somewhat) with the statement. In the interviews, when discussing organizational
resources, the nurse leaders shared examples about the importance of nurses having correct
procedural knowledge of the use of language phone lines, which is a resource used often in
hospitals as an interpretation service. Sharon shared that although she mentors her nurses on the
effective way to utilize the language line, there still needs to be training on the resource to
provide optimal care to the patients. She said,
You should still make eye contact with the person you’re speaking to. They’re just
translating the words. A lot of times I’ve seen the nurses using the language line and
they’re looking down and writing. They are not making that face-to-face contact to
express to the patient that they really care and that they are there for them. This is just an
aid; the conversation is still happening between you and the patient.
Cheryl shared additional information about the need to provide procedural knowledge on proper
use of the language lines by saying, “There is a lot to the visual cues, which you don’t get from
the telephone. You are not seeing body language and other things that allow you to read between
the lines and asks other questions.”
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Figure 4. Health care disparities that stem from language barriers can be reduced through
improved procedural knowledge of the nurses on how to effectively communicate with patients
for which English is not their primary language

Experience gained in the practice setting and non-formal transfer of knowledge from
ethnic and minority co-workers improves nurse leaders ’ knowledge of how to deliver and assess
culturally competent care. To be able to identify and apply evidence-based practices in providing
culturally competent care to patients of all ethnic and racial backgrounds, nurse leaders need to
know how to measure and assess successful strategies for providing culturally competent care.
The interviewed nurse leaders perceived that there is a limited amount of cultural competence
content included in formal nursing education, although exposure to patients and co-workers from
varied cultures contributes to the procedural knowledge of nurses on how to provide culturally
competent care.
3.1%
2.3%
3.8%
31.3%
59.5%
0%
10%
20%
30%
40%
50%
60%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
Health care disparities that stem from language barriers can be reduced
through improved procedural knowledge of the nurses on how to effectively
communicate with patients for which English is not their primary language
(n = 131)
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Knowledge gained in the practice environment. The perception of the interviewed nurse
leaders was that there is a limited amount of formal education, either in nursing school
curriculum or hospital continuing education, dedicated to teaching nurses how to provide
culturally competent care. Although there seems to be limited formal education, the interviewed
nurse leaders believe that cultural competency knowledge gained in the practice environment is
more prevalent. When asked about formal education for nurses on providing culturally
competent care, Kathy shared, “I don’t personally feel like they [nurses] get as much out of it
when they’re not hands on, or it’s not something that they have input in, or something that they
don’t have to do themselves.” Kathy also talked about the value of continued learning in the
practice setting and how she models learning to her team:
Don’t look at the patient as where they come from or their background. Look at the
patient as a human being. If a patient comes in and they speak a different language or
they have a different culture and you don’t know about it, look it up.
To further support the value of knowledge gained in the practice setting, Sharon said,
“The formal lessons are not that impactful because it’s just something nurses have to be exposed
to.” She added, “It just goes in the back of their heads, but they have to learn how to take it in
and then apply what they are learning” when they are treating a diverse population. Cheryl
shared that a few of the nurses on her team attended a cultural competency fellowship program.
They would bring back the knowledge they gained and share with the rest of the nursing team.
She thought this sharing of knowledge was a positive example of transferring knowledge to co-
workers in the practice setting. Throughout these examples, the nurse leaders supported that
applying knowledge gained in both formal and informal settings is more impactful when
combined with actual experience of applying the learned knowledge.
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Knowledge gained from co-worker interaction. The interviewed nurse leaders shared that
nurses often obtain cultural competence knowledge from working with colleagues from other
cultures. Sharon stated the school of nursing at her hospital held a culture day. She described the
culture day as, “the nursing students talking about their cultures, foods, and traditions. It got
people to open up about their culture.” During another interview, Meg said that her organization
has a physician who treats patients from all over the world and is very culturally aware. Through
the physician’s example, the clinical team learned how to treat patients from diverse
backgrounds. She described her experience as,
Through this exposure to diverse patients, it opened my eyes to, ‘oh, we need a
refrigerator in this patient’s room because he is a Hasidic Jew and he has to have this and
he has to have that. He cannot have anything served in our cafeteria.’ I learned a lot
through just really hands on.
Meg said that she is “very thankful for our physician team and the diversity that they bring and
the willingness to share.” She added that although her hospital holds an annual cultural week, she
believes that, “Most of our cultural competence comes from just communication between
physicians and nurses.”
Likewise, Kathy shared a story about a charge nurse at her hospital who does community
service work within an ethnically diverse neighborhood in their area. Kathy shared that this nurse
is a valuable resource to teaching other nurses at the hospital.
We have a nurse here on nights who is a charge nurse. She works very closely with a
depressed district that has a large Spanish speaking population . . . she comes back with
information and she teaches our nurses so that we can give good care to those individuals
when they come into our hospital.
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Knowledge gained from a culturally diverse staff. Because the nurse leaders perceive that
a significant amount of cultural competence knowledge is gained from co-worker interaction, the
diversity of the staff was also identified as a positive attribute. Liz shared, “The more diverse the
workforce is, and reflective of the patient population, the better off we will be, but we have a
long way to go.” She added that she recently attended a nursing school graduation ceremony and
there was very little diversity among the group of graduates. She said to improve the diversity
mix in the workplace, “There needs to be more diversity in education as well.” Meg discussed
this diversity in staff as, “We’re recruiting nurses from all over the world. No longer is nursing
who you raise in your backyard.” She also described a staff cultural exchange day that her
organization held. She explained the benefit of the culture day as,
It really opened my eyes to some of my staff members that I couldn’t just treat them all
like they were a Midwestern raised, born, and bred nurse. I have people [nurses] from
Africa and from India and many different cultures. We’ve got a lot of different people
and we have to really look at what is important in their personal lives as well, especially
for days off and scheduling. If I can’t take care of my staff appropriately and with good
sensitivity then I’m not a good leader.
Kathy also shared the diversity of her staff by saying, “We have a broad mix of employees. We
have a Filipino base, a high Spanish-Mexican base, and Indian base.” These examples illustrate
the important role that diversity within the health care workforce has on the spread and transfer
of knowledge regarding treating patients from varied cultures and ethnic backgrounds, as well as
embracing a culturally diverse practice environment.
Metacognitive knowledge. Nurse leaders understand the importance of dedicating time
to reflect on their own knowledge and level of competence in providing care to patients of all
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racial and ethnic backgrounds, as well as their own potential prejudice and bias (both conscious
and unconscious), yet do not dedicate ample time doing so. To be able to identify and apply
evidence-based practices in providing culturally competent care to patients of all ethnic and
racial backgrounds, nurse leaders need to know how to reflect on their own knowledge and level
of cultural competence in providing care, be aware of their own cultural self-biases, and
understand how to utilize their own cultural competency knowledge in clinical decision-making.
Nurse leaders understand the importance of dedicating time for self-regulation and self-reflection
to expand their level of cultural competence. As shown in Figure 5, 97.7% of respondents agreed
(strongly or somewhat) that self-reflection is important to expand their cultural competence. Of
this total, 78.6% strongly agreed and 19.1% somewhat agreed. Less than 1% (.8%) disagreed that
this self-reflection is important.

Figure 5. It is important that nurses dedicate time to reflect on their own knowledge and level of
cultural competence in providing care to patients of all races and ethnic minorities
0.8%
0.0%
1.5%
19.1%
78.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage It is important that nurses dedicate time to reflect on their own knowledge and level
of cultural competence in providing care to patients of all racial and ethnic
minorities (n = 131)
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Likewise, nurse leaders understand that prejudice and bias, including both conscious and
unconscious bias, affects the care that patients receive. As shown in Figure 6, nearly all of the
respondents agreed (91.7%) that prejudice and bias, including both conscious and unconscious,
affect the quality of care that patients receive. The percentage that strongly agreed with the
impact of prejudice and bias (58.9%) was significantly less than the 78.6% of respondents who
strongly agreed about the need for self-reflection on their own knowledge of cultural
competence. In the interviews, the respondent nurse leaders shared their thoughts on the
connection between prejudice and bias, and the importance of self-reflection.

Figure 6. Prejudice and bias, including both conscious and unconscious bias, impact the quality
of care that patients receive

1.5% 1.5%
5.3%
32.8%
58.8%
0%
10%
20%
30%
40%
50%
60%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
Prejudice and bias, including both conscious and unconscious bias,impact
the quality of care that patients receive (n = 131)
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Presence of unconscious bias. Although the interviewed nurse leaders said they rarely, if
ever, see the presence of conscious bias in nursing, they did acknowledge the underlying
presence of unconscious bias. Meg shared, “There are always unconscious factors. There is
always preconceived ideas before you get to know a patient. The really good nurses can set aside
those ideas, start with the diagnosis and build a bond with the patient.” Cheryl also expressed her
thoughts on the presence of unconscious bias by saying,
I think health care disparities and cultural competence are intimately linked because I
don’t think we realize our inherent biases, no matter how much we talk about it, it gets
hard to look in the mirror and say that could be me.
Sharon shared a personal story, as a racial minority and cancer patient, of the care she received
as a patient during her cancer treatments at her hospital by saying,
For instance, for me, I know the nurse didn’t mean anything by it, but I know she just
didn’t really understand. It was a pain tolerance thing for me. I have lymphoma and I was
having a lot of pain from my radiation. She just made a comment saying, ‘My mom used
to say that black women just have a higher pain tolerance.’ I responded by saying, ‘No,
this one doesn’t. Guess what? This one does not like pain.’
Sharon said she used it as a teaching moment by telling the nurse, “Remember what you learned
in nursing school, that pain is objective, based on an individual’s experience. Not all black
women are going to have less pain because they are black. I have pain because I am me.” Sharon
added, “I’m certainly guilty of it my own self. Self-reflection is huge. You make quick
judgements on people before they even open their mouth, before you even know their story.”
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Bias based on diagnosis and other factors. Interestingly, several of the nurse leaders said
that they see more bias directed to patients with a specific diagnosis, versus bias based on race,
ethnicity, or culture. Meg shared,
The biggest disparity that I have seen does not have to do with race or culture. For me,
bariatrics is one of the biggest populations that have a huge disparity. No one wants to
care for them because they don’t want to get hurt; they don’t want to have to go through
how much effort it takes to take care of them. It really doesn’t matter what color of the
rainbow the patient was, if they were a bariatric patient, I couldn’t find a care provider for
that patient.
Meg added that she finds nurses typically gravitate to certain population groups based on their
diagnosis. To illustrate, she shared that nurses who enjoy working with transplant patients
gravitate to that populations group, regardless of race, ethnicity, or culture.
Another example of bias, not associated with race or ethnicity, was shared by Kathy. She
said that she sees more bias towards affluent patients, who expect to be treated differently
because they might have made a donation to the hospital, compared to racial and ethnic minority
patients. She shared, “Our nurses feel they should provide good care to all patients, not just those
who are more privileged.” David provided another example of bias not related to culture or
ethnicity, “If a patient comes in with a history of chronic pain, the nurses may have a bias that
the patient will be seeking pain medications.” He said that this type of bias is more prevalent
than bias based on race and ethnicity.
Role of self-reflection. In the interviews, the nurse leaders discussed the connection
between bias and the need for self-reflection. For example, Sharon said when asked about the
connection between self-reflection, bias, and providing culturally competent care she said,
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92
I think there is a huge relationship. When you become aware of your own experiences,
your own prejudice that plays a huge part in making things a bit better. You make quick
judgements about people before they even open their mouth, before you can find out their
story. You never know what someone’s story is unless you can walk in his or her shoes.
Sharon discussed the process that she uses to self-reflect on her own biases by saying,
I am a big proponent of self-reflection and its impact on improving your environment.
Become more aware of your own experiences and prejudices plays a huge part in making
things a bit better. I try to be more self-reflective. Whatever armor we put on as soon as
wake up and walk through the door, you never know what battle people are fighting. We
have to look at our own experiences and our own biases that we’re raised with that we
didn’t know we had.
To aid nurses in the self-reflection process, Kathy said that her hospital focuses on
relationship-based care, where people spend time reflecting on why they went into health care.
They explore what they need to do to keep their spirits ignited, and learn how to not only take
care of their patients, but also how to take care of their colleagues and themselves. Cheryl said
that her hospital, several years ago, offered a course where nurses shared potential scenarios
regarding patients of various ethnic and racial backgrounds. She said a goal of the program was
to uncover and address unconscious bias and although the program received positive feedback, it
was not offered again due to time and resources. She said, “I don’t know if I can add one more
thing to everyone’s plate right now. So we have been dealing with that more on a case-by-case
basis.”
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Results for Motivation Causes
Expectancy value theory. It is important to nurse leaders that they lead their teams in
providing culturally competent care, although there are many competing priorities. To be able to
identify and apply evidence-based practices in providing culturally competent care to patients,
nurse leaders need to see the value in their staff providing culturally competent care and believe
that they can be successful in doing so. As shown in Figure 7, nearly all the respondents (98.4%)
said that they agreed (strongly or somewhat) that it is important for them to lead their nursing
staff in providing culturally competent care. Of the 98.4%, only 5.5% somewhat agreed; the
remaining 92.9% strongly agreed. Less than 1% of the respondents disagreed; none of the
respondents strongly disagreed.

Figure 7. It is important for me to lead my nursing staff in providing culturally competent care

0.8% 0.8%
5.5%
92.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Somewhat disagree Neither agree nor
disagree
Somewhat agree Strongly agree
Percentage
It is important for me to lead my nursing staff in providing culturally
competent care (n = 127)
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94
Important to lead by example. The comments from the interviewed nurses support the
survey data that it is important to them that they lead their nursing teams in providing culturally
competent care, as well as serve as role models and mentors. Sharon shared her thoughts on
leading by example:
First of all, I think it’s an important part of my role as being a mentor. I want to say
monkey see, monkey do. They see me acting a certain way and if I am not culturally
competent then they are going to think it is okay for them not to be. When we go on
nursing rounds we do a lot of debriefing on a lot of different things. I’ll bounce questions
back to them if they have a question about something or if a situation comes up.
David shared, “I try to lead by example. I’ve had leaders in the past you could tell might be a
little bit biased towards different races. That was not a good fit for me.” He also discussed the
importance of modeling and seeking additional resources or support if needed, by saying, “If we
have a family that has certain cultural dietary restrictions . . . or if their family member can’t
leave at sundown on Friday, if I don’t know the correct protocol, I will utilize available resources
to find out.” Meg also discussed the importance of modeling appropriate behavior to other
members of the team. She said,
I want to make sure that I know things like if a nurse is fasting that day. My goal is to
train my nurses to make sure that everyone is as competent as possible to take care of
every patient that comes through the door. If you are in there showing them, they start to
absorb it.”
These examples illustrate the importance nurse leaders place on modeling and leading by
example to support their teams in providing culturally competent care, although they must have
dedicated time to do so.
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Self-efficacy theory. Nurse leaders are confident in their abilities to lead their teams in
providing culturally competent care, although there is room for improvement. To be able to
identify and apply evidence-based practices in providing culturally competent care to patients of
all ethnic and racial backgrounds, nurse leaders need to believe that they are capable of leading
their staff in providing culturally competent care. As shown in Figure 8, nurse leaders have high
levels of self-efficacy related to their ability to lead their nursing staff in providing culturally
competent care, although there is room for improvement. Nurse leaders who strongly agreed that
they are confident in their ability to lead their nursing staff in providing culturally competent
care represented 40.9% of the total respondents; an additional 45.4% somewhat agreed, equaling
86.3% agreeing overall (strongly or somewhat). Only 6.1% felt they were not confident in their
abilities to lead their teams in providing culturally competent care.

Figure 8. I am confident in my ability to lead my nursing staff in providing culturally competent
care

0.8%
5.3%
7.6%
45.4%
40.9%
0%
10%
20%
30%
40%
50%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
I am confident in my ability to lead my nursing staff in providing culturally
competent care (n = 132)
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96
When asked about their level of self-efficacy in leading their nursing teams to provide
culturally competent care, the interviewed nurse leaders further supported that although they
have relatively high-levels of self-efficacy, there is room for improvement. Meg said, “I feel very
confident my competency is continually growing.” Sharon shared the need to continue to learn
by saying,
I guess on a scale of one to 10, I’m probably like a seven or eight, because 10 would
mean that I know everything. I don’t think I can ever know everything. I think there are
always ways to improve and ways to learn more. You should never be stagnant; the river
should always be moving. I think that is what makes a better nurse, always wanting to be
moving like a river and not there like a pond.
Sharon said that her self-efficacy in leading her team to provide culturally competent care
comes from having opportunities to apply learned knowledge. She shared, “I feel the more
nurses apply their knowledge, the more they are open and receptive to their knowledge.” She
added that in the current political environment, following the 2016 U.S. Presidential election,
that it has become harder to trust your ability to meet the cultural needs of patients. She
explained by saying, “It’s very uncomfortable right now with the election and things that really
separated a lot of people. It is more uncomfortable talking about some things.” Not all of the
nurse leaders felt confident in their abilities to lead their team to provide culturally competent
care. Lori shared her concerns by saying, “It’s like I am responsible to meet everyone’s cultural
desires or I’m incompetent. I feel that is an unrealistic expectation.”
Results for Organizational Causes
Ineffective and inefficient organizational processes and a lack of resources often create
barriers to achieve performance goals (Clark & Estes, 2008). Organizational support is needed to
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ensure that employees feel supported, narrow identified performance gaps, and reach targeted
goals. Within hospitals, organizational support is needed to improve the cultural competence of
nurse leaders and the nursing teams they manage (Maddalena, 2009).
Organizational influence. Reducing health care disparities, by improving the cultural
competence of care providers, is not consistently included as a priority on the strategic plan of
hospitals. As shown in Figure 9, 62% of respondents agreed (strongly or somewhat) that their
organization’s strategic plan included guidelines for incorporating cultural and linguistic
competence into nursing operations. Of this percentage, only 37.2% strongly agreed, with the
remaining 24.8% somewhat agreeing. Nearly a quarter of the respondents (24.8%) disagreed
(either strongly or somewhat) that their organization’s strategic plan included guidelines for
incorporating cultural and linguistic competence into nursing operations.

Figure 9. My organization’s strategic plan includes guidelines for incorporating cultural and
linguistic competence into nursing operations

6.2%
18.6%
13.2%
24.8%
37.2%
0%
10%
20%
30%
40%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
My organization's strategic plan includes guidelines for incorporating
cultural and linguistic competence into nursing operations (n = 129)
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98
Similar to the findings of the survey data, the interviewed nurse leaders perceived that
their organizations do not consistently include, in their strategic plans, guidelines for
incorporating cultural and linguistic competence into nursing operations. To illustrate, Meg
described the limited inclusion as, “It’s just a column on the strategic plan.” Sharon explained
the lack of hospital vision by saying, “I don’t feel like there is any clear vision, at least not from
the hospital itself or the organization itself.” David said, “Improving cultural competence is
implied in our mission statement, although we do not have any specific cultural expectations.”
Likewise, Cheryl made a similar comment about improving cultural competence being an
implied goal as part of their mission statement.
It’s inherent in our mission statement, in our vision, in our core values. We talk about the
quadruple aim a lot. We talk about metrics being our true north and being people-centric,
as it pertains to our patients and families, as well as our colleagues and physicians.
Although overall the comments supported that improving the cultural competence of staff
is not typically included in the organization’s strategic plan, Kathy shared that the nursing
department in her hospital had a business-unit specific strategic plan that supported improving
the cultural competence of the nursing teams. Kathy elaborated by saying,
We have a nursing strategic plan we do every year. On the plan, we have nurses who are
in charge of certain initiatives, including drafting metrics. A lot of our initiatives have an
element of cultural competence. The organization’s strategic plan is very different from
the nursing strategic plan. It is mostly based on safety, finance, and goals for expanding
our physician base.
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Kathy explained that the development of the nursing strategic plan is part of their shared
governance structure, although based on her comments the nursing plan is not supported by
similar cultural competence goals in the organizational strategic plan.
Many hospitals do not set clearly defined goals and objectives to improve the level of
cultural competence of their nursing teams, nor do they hold their leaders accountable to do so.
In addition to not including improving cultural competence as a priority on the organizational
strategic plan, hospitals also do not consistently disseminate clearly defined goals and objectives
to improve cultural competence, nor do they hold their leaders accountable to do so. As shown in
Figure 10, only 60.3% of respondents agreed (strongly or somewhat) that they receive clearly
defined goals and objectives from their organizations’ senior leadership and governance body to
improve the level of cultural competence of their nursing staff. Of the total who agreed to this
statement, only 22.9% strongly agreed, while 37.4% somewhat agreed. Over a quarter of the
respondents (26.7%) disagreed (either strongly or somewhat) that they receive clearly defined
goals and objectives from their organization’s senior leadership and governance body to improve
the level of cultural competence of their nursing staff.
Likewise, as shown in Figure 11, only slightly more than half of respondents (56.5%)
agreed (strongly or somewhat) that the leaders in their organizations are held accountable for
improving the level of cultural competence of their staff. Slightly less than a quarter of the
respondents (21%) disagreed (either strongly or somewhat) that the leaders in their organizations
are held accountable for improving the level of cultural competence of their staff.

HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

100

Figure 10. I receive clearly defined goals and objectives from my organization’s senior
leadership and governance body to improve the level of cultural competence of my nursing staff

Figure 11. My organization’s chief executive officer and governance body holds leaders
accountable for improving the level of cultural competence of their staff

6.9%
19.8%
13.0%
37.4%
22.9%
0%
10%
20%
30%
40%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
I receive clearly defined goals and objectives from my organization's senior
leadership and governance body to improve the level of cultural
competence of my nursing staff (n = 131)
4.7%
16.3%
22.5%
35.6%
20.9%
0%
10%
20%
30%
40%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
My organization's chief executive officer and governance body holds
leaders accountable for improving the level of cultural competence of their
staff (n = 129)
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101
The comments provided in the interviews supported the survey data that within hospitals
and health care systems there is a lack of clearly defined organizational goals and objectives to
improve the cultural competency of the nursing staff, as well as a lack of leadership
accountability. David shared the expectation in his organization:
It has never been one of our action plan goals. It is not handed down to us to meet any
specific cultural expectations. Our average length of stay in only 2.5 days, so we don’t
have a big amount of time . . . while they are here we just treat them as well as we can.
Cheryl explained that in her hospital, improving cultural competence is “part of a dashboard that
we submit but it’s simply reporting the numbers, which to me, is just a reporting process. It is not
about changing the outcome.”
Likewise, the interviews supported the survey data that there is limited leadership
accountability within hospitals and health care systems to improve the level of cultural
competence of their staff. David said,
We don’t get a lot of complaints. I’m sure if we started getting a lot of complaints from
patients and they started to see some sort of commonality around culture, race, gender, or
whatever, they might start having us look more into that but it’s not something we’ve had
to focus on.
Meg shared that in her organization, “We just finished our performance evaluations and there is
nothing specific on our evaluations.” When asked why she thought it was not a performance
metric she responded, “I think it’s an uncomfortable measure. I think people are uncomfortable
putting those numbers on paper.” Liz described the importance of data and the accountability of
collecting accurate data. She said, “You have to have data to have responsibility. Data has to be
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collected at the individual level.” Liz explained that although race and ethnicity data is collected
at registration at her hospital, she feels the data is unreliable. She said,
I’m not confident that when we gather information about race and ethnicity at registration
that it’s necessarily valid. I think there’s still a lot more of registration staff selecting
versus actually asking the patient what category do they place themselves in. I’ve been a
patient here many times and never once have been asked. I have Hispanic staff who tell
me that they have never been asked and so, I think, it’s still a lot more about selecting
‘what I see.’
Limited ways to measure success. The interviewed nurse leaders shared that in addition to
a lack of clearly defined goals and accountability at the hospital-wide level, it is also difficult to
clearly measure if the nursing teams in their organizations are being successful in providing
culturally competent care. One example shared by Kathy, provided as a way to measure the
delivery of culturally competent care, was the review of serious incident reports in daily or
weekly nursing huddles. She said,
We have our serious incident reports and safety incident reports. It is a way for us to be
able to track and trend certain events. It’s also to look at our near misses. We go through
them and ask if there could have been a cultural bias that contributed to the incidents.
Another strategy identified to measure if the care provided is culturally competent is the review
of patient satisfaction scores, although scores for racial and ethnic patients are seldom reviewed
collectively. Cheryl also shared the limitations of measuring if her nursing teams are successfully
delivering culturally competent care.
I tend to use our information from the narrative comments that we get in our patient
experience data, and any of our grievance data, and try to pull perspectives from that.
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That’s really the best I have. We don’t really have any good way to look at it other than
the stories, and what comes through in those surveys.
Although various strategies are used to attempt to measure if culturally competent care is
provided, there is no consistent way to measure and nurse leaders are uncertain of their
effectiveness.
Although hospitals provide some resources to improve the staff ’s cultural competence,
there are still gaps in needed resources. As shown in Figure 12, 70.7% of nurse leaders agreed
(strongly or somewhat) that their organizations value and place importance on improving the
level of nursing cultural competence through the allocation of resources and education. Yet, of
that percentage, only 25.4% strongly agreed, while 45.3% somewhat agreed. Approximately
13.9% of the respondents disagreed that their organization values and places importance on
improving the level of nursing cultural competence through the allocation of resources and
education.
Likewise, as shown in Figure 13, slightly more than half of respondents (53.7%) agreed
(strongly or somewhat) that their organizations support quality improvement projects that are
aimed at improving the quality of care provided to diverse patient populations. Nearly a third
(29.6%) of the respondents disagreed that their organizations support quality improvement
projects that are aimed at improving the quality of care provided to diverse patient populations.

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Figure 12. My organization values and places importance on improving the level of cultural
competence in delivering care through the allocation of resources and education to the nursing
staff

Figure 13. Quality improvement projects that are aimed at improving the quality of care
provided to diverse patient populations are in place at my organization

5.4%
8.5%
15.4%
45.3%
25.4%
0%
10%
20%
30%
40%
50%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
My organization values and places importance on improving the level of
cultural competence in delivering care through the allocation of resources
and education to the nursing staff (n = 130)
9.9%
19.7%
16.7%
31.7%
22.0%
0%
10%
20%
30%
40%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
Quality improvement projects that are aimed at improving the quality of care
provided to diverse patient populations are in place at my organization
(n = 132)
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105
Educational resources. As shown in Figure 14, 74.8% of respondents agreed (strongly or
somewhat) that cultural competency training is required as part of their organizations’ new staff
orientation. Of the 74.8%, 48.1% strongly agreed, while 26.7% somewhat agreed. This data is
consistent with the IFD (2015) study noted in Chapter 1 that reported 80% of hospitals provide
cultural competence training during hospital orientation.

Figure 14. Cultural competency training is required at my organization for new staff orientation

Although nearly three-fourths of the respondents agreed that cultural competency training
is included in new employee orientation, as shown in Figure 15, only 59.2% agreed (strongly or
somewhat) that cultural content areas are included as a required component of continuing
nursing education at their organization. Of that the 59.2%, 32.3% strongly agreed, while 26.9%
3.1%
12.2%
9.9%
26.7%
48.1%
0%
10%
20%
30%
40%
50%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
Cultural competency training is required at my organization for new staff
orientation (n = 131)
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106
somewhat agreed. This data does not align as closely with the IFD (2015) study that reported
79% of hospitals provide ongoing staff cultural competence education.

Figure 15. Cultural content areas are included as a required component of annual nursing
education at my organization

The interviewed nurse leaders supported that their organizations included cultural
competency training as part of new staff orientation, although the amount and quality of ongoing
education provided varied across organizations. David described his organization’s training as
limited:
It is included in orientation and then it’s an annual competency that we do through our
continuing education. It is a video presentation and then questions afterwards. It is like an
hour. You can choose to watch the video and then do the test or you can read through the
education part and then answer questions at the end.
8.5%
22.3%
10.0%
26.9%
32.3%
0%
10%
20%
30%
40%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
Cultural content areas are included as a required component of annual
nursing education at my organization (n = 130)
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107
Sharon shared a similar amount of required education in her hospital centered around cultural
competence:
Cultural competency education is included in hospital orientation and then one online
lesson a year, outside of that there really isn’t anything. It probably takes me more or less
ten minutes to do it. The thing is we have so many of them to do that we clearly just whip
through it. We’re just trying to get through them [educational requirements]. It’s not
really impacting our health care or impacting our health practice as much as it should be.
Meg also described the lack of ongoing education and how her team often receives information
through other resources:
I recently participated in orientation and there wasn’t a cultural component. We have a
few ongoing things, but not much. Any of the medical education resources don’t really
have a cultural component. It’s is all diagnostic-driven. If people have questions, they
Google. It’s not a bad resource depending on what you find.
Cheryl’s organization seemed to provide more ongoing education compared to the other
hospitals. She said:
We are sent to a leadership institute every year. It always has an element of cultural
competence in it. Then we bring it back to our staff, what we’ve learned. During staff
meetings, we will take sections and we’ll go through it with them.
Sharon shared that her hospital participated in a local culture day held in conjunction with the
local nursing school. She said individuals from the community, representing various cultures, are
invited to share information about their cultures, foods, and traditions. She said her team felt the
culture day was beneficial, but it is only offered one time per year. When asked what the barriers
are to providing more education, Cheryl said it is “Simply time. Time and resources. The list of
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things that we’re in the process of working on, and other projects that are on the plate.” She
shared simulations that they do to understand seniors better:
We’ve done a lot of work doing simulations with seniors with glasses with Vaseline on
them and with big mitts while staff try to pick up things and make every staff member go
through one of the simulations. I think these kind of experiences are very helpful to help
people see the other side of the world.
Although these simulations are used in her organization to learn how to better care for the
elderly, Cheryl said they have not been used to better understand racial and ethnic minority
patients.
Translation services. Although resources to aid in the delivery of culturally competent
care are limited, the use of interpreters and language lines seem to be used regularly in hospitals
to improve the care provided to patients for which English is not their primary language. As
shown on Figure 16, (91.7%) agreed (strongly or somewhat) that their nursing staff has adequate
access to language assistance services to aid in such functions as interpreting for patients for
which English is not their first language. Only 6.8% disagreed (strongly or somewhat) that that
their nursing staff has adequate access to language assistance services to aid in such functions as
interpreting for patients for which English is not their first language.

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Figure 16. My staff has adequate access to language assistance services, to aid in such functions
as interpreting for patients for which English is not their first language

The interviewed nurse leaders agreed that although other resources are limited, there is
significant support with language assistance services. When asked about available resources to
support improving nurse leader cultural competence, Sharon shared, “The only resource I can
think of is the language line for the patients. That is the only resource provided outside of the one
annual cultural competence class.” The language line service allows nurses and other clinicians
to translate the conversation between the patient and clinician. Interestingly, one nurse leader
shared that she mentors her nurses on the effective way to utilize the resources. Meg described
the language line as a valuable resource:
We actually have the translation telephones so that language isn’t as much of a barrier as
it used to be. I remember when I first started, we called takeout restaurants to try and get
them to translate. Or finding anybody on staff who might be close to that language,
1.5%
5.3%
1.5%
27.5%
64.2%
0%
10%
20%
30%
40%
50%
60%
70%
Strongly
disagree
Somewhat
disagree
Neither agree
nor disagree
Somewhat
agree
Strongly agree
Percentage
My staff has adequate access to language assistance services, to aid in
such functions as interpreting for patients for which English is not their first
language (n = 131)
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110
whether or not they were fluent in English or not. We really use the translation phones
and they have like 80 some languages on them.
One identified barrier to the use of the language lines is the limited access on some hospital
units. Meg explained by saying, “Certain units have had to purchase their own. It used to be that
you had to clear it with communications and check it out. It’s really hard to meet their cultural
needs when you can’t meet their language needs.” Although access is sometimes limited by
hospital unit, overall, the use of language lines to support patients for which English is not their
first language appears to be a standardly used resource in hospitals.
Summary of Findings
The survey and interview data provided key insights into the knowledge, motivation, and
organizational barriers influencing the ability of nurse leaders to lead their teams in providing
culturally competent care. The study showed that nurse leaders believe in the critical importance
of leading their teams in providing culturally competent care, have strong self-efficacy in their
abilities to do so, and are strong mentors to their teams. Yet, the data also validated gaps in the
areas of knowledge, motivation, and organizational influences. Although the interviews
demonstrated the care and compassion of nurse leaders to provide optimal health care to all
patients, both the survey and interview data identified areas of improvement to improve the
ability of nurse leaders to lead their teams in providing culturally competent care.
Key gap areas were demonstrated in the areas of knowledge, motivation, and
organizational influences. Specifically, there is an identified need to increase nurse leader
knowledge of the prevalence of health care disparities for racial and ethnic minority patients and
the resulting reduced health outcomes for these population groups (factual knowledge). Further,
a deeper understanding of the meaning of providing culturally competent care is needed
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(conceptual knowledge). Throughout the interviews, the nurse leaders shared that all patients are
treated equally, but this conflicts with the meaning of providing culturally competent care, which
requires that care is delivered to meet the patients’ social, cultural, and linguistic needs (HRET,
2011). Although nurse leaders understand the importance of knowing how to implement
practices to provide culturally competent care, there is sometimes a gap in implementation
(procedural knowledge). There is also a need to address caregiver bias (both conscious and
unconscious) and dedicate increased time to self-reflection on these biases and one’s own ability
to provide culturally competent care (metacognitive knowledge). Although nurse leaders are
motivated to lead their team to provide culturally competent care, it is difficult to dedicate ample
time and difficult to measure success (expectancy value/motivation). Further, although confident
in their abilities to lead their teams in providing culturally competent care, there is room to
expand this level of confidence (self-efficacy/motivation). In addition to these identified gaps in
knowledge and motivation, there are also organizational barriers that contribute to the delivery of
culturally competent care. In many hospitals and health systems, improving cultural competence
is not identified as a key strategic priority, there are limited organizational goals aimed at
improving cultural competence, and leadership is not held accountable to improve the level of
cultural competence of their staff (organizational). In addition, education and resources are
provided, more resources are needed, especially in the areas on ongoing staff education
(organizational).
This chapter identified the key knowledge, motivation, and organizational influencers
that impact nurse leaders leading their teams in providing culturally competent care. Chapter 5
will provide recommendations to close the knowledge, motivation, and organizational influence
gaps and an integrated implementation and evaluation plan to assess program outcomes.
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CHAPTER 5
RECOMMENDATIONS
Chapter 4 addressed the study’s first research question: What are the knowledge,
motivation, and organizational elements related to achieving the stakeholder goal that by October
2018, all AONE-member nurse leaders will be able to identify and apply evidence-based
practices in providing culturally competent care to patients of all ethnic and racial backgrounds?
Key study findings, synthesized from the survey and interviews, were used to validate the
assumed influences in the categories of knowledge, motivation, and organizational influences.
Chapter 5 addresses the second research question: What are the recommendations for
organizational practice in the areas of stakeholder knowledge, stakeholder motivation, and
organizational influences? This chapter provides recommendations for practice to address the
validated knowledge, motivation, and organizational influences, as well as an integrated
implementation and evaluation plan. The New World Kirkpatrick Model, which utilizes four-
levels of evaluation, serves as the implementation and evaluation framework (Kirkpatrick &
Kirkpatrick, 2016). This updated version of the previous Kirkpatrick Four-Level Model of
Evaluation reverses the original order of evaluation by starting at Level 4, which is determining
the desired outcome or result of the implementation plan. The model then progresses to the
remaining three levels, which include behavior, learning, and reaction.
Recommendations for Practice to Address KMO Influences
Knowledge Recommendations
Knowledge influences, in addition to motivation and organizational influences, are a key
contributor to performance gaps (Clark & Estes, 2008). When assessing gaps in performance, it
is important to examine if people know how to achieve a set performance goal. According to
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Clark and Estes (2008), individuals are often unaware of their own knowledge deficits. Table 8
includes a summary of the assumed knowledge influences related to this study. Derived from a
review of the literature, each assumed knowledge influence was validated through the study’s
data. A learning principle and context-specific recommendation supports each influence need.
The knowledge influences identified are segmented by the four primary knowledge types that
contribute to learning, including factual, conceptual, procedural, and metacognitive (Krathwohl,
2002). Following the table is an overview of the context-specific recommendations, grounded in
learning theory, relevant literature, and the study data findings. Clark and Estes (2008)
recommends four types of recommendations for addressing knowledge needs including
providing information, job aids, training, and education. Information, job aids and training are
recommended when individuals do not know how to achieve a set performance goal and
education is recommended when application of knowledge to future challenges will be needed.

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Table 8
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence
Validated
(Y, N) Principle and Citation Context-Specific Recommendation
Declarative (Factual):
Nurse leaders need to
know the impact that
disparities of care have on
health outcomes for racial
and ethnic minorities.
Yes Declarative knowledge
includes both factual
knowledge, which includes
understanding basic
terminology, and conceptual
knowledge, which includes
connecting patterns and
relationships (Clark & Estes,
2008).
Provide information on current health
disparity data by racial and ethnic
minority groups to illustrate the
impact to patient care.
Provide a job aid that includes a
primer on key terminology and
principles related to providing
culturally competent care.
Declarative (Conceptual):
Nurse leaders need to have
an understanding of the
meaning of providing
cultural competent care.
Yes Information learned
meaningfully and connected
with prior knowledge is stored
more quickly and remembered
more accurately because it is
elaborated with prior learning
(Schraw & McCrudden,
2006).
Provide training that includes
reviewing prior cases of racial and
ethnic minority patients to identify
the influence of the individual,
family, and community in providing
culturally competent care.
Provide education that supports
gaining an understanding of the
theories and core principles of
providing culturally competent care.
Procedural: Nurse leaders
need to know how to
implement and assess
successful strategies and
practices of providing
cultural competent care.
Yes To develop mastery,
individuals must acquire
component skills, practice
integrating them, and know
when to apply what they
learned (Schraw &
McCrudden, 2006).
Facilitating transfer promotes
learning (Mayer, 2011)
Utilize simulation training to provide
procedural knowledge on providing
culturally competent care.
Provide train-the trainer education to
formalize the informal knowledge
transfer that occurs between peers
from diverse ethnicities and cultures
in the practice setting.
Metacognitive: Nurse
leaders need to know how
to reflect on their own
knowledge and level of
cultural competence in
providing care, be aware of
their own cultural self-
biases, and understand how
to utilize their own cultural
competency knowledge in
clinical decision-making.
Yes The use of metacognitive
strategies facilitates learning
(Baker, 1989).
Increasing germane cognitive
load by engaging the learner
in meaningful learning and
schema construction facilitates
effective learning (Kirschner,
Kirschner, & Paas, 2006).
Provide mindfulness training on how
to improve metacognitive skills and
increase self-reflection and self-
regulation.
Provide education that demonstrates
how to self-evaluate level of cultural
competence and identify areas of
needed improvement.

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Declarative knowledge solutions. Nurse leaders need to know the impact that disparities
of care have on health outcomes for racial and ethnic minorities (declarative/factual knowledge).
According to AHRQ (2013), racial and ethnic minorities receive lower quality of care, compared
to non-minorities, in approximately 30% to 40% of quality measures, depending on race and
ethnicity. Despite this data, nearly one-third (30.3%) of the survey respondents disagreed that
racial and ethnic minority patients receive lower quality of care, resulting in reduced health
outcomes. Further, a common theme in the interviews was the perception that all patients are
treated the same regardless of their ethnicity or race. This is in contrast to the definition of
providing cultural competent care, which attributes cultural competence as the “ability of health
care systems and providers to deliver care to patients with varied and diverse values, beliefs, and
behaviors, while meeting the patients’ social, cultural, and linguistic needs” (HRET, 2011, p. 5).
The survey data and interviews support the need to improve the factual knowledge of nurse
leaders related to the presence of health care disparities.
Declarative knowledge includes both factual knowledge, which includes basic
terminology, and conceptual knowledge, which includes connecting patterns and relationships
(Clark & Estes, 2008). This understanding of declarative knowledge would suggest that
providing information to learners, which helps them understand factual knowledge of a subject
and the connection of this subject to other areas, would increase the learners’ general declarative
knowledge of a subject. To address nurse leader gaps in declarative/factual knowledge related to
cultural competence, one recommendation is to provide information on current health disparity
data by racial and ethnic minority groups to illustrate the impact these disparities have on patient
care. Further, a job aid that includes a primer on key terminology and principles related to
providing culturally competent care would help nurse leaders gain factual knowledge. Both of
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116
these resources would help nurse leaders gain factual knowledge related to the presence of
disparities and the relationship between cultural competence, health care disparities, and patient
outcomes.
Nurse leaders also need to have an understanding of the meaning of providing culturally
competent care (declarative/conceptual knowledge). Although the survey data and interviews
supported that nurse leaders have an understanding of the meaning of providing culturally
competent care, the depth of their understanding varied. Some of the interviewed nurse leaders
broadly understood how the cultural context of patients influences their care, other focused on
the importance of treating all patients the same, or narrowly addressing cultural competence as
race issues. Although not as high of a priority as the declarative/factual knowledge gaps,
improved conceptual knowledge would assist nurse leaders in broadening their understanding of
cultural competence.
According to Schraw and McCrudden (2006), information learned meaningfully and
connected with prior knowledge is stored more quickly and remembered more accurately
because it is elaborated with prior learning. This would suggest that helping learners connect
new knowledge with previously acquired knowledge helps them develop meaning and increased
ability to apply the knowledge. To address nurse leader gaps in declarative/conceptual
knowledge related to cultural competence, one recommendation is to provide training that
includes reviewing prior cases of racial and ethnic minority patients to identify the influence of
the individual, family, and community in providing culturally competent care. Another
recommendation is to provide education that supports gaining an understanding of cultural
competence theories and core principles. These resources would help nurse leaders gain
conceptual knowledge related to the broad understanding of providing cultural competent care
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117
and help them make the connection between the many influences that affect the delivering of
culturally competent care.
Clark and Estes (2008) found that providing information is useful to inform individuals
about key knowledge areas needed for them to be successful in their performance. The cultural
competence of nurses and other clinicians contributes significantly to the health status of racial
and ethnic minority patients. Potential gaps in the declarative knowledge of nurse leaders will
most likely persist until they understand the presence of health care disparities, the connection
between providing culturally competent care and health outcomes, and the many influences that
impact providing culturally competent care (Betancourt et al., 2002). Yet, obtaining cultural
knowledge can be impaired because patients and health care providers each have their own
unique sets of cultural backgrounds and assumptions (Ornelas, 2008). Providing information and
education allows individuals to obtain conceptual and theoretical knowledge applicable to
problems they face in the future (Clark & Estes, 2008). From a theoretical perspective,
increasing nurse leader knowledge on the impact that health care disparities have on patient care
and the understanding of the meaning of providing culturally competent care, would increase
their knowledge of providing culturally competent care.
Procedural knowledge solutions. Nurse leaders need to know how to implement and
assess successful strategies and practices of providing culturally competent care (procedural
knowledge). One finding that emerged from the interviews was the perception of the nurse
leaders that culturally competence knowledge gained in practice and through the informal
transfer of knowledge from co-workers of various ethnicities and cultures is more effective than
formal methods of education. This creates opportunities to formalize and build upon these
informal exchanges of knowledge.
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Schraw and McCrudden (2006) found that to develop mastery, individuals must acquire
component skills, practice integrating them, and know when to apply what they learned. This
would suggest that providing learners with the ability to learn, practice skills, and apply these
learnings and skills in the practice environment would increase their procedural knowledge. To
address nurse leader gaps in procedural knowledge, a recommendation is to utilize simulation
training to increase procedural knowledge on providing culturally competent care. This would
provide opportunities for nurse leaders and the nursing teams they lead to practice and apply, in
the practice setting, learned cultural competence knowledge and skills. Further, Mayer (2011)
found that facilitating transfer promotes learning. This would suggest that encouraging the
transfer of learned knowledge aids in obtaining procedural knowledge. To further address gaps in
procedural knowledge, a second recommendation is to provide train-the-trainer education to
formalize the informal knowledge transfer that occurs between peers from diverse ethnicities and
cultures in the practice setting.
Procedural knowledge enables learners to understand how to do something (Clark &
Estes, 2008). For example, procedural knowledge is needed to know how to effectively
communicate with patients for whom English is not their first language (Diamond & Jacobs,
2009). Training is often an effective tool to assist individuals in obtaining knowledge on how to
complete a task or master a body of knowledge, by enabling the learner to practice and receive
guidance and feedback for improvement (Clark & Estes, 2008). From a theoretical perspective,
improving the procedural knowledge of nurse leaders by providing them with opportunities to
implement and assess successful strategies and practices would improve their level of cultural
competence.
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Metacognitive knowledge solutions. Nurse leaders need to know how to reflect on their
own knowledge and level of cultural competence in providing care, be aware of their own
cultural self-biases, and understand how to utilize their own cultural competency knowledge in
clinical decision-making (metacognitive knowledge). The survey data and interviews showed
that nurse leaders understand the importance of dedicating time to reflect on their own level of
competence in providing care to patients of all racial and ethnic backgrounds. In the survey,
nearly all the respondents (97.7%) agreed that self-reflection is important, but the interviewed
nurse leaders said it is difficult to find time to do so. Likewise, nearly all the interviewed nurse
leaders (91.7%) agreed that prejudice and bias, including both conscious and unconscious bias,
affects patient quality of care. Yet, again in the interviews, the nurse leaders said they rarely see
nurse bias in the practice setting.
According to Baker (1989), the use of metacognitive strategies facilitates learning. This
would suggest that providing learners with opportunities to self-reflect on their own abilities
would increase their metacognitive knowledge. Self-reflection is an important component of the
emerging practice of cultural humility. Tervalon and Murray-Garcia (1998) described the
concept as, “Cultural humility incorporates a lifelong commitment to self-evaluation and
critique, to redressing the power imbalances in the physician-patient dynamic, and to develop
mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals
and defined populations” (p. 123). Proponents of a focus on cultural humility, over culture
competence, stress that the latter focuses on the assumption that one’s own culture is the norm
and that it is necessary to learn about ‘other cultures’ versus self-reflecting on one’s own cultural
influences in the provider-patient relationship (Yeager & Bauer-Wu, 2013). To address nurse
leader gaps in metacognitive knowledge, one recommendation is to provide mindfulness training
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on how to improve metacognitive skills and increase self-reflection and self-regulation.
Mindfulness training is an important component of cultural humility. Used as a mental practice,
mindfulness encourages clinicians to be more attentive to the present moment, and more self-
aware of their responses to situations, including patient interactions (Yeager & Bauer-Wu, 2013).
In addition, increasing germane cognitive load by engaging the learner in meaningful
learning schema construction facilitates effective learning (Kirschner et al., 2006). This supports
that allowing learners to have the dedicated time to self-reflect could increase their
metacognitive learning. A recommendation to address this gap is to provide education that
demonstrates to nurse leaders how to self-evaluate their level of cultural competence and identify
areas of improvement. As identified in Chapter 2 of this study, there are various tools available
in the field available to assess cultural competence. One tool is the Inventory for Assessing the
Process of Cultural Competence among Healthcare Professionals (IAPCC). Based on Campinha-
Bacote’s model of cultural competence, the 20-item tool measures cultural awareness,
knowledge, skill, and encounter (Campinha-Bacote, 2002). This framework complements the
Clark and Estes (2008) gap analysis framework that explores knowledge, motivation, and
organizational gaps and could be an effective component of the education program offered to
nurse leaders.
Metacognition influences one’s own thinking and self-regulation, as well as the
successful transfer of learning to new situations (Krathwohl, 2002). Prejudice and bias,
including both conscious and unconscious bias, affect the quality of care that patients receive
(Ornelas, 2008). Although education and training are useful to expand nurse leaders’ knowledge,
it is also important that clinicians internalize the foundation of culturally competent care to build
continual respect for all patients (Smith, 2014). The successful transfer and application of prior
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learning to new situations or practice is an important part of metacognition (Krathwohl, 2002).
To transfer successfully knowledge obtained from previous educational programs, training, and
lived experiences, ongoing evaluations and self-assessments are needed. From a theoretical
perspective, providing nurse leaders with resources to improve their metacognitive knowledge
would increase their level of cultural competence.
Motivation Recommendations
Motivation influences, in addition to knowledge and organizational influences, are a key
contributor to performance gaps (Clark & Estes, 2008). Motivation affects our ability to start a
task, continue to persist until the task or goal is completed, and dedicate ample mental effort to
be successful (Clark & Estes, 2008). Table 9 includes a summary of the assumed motivation
influences related to this study. Derived from a review of the literature, each assumed motivation
influence was validated by the study’s data. A learning principle and context-specific
recommendation support each influence need. The expectancy value motivation and self-efficacy
theories serve as constructs to frame the motivation influences.

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Table 9
Summary of Motivation Influences and Recommendations
Assumed
Motivation
Influence
Validated
(Y, N) Principle and Citation
Context-Specific
Recommendation
Expectancy value
motivation theory:
Nurse leaders need
to see the value in
providing cultural
competent care and
believe that they
can be successful in
doing so.
Yes Rationales that include a
discussion of the
importance and utility
value of the work or
learning can help
learners develop positive
values (Eccles, 2006;
Pintrich, 2003).
Higher expectations for
success and perceptions
of confidence can
positively influence
learning and motivation
(Eccles, 2006).
Provide information on
current health disparity data
by racial and ethnic minority
groups to illustrate the impact
to patient care.
Provide train-the-trainer
modules for learners to model
values, enthusiasm, success,
and interest in providing
culturally competent care.
Self-efficacy
theory:
Nurse leaders need
to believe that they
are capable of
leading their staff in
providing cultural
competent care.
Yes High self-efficacy can
positively influence
motivation (Pajares,
2006).
Feedback and modeling
increases self-efficacy
(Pajares, 2006).
Utilize simulation training to
allow learners to practice
learned skills and increase
self-efficacy.
Utilize scaffolding through
the instructional support
provided in education
programs to build on prior
knowledge, provide feedback
and modeling opportunities,
and demonstrate the ability of
the learner to be successful.

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Expectancy value theory solutions. Nurse leaders need to see the value in providing
cultural competent care and believe that they can be successful in doing so. Nearly all of the
survey respondents (98.4%) agreed that is it important to them to lead their staff in providing
culturally competent care. This finding was also validated in the interviews, where the nurse
leaders discussed the importance of leading their teams in providing culturally competent care, as
well as serve as role models and mentors. Although they expressed the importance of doing so,
they also shared that there are many competing priorities as part of their roles, which limits their
ability to dedicate ample time.
According to Eccles (2006) and Pintrich (2003), rationales that include a discussion of
the importance and utility value of the work or learning can help learners develop positive
values. This would suggest that providing information to learners that demonstrate the
importance and the impact of a task would increase the value that learners place on the task.
Further, Eccles (2006) supports that higher expectations for success and perceptions of
confidence can positively influence learning and motivation. This would suggest that placing
high expectation for success and modeling what that success looks like could increase the
learners’ perception of their own ability to succeed. Two recommendations to address these
motivation needs are addressed below. First, provide information on current health disparity data
by racial and ethnic minority groups to demonstrate the gap in treatment outcomes. This
resource, also identified as a resource to increase nurse leader factual knowledge, can serve to
demonstrate the value of providing culturally competent care. In addition to providing the above
information, a second recommendation is to provide train-the-trainer modules for nurse leaders
to model values, enthusiasm, success, and interest in providing culturally competent care.
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Clark and Estes (2008) found that focusing on the achievement of a positive outcome or
avoidance of a negative outcome improves the motivation of learners. The goal of achieving a
higher level of cultural competency is not valued equally among all clinicians (Jeffreys et al.,
2007). One reason that providing culturally competent care is not valued equally among
clinicians is that providing this level of care competes with many other priorities and interest
areas (Jeffreys et al., 2007). These competing priorities and interest areas affect the value that
nurse leaders place on providing culturally competent care. According to Campinha-Bacote
(2002), nurse leaders must develop the motivation to achieve a higher level of proficiency and
competency in providing culturally competent care. From a theoretical perspective, increasing
the value that nurse leaders place on providing culturally competent care would increase their
ability to provide culturally competent care and would have a positive impact on patient
outcomes.
Self-efficacy theory solutions. Nurse leaders need to believe that they are capable of
leading their staff in providing culturally competent care. The survey data supported that nurse
leaders have a high level of self-efficacy in leading their teams to provide culturally competent
care. Most (86.3%) of the respondents felt confident in their abilities; only 6.1% were not
confident. Although the interviews supported this finding, the respondent nurse leaders shared
that there is always more to learn and to remain cultural competent requires ongoing learning and
application of knowledge.
Pajares (2006) found that high self-efficacy can positively influence motivation. This
would suggest that providing learners with opportunities to improve their self-efficacy can
increase their motivation to be successful at achieving a goal. Further, Pajares (2006) supports
that feedback and modeling increases self-efficacy. To increase nurse leader self-efficacy, a
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recommendation is to utilize simulation training for the nurse leaders and their teams to apply
their learning and gain confidence outside of the practice setting. This recommendation was also
included as a recommendation to improve the procedural knowledge of nurse leaders and the
teams they lead. An additional recommendation to build self-efficacy is to utilize scaffolding
through the instructional support provided in the education program to build on prior knowledge,
provide feedback and modeling opportunities, and demonstrate the ability of the nurse leader to
be successful in leading their teams.
According to Clark and Estes (2008), individuals will not choose and persist at a task if
they do not believe they can be successful. Lee et al. (2006) note that in addition to allowing
nurses to feel more secure in their roles, increasing the self-efficacy of nurses also increases their
job satisfaction, which improves their overall delivery of care. Further, according to Campinha-
Bacote (2003), to become culturally competent, nurses need to engage in cultural desire, which is
having the motivation to become culturally competent. From a theoretical perspective, it would
appear that increasing the level of nurse leader self-efficacy in leading their teams to provide
culturally competent care would improve the cultural competence of nurse leaders and result in
improved health outcomes for racial and ethnic minority patients.
Organization Recommendations
In addition to knowledge and motivational barriers, organizational influences are another
contributing barrier to performance gaps. Ineffective and inefficient organizational processes, in
addition to a lack of needed resources, often result in organizational barriers that impede the
achievement of meeting performance goals (Clark & Estes, 2008). Within hospitals,
organizational support is needed to improve the cultural competence of nurse leaders and the
nursing teams they manage (Maddalena, 2009). Table 10 includes a summary of the assumed
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organizational influences related to this study. Derived from a review of the literature, each
assumed organization influence was validated by the study’s data. A learning principle and
context-specific recommendation support each influence need.

Table 10
Summary of Organization Influences and Recommendations
Assumed Organization
Influence
Validated
(Y, N) Principle and Citation
Context-Specific
Recommendation
Nurse leaders need to
receive clearly defined
goals and objectives from
the senior leader of their
organizations to improve
the level of cultural
competence of their staff,
as well as hold the leaders
within the organization
accountable to achieve
this goal.
Yes Organizational
performance increases
when structures and
processes are aligned
with clearly defined and
measurable goals (Clark
& Estes, 2008).
Learning, motivation and
performance will be
enhanced if participants
have clear, current, and
challenging goals
(Kluger & DeNisi,
1996).
Include goals and
objectives for providing
culturally competent
care into the
organization’s strategic
plan.
Incorporate goals and
metrics for improving
staff cultural
competence into the
annual performance
goals of all leaders and
staff.
Nurse leaders need to see
that their organizations
value and place
importance on improving
the level of cultural
competence in delivering
care through the allocation
of education and
resources.
Yes Organizational
performance increases
when adequate processes
and materials are
provided to aid in
achieving performance
goals (Clark & Estes,
2008).
Allocate financial
resources to provide
nursing education and
other resources that
support the delivery of
culturally competent
care and to measure the
impact of execution.

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Process solutions. Nurse leaders need to receive clearly defined goals and objectives
from the senior leaders of their organizations to improve the level of cultural competence of their
staff, as well as hold the leaders within the organization accountable to achieve this goal. The
findings of the study showed that in many healthcare organizations, goals and priorities are not
clearly defined and leaders are not held accountable to improve staff culturally competence. The
survey showed that only 62% of the respondents agreed that their organizations included cultural
competence as a priority on their strategic plan, 60.3% agreed that their organizations set clearly
defined goals and objectives, and just slightly more than half (56.5%) felt that leaders are held
accountable for improvements. The interview data supported the lack of priority, goals, and
accountability.
According to Clark and Estes (2008), organizational performance increases when
structures and processes align with clearly defined and measurable goals. This suggests that
goals and objectives for providing culturally competent care could improve the level of cultural
competent care provided. To address this organizational influence, organizations should consider
providing support and resources to hospital and health system leaders to include goals and
objectives for providing culturally competent care into the organization’s strategic plan, set clear
and measurable goals to improve cultural competence, and implement methods to hold leaders
accountable. Implementing these process solutions could improve cultural competence and
positively affect the quality of patient care. In addition, Kluger and DeNisi (1996) support that
learning, motivation and performance will be enhanced if participants have clear, current and
challenging goals. This would suggest that defining specific outcome metrics could affect the
level of staff cultural competence. A recommendation for hospitals and health systems is to
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incorporate goals and metrics for improving staff cultural competence into the annual
performance goals of all leaders and staff.
Clark and Estes (2008) support that establishing a clear vision and specific goals is an
important part of effective organizational change and performance improvement initiatives. The
strategic plan of a hospital outlines the organization’s key priorities and demonstrates the value
the organization places on these priorities (Douglas et al., 2014). The mission and vision of an
organization are important components of its strategic plan and provide direction on the
organization’s purpose and desired future state (Gulati, Mikhail, Morgan, & Sittig, 2016).
Collectively, the mission, vision, and strategic plan of a hospital should reflect the needs of the
patient population the hospital serves and include statements regarding the importance of
diversity and inclusion (Purnell et al., 2011). Individual performance goals and metrics should
align with the organizational strategic plan. From a theoretical perspective, it would appear that
providing clearly defined goals and objectives in the organizational strategic plan and
incorporating goals and metrics for improving staff cultural competence into the annual
performance goals of all leaders and staff would improve the level of cultural competence of the
nursing staff and overall health outcomes for patients of all races and ethnicities.
Resource solutions. Nurse leaders need to see that their organizations value and place
importance on improving the level of cultural competence in delivering care through the
allocation of education and resources. Although the survey data supported that hospitals and
health systems provide resources to support improving cultural competence, most of these
resources were dedicated to language lines and interpretation services. Nearly three-fourths
(74.8%) of the survey respondents said their organizations offer cultural competence training as
part of new hospital orientation; 59.2% said that cultural content areas are including in ongoing
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annual nursing education. Yet, in the interviews, the nurse leader respondents shared that
although education is provided, the purpose of offering the education seems to be to merely
check-off completion, rather than have an impact on cultural competence.
According to Clark and Estes (2008), organizational performance increases when
adequate processes and materials are provided to aid in achieving performance goals. This
suggests that hospital leaders need to demonstrate their managerial support to improving the
level of cultural competence of their staff through the allocation of financial resources needed to
improve the cultural competence of their teams. A recommendation for hospitals and health
systems is to allocate financial resources to nursing education and other resources that support
the delivery of culturally competent care and to measure the impact of execution.
Taylor and Alfred (2010) studied key organizational barriers that affect nurses providing
culturally competent care. The study included interviews with 23 nurses, as well as an analysis of
relevant documents and critical incident reports. In a sample of 23 interviews, nurses identified a
lack of dedicated resources, including training, as a key barrier to providing culturally competent
care. Major themes that emerged from the interviews included that current levels of cultural
competency training were inadequate, not included in staff orientation, and often not mandatory
to attend and complete. The nurses specified that these barriers contributed significantly to their
ability to provide culturally competent care and as a result affect patient outcomes. This
empirical study supports that the allocation of financial resources by senior leaders, to provide
nursing education and other resources, contributes to the delivery of culturally competent care.
Integrated Implementation and Evaluation Plan
To evaluate the effectiveness of implemented recommendations, it is critical to assess
learning and targeted organizational change metrics. According to Clark and Estes (2008),
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evaluation, and assessing progress and results, is an important component of closing performance
gaps. The recommendations to close the validated knowledge, motivation, and organizational
influences outlined previously in this chapter, center around the areas of information, job aids,
education and training, and organizational policies and resources. An implementation and
evaluation plan is outlined below that will measure if the recommendations emerging from this
study affect the achievement of the stakeholder performance goal.
Implementation and Evaluation Framework
The model used for this implementation and evaluation plan is the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016). This model is an updated version of the
original Kirkpatrick Four Level Model of Evaluation that was developed by Don Kirkpatrick in
the 1950s, as part of his doctoral dissertation (Kirkpatrick & Kirkpatrick, 2016). The original
model is based on four levels of evaluating training programs, including reaction, learning,
behavior, and results. The updated model includes the same primary steps, but reverses the order
of evaluation to start with Level 4, which includes determining the desired outcome or results of
the training. To be successful, Level 4 must include leading indicators, or measurements that
track progress. Level 3 includes an evaluation of the degree to which participants can apply
critical behaviors needed for success on the job, because of the training. Level 3 is often the most
critical level, requiring the most resources (Kirkpatrick & Kirkpatrick, 2016). Level 2 measures
the degree to which participants have gained the needed knowledge, skills, and motivation to
achieve their goals because of the training. The final stage, Level 1, measures the participant’s
satisfaction with the training (Kirkpatrick & Kirkpatrick, 2016).
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Organizational Purpose, Need and Expectations
A primary organizational purpose of AONE is to support nurse leaders in their efforts to
help individuals and communities reach optimal health. The presence of health care disparities
for racial and ethnic minority patients is a critical factor that affects both individuals and
communities in reaching optimal health. To support the reduction of health care disparities, the
organizational goal for this study is that all nurses led by AONE-member nurse leaders will
provide culturally competent care to patients of all ethnic and racial backgrounds. To assist in
meeting the organizational goal, the stakeholder goal for this study was that all AONE-member
nurse leaders will be able to identify and apply evidence-based practices in providing culturally
competent care to patients of all ethnic and racial backgrounds. The role of the nurse leader is
critical to support bedside nurses in providing culturally competent care. Part of the proposed
solution to close the gap in meeting the stakeholder goal is a comprehensive education program
offered by AONE. The program description follows the evaluation framework section.
Level 4: Results and Leading Indicators
Outcomes, metrics, and methods. Level 4 evaluation connects the training or education
program to targeted organizational results (Kirkpatrick & Kirkpatrick, 2016). Table 11 outlines
the proposed Level 4 plan, by defining outcomes, metrics, and methods. Both external and
internal outcomes are important components of the evaluation plan. Internal leading indicators
are part of the organizational structure and include individual targets that define how
stakeholders will contribute to the organizational goal. External leading indicators relate to how
the external stakeholder groups react to critical behaviors initiated within the organization
(Kirkpatrick & Kirkpatrick, 2016).

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Table 11
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased patient satisfaction
scores for racial and ethnic
minority patients.
Patient satisfaction scores on
the Hospital Consumer
Assessment of Healthcare
Providers and Systems
(HCAPHS) survey.
Review ethnic and racial
minority patient HCAPHS
scores monthly.
Reduction in re-admission
rates for racial and ethnic
minority patients.
Readmission rates reported to
CMS.
Review ethnic and racial
minority patient readmission
rates monthly.
Internal Outcomes
Increased nursing awareness
of the presence of health
care disparities for racial and
ethnic minority patients.
Successful completion of
culturally competency course
that provides health disparities
data by racial and ethnic
minority patients.
Administer annual nurse
leader competency course that
provides data on health
disparities for racial and
ethnic minority patients.
Improved satisfaction of
nurse leaders with their level
of cultural competence.
Nursing satisfaction rates
measured through annual
employee survey.
Administer annual employee
survey.
Improved individual
performance metrics for
nurse leaders specific to
providing culturally
competent care.
Annual performance measured
against individual targets to
improve level of cultural
competence.
Administer annual employee
survey.
Increased ability for nurse
leaders to self-reflect on
their individual level of
cultural competence and
potential biases.
Completion of semi-annual
nurse leader cultural
competency self-assessment.
Administer semi-annual nurse
leader cultural competency
self-assessment.

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Level 3: Behavior
Critical behaviors. Level 3 evaluation determines the level to which learners can apply
what they learned in training directly to their jobs. It is typically the most important level of the
evaluation and allows for adjustments and modifications during the training to ensure the
objectives are being met (Kirkpatrick & Kirkpatrick, 2016). An important part of Level 3
evaluation is the identification of critical behaviors of the learners that will drive the achievement
of Level 4 outcomes. For the primary stakeholder group of AONE-member nurse leaders, the
first critical behavior is that nurse leaders will demonstrate an understanding of the presence of
health care disparities for racial and ethnic minority patients. The second critical behavior is that
nurse leaders will lead their teams in effectively communicating with patients who have limited
English proficiency. The third critical behavior is that nurse leaders lead their teams in
conducting cultural assessments on racial and ethnic minority patients. The fourth critical
behavior is the nurse leaders spend time evaluating their ability to provide and lead their teams in
providing culturally competent care. Table 12 lists the specific metrics, methods, and timing for
each of these outcome behaviors.

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Table 12
Critical Behaviors, Metrics, Methods, and Timing for New Reviewers
Critical Behavior Metric(s) Method(s) Timing
1. Nurse leaders will
demonstrate an
understanding of the
presence of health care
disparities for racial and
ethnic minority
patients.
Successful completion
of nursing education
course and evaluation
on the impact of health
care disparities for racial
and ethnic minorities.
A nursing education
course of the impact
of health care
disparities will be
included as part of
nursing education
requirements.
Complete as part
of new employee
orientation and
then annually.
2. Nurse leaders will
lead their teams in
effectively
communicating with
patients who have
limited English
proficiency.
Use of available
resources that support
communicating with
patients with limited
English proficiency.
Review HCAPHS
scores to assess
patient satisfaction
for racial and ethnic
minority patients.
Review ethnic
and racial
minority patient
HCAPHS scores
monthly.
3. Nurse leaders will
lead their teams in
conducting cultural
assessments on racial
and ethnic minority
patients.
Achieve targeted
number of completed
assessments by patient
population.
Track the number of
completed cultural
assessments for racial
and ethnic minority
patients.
Review tracking
report monthly.
4. Nurse leaders will
evaluate their ability to
lead their nursing teams
in providing culturally
competent care.
Participation in
culturally competent
self-assessment.
Annual nursing
education
requirements will
include self-
assessment
component to
evaluate cultural
competence
leadership.
Monitor
education and
performance
evaluation
requirements
annually.

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Required drivers. Another component of the Level 4 evaluation is the incorporation of
required drivers or processes and systems that reinforce, monitor, encourage, and reward the
application of critical behaviors once the learner is back on the job (Kirkpatrick & Kirkpatrick,
2016). To achieve the stakeholder goal, nurse leaders must have knowledge about disparities of
care to understand the impact that these disparities of care have on the health outcomes for racial
and ethnic minorities. They also need dedicated resources and education from their organizations
to improve their level of cultural competence and the level of cultural competence of their teams.
Further, they need to be recognized for growth and improvement in their achievement of cultural
competence. Table 13 includes the recommended drivers to support critical behaviors of AONE-
member nurse leaders to help them reach the targeted stakeholder goal.

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Table 13
Required Drivers to Support Nurse Leaders ’ Ability to Identify and Apply Evidence-based
Practices in Providing Culturally Competent Care
Method(s) Timing
Critical
Behaviors
Supported
Reinforcing
Provide information on current health disparity data by racial and ethnic minority
groups to illustrate the impact to patient care.
Orientation/
Annual
1
Provide a job aid that includes a primer on key terminology and principles related
to providing culturally competent care.
Ongoing 1, 3, 4
Provide training that includes reviewing prior cases of racial and ethnic minority
patients to identify the influence of the individual, family, and community in
providing culturally competent care.
Quarterly 2, 3, 4
Provide training that demonstrates how nurse leaders can self-evaluate their level
of cultural competence and identify areas of needed improvement.
Annually 4
Provide education that support gaining an understanding of the theories and core
principles of providing culturally competent care.
Quarterly 2, 3, 4
Provide train-the trainer education to formalize the informal knowledge transfer
that occurs between peers from diverse ethnicities and cultures in the practice
setting.
Quarterly 2, 3, 4
Utilize simulation training to provide procedural knowledge on providing
culturally competent care.
Quarterly 2, 3, 4
Encouraging
Provide mindfulness training on how to improve metacognitive skills and increase
self-reflection and self-regulations.
Quarterly 4
Provide opportunities for learners to model values, enthusiasm and interest in
providing culturally competent care.
Ongoing 2, 3, 4
Share evidence-based practices and case studies that demonstrate successful
delivery of culturally competent care.
Ongoing 2, 3, 4
Utilize scaffolding through the instructional support provided in education
programs to build on prior knowledge, provide feedback and modeling
opportunities, and demonstrates the ability of the learner to be successful.
Ongoing 1, 2, 3, 4
Rewarding
Monitor individual attainment of cultural competence tied to performance goals
and incentive structure.
Annually 3
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Monitoring. Various strategies can be utilized to ensure that the recommended required
drivers are occurring. These strategies can include observations by nurse leaders of interactions
with racial and ethnic minority patients and self-evaluations of nurse leaders during new
employee orientation and within 90 days of the completion of a new resource or training.
Level 2: Learning
Learning goals. Level 2 evaluates if the participants have gained the knowledge, skills,
attitude, confidence, and commitment to reach their goals, because of the training or education
program. Following completion of the recommended solutions, the stakeholder group for this
study will be able to:
1. Articulate the impact that disparities of care have on health outcomes for racial and
ethnic minorities. (D)
2. Understand the meaning of providing culturally competent care. (D)
3. Measure and assess successful strategies and practices for providing culturally
competent care. (P)
4. Reflect on their own knowledge and level of cultural competence. (M)
5. See the value in their teams providing culturally competent care. (EV)
6. Accept that they can be successful in leading their teams in providing culturally
competent care. (EV)
7. Believe that they are capable of leading their teams in providing culturally competent
care. (SE).
Program. The learning goals will be supported by a comprehensive program that
includes resources and educational offerings developed by AONE, to support AONE-member
nurse leaders within their hospitals. The framework of the recommended program will be a
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three-prong approach, including increasing knowledge and motivation through education and
modeling, providing tools and resources to promote organizational support, and disseminating
ways to reinforce and reward positive outcomes. The program will be provided on the AONE
learning management system (LMS) to the key stakeholder group of AONE-member nurse
leaders. The learning will be completed asynchronous to allow learners to complete at their own
pace. Three modules will be included that focus on improving the critical areas of nurse leader
knowledge, nurse leader motivation and self-efficacy, and organizational processes to improve
cultural competence and improve patient care. A fourth module will provide resources and tools
to disseminate a train-the-trainer program in the learner’s organization that will provide
opportunities to practice and apply the learning. In addition to the asynchronous learning
modules, there will be an online learning community for learners to share further evidence-based
practices and provide peer modeling. The learning community will provide opportunities to share
meaningful stories of optimal patient care to celebrate and encourage compassionate delivery of
care and advance the tenets of cultural humility.
The first module, focusing on improving nurse leader knowledge related to providing
culturally competent care, will provide information on current health disparity data by specific
racial and ethnic minority groups to illustrate the impact to patient care. The resource will be
available for nurse leaders to utilize in their own organizations for new staff orientation. This job
aid will be supported by an educational video that illustrates the connection between disparity
data by specific racial and ethnic minorities and actual patient case studies (blinded for
confidentiality). Learners will have the opportunity to measure and assess the application of
successful strategies for providing culturally competent care based on a review of the case
studies. This module will also provide tools and resources aligned with expanding a cultural
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humility framework of life-long learning. Although gaining cultural competence knowledge is an
important part of the program, learners will also be provided with resources, such as mindfulness
tools, to incorporate learning from their hearts and presence, as well as their head.
The second module, focusing on nurse leader motivation and self-efficacy, will include a
job aid to be used as a self-assessment to measure the learners’ perceived cultural competence.
This resource will be available for the learners to utilize with their teams within their own
organization. Another resource as part of this module will be a set of guiding principles that
model evidence-based practices for providing culturally competent care. These resources will be
reviewed in a series of brief online units. One of the units will include a mindfulness training
session that will demonstrate to the leader how to improve metacognitive skills and increase self-
reflection and self-awareness of any potential bias.
The third module, focusing on improving organizational processes to improve cultural
competence and improving nurse leader self-efficacy will provide resources that can be
incorporated at the organizational level, including strategies to monitor individual attainment of
cultural competence into organizational strategic and operational goals, as well as individual
performance goals.
The fourth module will provide tools and resources to launch a train-the-trainer program
in each of the learners’ organizations. This module will include tools and strategies that will help
nurse leaders formalize the non-formal transfer of knowledge from ethnic and minority staff
members to their co-workers and increase nurse leader self-efficacy in leading their teams. This
informal transfer of knowledge was identified in Chapter 4 as a key way that cultural
competence knowledge is currently gained in the practice setting.
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Components of learning. According to Kirkpatrick and Kirkpatrick (2016), there are
five components of Level 2 learning, including, knowledge, skill, attitude, confidence, and
commitment. These align closely with the knowledge and motivation influences of the Clark and
Estes (2008) model and provide a complimentary framework of evaluation. Table 14 provides an
overview of the methods and activities that will support the component of learning for the
proposed educational program. Both the knowledge and motivation of the learner will be
evaluated to determine the likelihood of successfully transferring the knowledge to the practice
setting.

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Table 14
Components of Learning for the Program
Methods and Activities Timing
Declarative Knowledge “I know it.”
Knowledge checks using brief quizzes to test understanding of the
content.
At the completion of each
module.
Procedural Skills “I can do it right now”
Task completion during simulation training to demonstrate ability to
apply knowledge.
During training.
Required postings on online community board to demonstrate the
application of learned principles.
Ongoing.
Pre-assessment and post-assessment to measure increased
competence.
Prior to beginning of each
module and post completion.
Attitude “I believe this is worthwhile.”
Track individual module completion rates and completion rates of
all four modules.
Ongoing.
Track participation levels on the online discussion board/online
communities.
Ongoing.
Confidence “I think I can do it on the job.”
Pre-assessment and post-assessment to measure increased
confidence.
Prior to beginning of each
module and post completion.
Track learner comments on the online discussion board/online
communities.
Ongoing.
Commitment “I will do it on the job.”
Complete of an individual action plan to implement learnings and
strategies within organization.
Post completion of all modules.

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Level 1: Reaction
Level 1 evaluation is used to determine if the quality of a program is acceptable to the
learner. The evaluation intends to measure the overall engagement, relevance, and customer
satisfaction of the learner (Kirkpatrick & Kirkpatrick, 2016). Evaluation methods can be both
formative, which involves reviewing the program while in progress, or summative, which
evaluates the program post-completion. Table 15 provides an overview of methods and tools that
will be used to evaluate the proposed education program.

Table 15
Components to Measure Reactions to the Program
Methods and Tools Timing
Engagement
Average time to complete each module Post-module
Percentage of learners who completed all three modules Post-program
Number of posted comments on discussion board Ongoing
Relevance
Feedback button in each module Ongoing
Course evaluation Post-module
Comments on discussion board Ongoing
Customer Satisfaction
Course evaluation Post-module/program

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Evaluation Tools
Immediately following the program implementation. Participants will be provided the
opportunity to evaluate the asynchronous educational program during the program and at the
completion of each of the four learning modules. The online surveys will be accessed on the
LMS and will be electronically submitted. These surveys will be used to monitor Level 1
learning, which measures the user’s engagement, relevance, and satisfaction with the program,
and Level 2 learning, which measures the user’s attainment of the needed knowledge and skills,
as well as user attitude and confident (Kirkpatrick & Kirkpatrick, 2016). Throughout each of the
learning modules, there will be a feedback button that will allow the learner to ask a clarifying
question or provide feedback on the learning instruction. The feedback button will be another
method to gauge user satisfaction or dissatisfaction. The AONE education department will
monitor this feedback and responses will be provided within one business day. There will also be
a button that allows the user to provide feedback or report challenges regarding technology
issues. This open-ended user feedback will be directed to the LMS provider and will be
responded to 24 hours a day/seven days a week.
The post-completion survey will include questions that probe for Level 1 learning
including, user engagement, course relevance, and user customer satisfaction. Questions will be
based on a 5-point Likert scale, with responses rated from strongly disagree to strongly agree.
Questions will include evaluation of the learning environment, application and relevance of
material to the user’s job, and willingness to recommend program to another learner. The survey
will also include open-ended questions that allow for feedback that is more detailed for each of
the above areas. In addition to the online surveys, user engagement will also be monitored by
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data reported through the LMS, including completion rates of each module, time spent per
module, and participation in the online discussion board.
The post-completion survey will also include questions that probe for Level 2 learning,
including evaluation of knowledge gain, attitude, and confidence. Knowledge gain will be tested
primarily through knowledge tests and takeaways assignments during the modules. The survey
will include an opportunity to provide open-ended feedback on knowledge gain. A similar open-
ended question format will be used to evaluate attitude and motivation, in addition to questions
rated on a 5-point Likert scale. Further questions using a Likert scale rating will also be used to
measure learner confidence. User skill will be tested as part of the learning modules, versus the
post-completion survey. Sample questions for the online surveys are provided in Table 16.

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Table 16
Sample: Evaluation Tool Immediately After Training
Learning
Component Survey Item
Declarative
Knowledge
Provide a brief overview of the impact that cultural competencies has on
health outcomes for racial and ethnic minority patients (open-ended
question).
Procedural Explain the steps utilized to ensure that the linguist needs of a patient is
being adequately met (open-ended question).
Attitude I believe that it is beneficial to apply the cultural competency knowledge
that I learned in this course to my role as a nurse leaders (5-point Likert
scale question).
Confidence I am confident that I will be able to apply the cultural competency
knowledge that I gained in this course to my role as leading my nursing
team (5-point Likert scale question).
Commitment I am committed to applying the cultural competency knowledge that I
gained in this course to my role as a nurse leader (5-point Likert scale
question).
Engagement The content of the learning module held my interest through completion (5-
point Likert scale question).
Relevance The takeaway assignments helped me apply my learning to my role of
improving the cultural competence of my nursing team (5-point Likert
scale question).
Customer
Satisfaction
I would recommend participating in this program to another nurse leader
colleague or co-worker (5-point Likert scale question).

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Delayed for a period after the program implementation. Participating nurse leaders
will be sent a follow-up survey six months after completing all four learning modules. The
primary goal of a post-completion training survey is to measure Level 3 learning, how users have
applied what they learned on the job, and Level 4 learning, how the training has affected results
and outcomes (Kirkpatrick & Kirkpatrick, 2016). Although evaluation of Level 3 learning and
Level 4 learning will be the primary focus of this 90-day post completion survey, Level 1 and
Level 2 learning will also be reassessed. Using a blended evaluation approach, combining the
evaluation from all four levels, reduces the possibility of survey fatigue (Kirkpatrick &
Kirkpatrick, 2016). A combination of closed-end question using a 5-point Likert rating scale will
be used to measure post-completion relevance of the learned material to the nurse leader’s role,
as well as user satisfaction. Open-ended questions will be included for the nurse leader to
provide more detailed and in-depth responses.
The majority of the survey questions will probe for Level 3 learning gains, which will
measure how successful the nurse leaders have been in transferring the learning to their nursing
teams. The close-ended questions will be rated on a 5-point Likert scale from little to no
application to very strong application of learning. Level 4 learning will be measured by the use
of survey questions that self-assess the application of the learning materials and achievement of
progress to reaching the organizational goal that focuses on all nurses providing culturally
competent care. For both Level 3 and Level 4 evaluation, open-ended questions will be included
to allow a more thorough evaluation and response. Surveys have limited ability to measure the
actual transfer of knowledge (Level 3) and progress to achieving the organizational goal (Level
4) in the practice setting. Due to these limitations, nurse leaders will also be asked to report other
metrics to measure the application of the education program, including general observation
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feedback of the nurses they lead, as well as changes to HCAPHS survey scores, readmission
rates for racial and ethnic minority and patients, and nursing satisfaction scores.
Data Analysis and Reporting
The findings of the evaluations will be reviewed internally within the AONE operations
team on a monthly basis. On a quarterly basis, the evaluations will be reported to the AONE
chief executive officer and the AONE board of directors. Table 17 provides a sample of a
dashboard that will be used to track progress to identified metrics.

Table 17
Sample Monthly Dashboard: May
Metric
Percentage
Responding
Yes (Target)
Percentage
Responding
Yes (Actual) Success
I was successfully able to apply what I
learned in the course to my nurse leader
role.
100% 100% On Target
I understand how to complete and am able
to apply a cultural assessment for patients
of all ethnicities and cultures.
100% 80% Needs
Improvement
I have successfully applied the learning
that I obtained in this course to my role as
a nurse leader.
100% 100% On Target
Patient satisfaction scores on HCAPHS
surveys have increased by target increase
of 10%.
100% 85% Needs
Improvement

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Summary of Program
The purpose of the program is to help achieve the stakeholder goal that by October 2018,
all AONE-member nurse leaders will be able to identify and apply evidence-based practices in
providing culturally competent care to patients of all ethnic and racial backgrounds. Although the
program is intended to close the identified knowledge, motivation, and organizational gaps that
affect the stakeholder goal, ample participation in the program will be needed from nurse leaders
in the field to reach this goal. As reported in Chapter 4, cultural competency education is
included in new staff orientation programs at nearly 75% of the respondents’ organizations.
Unfortunately, this percentage drops to 59.2% for annual nursing continuing education. Further,
as noted in the interviews, continuing education is often limited to one program per year that
includes one hour or less of content.
For this educational program to be successful, it will be important that nurse leaders
continue to place importance on improving the level of cultural competence of their teams,
despite the many other conflicting priorities that are part of their roles. It will also require a
commitment from the senior leaders within hospitals to support the nurse leaders, and the
nursing teams they lead, by financially supporting access to the education program, as well as
allowing the time required to participate. For nurse leaders who participate, it will be critical that
they remain engaged in the learning process throughout the program, and spread the obtained
knowledge and resources within their organizations, using the resources obtained from the train-
the-trainer module. To evaluate if the education program is meeting the determined program
goals, it will be important to utilize the data collected from the implemented New World
Kirkpatrick Model, to implement strategies for continual improvement of the program.
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Strengths and Weaknesses of the Approach
This study used a modified version of the Clark and Estes (2008) gap analysis model as
the framework to identify the knowledge, motivation, and organizational goals of AONE-
member nurse leaders, related to their ability to identify and apply evidence-based practices in
providing culturally competent care to patients of all racial and ethnic backgrounds. A modified
version was used to evaluate and identify the presence of gaps, versus the causes of gaps, which
is the basis of the Clark and Estes (2008) model. The strength of the Clark and Estes model is
that it provides a systematic approach to analyze gaps in performance related to human causes
(Clark & Estes, 2008). The model begins with defining goals, followed by determining gaps,
validating and prioritizing causes, developing solutions, and evaluating outcomes. The model
also allows the user to identify both individual and organizational goals, from short-term and
long-term perspectives. By thoroughly evaluating the assumed causes of identified performance
gaps, resources can be assigned more effectively and efficiently to improve performance (Rueda,
2011). Further, evaluating outcomes reduces the risk that organizations will implement
ineffective solutions to performance gaps that result in failed results. Another strength of the
model is that it is applicable to real-world problems faced in organizations of all sizes and
industry categories, versus problem-solving using strictly a theoretical approach (Rueda, 2011).
Although the Clark and Estes model used in this study has numerous strengths, the model
also has weaknesses. One identified weakness is the perception of leaders within organizations
that a gap analysis evaluation is too time consuming (Clark & Estes, 2008). Organizational
leaders may not be willing to dedicate the time needed to progress through the four steps of the
analysis. Specifically, organizations may be inclined to not complete the final stage of the model,
the evaluation step, and may assume the implemented solutions were effective, versus evaluating
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to ensure the solutions were effective. Additional weaknesses of the model include the
perception of leaders that the model is too complicated and that the model will be too expensive
to execute (Clark & Estes, 2008).
Limitations
As with every research study, this study has limitations. One limitation related to the
study methodology was limiting the sample to AONE-member nurse leaders, due to the
organizational setting of the study. The assumption that AONE-member nurse leaders are
reflective of non-AONE members may not be accurate. It is not clear if there are certain
characteristics of nurse leaders who are members of a national nursing association, versus nurse
leaders who do not belong to a national nursing association and the impact these differences
could have on their cultural competence knowledge and motivation. Another study limitation is
the potential that the nurse leaders, both surveyed and interviewed, responded to the questions in
a way that they felt was professionally expected. Although the survey was anonymous, the nurse
leaders may still have been concerned that their personal responses could be identified.
Similarly, the nurse leaders may have felt the need to respond in a certain way because the
researcher is a senior leader within AONE. In addition, although within the scope of this survey,
the small sample size of the interviews, which included six nurse leaders, could also be a study
limitation. Based on the study sample size, it is not evident if a saturation of the key themes was
reached (Merriam & Tisdell, 2009).
Future Research
Emerging from this study are various potential opportunities for future researchers to
consider. Future researchers exploring this topic may consider determining if the influence of
belonging to a national nursing association affects nurse leaders’ perceived cultural competence
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151
knowledge and motivation. As noted in the limitation section, this study’s sample included only
AONE-member nurse leaders, who could potentially have a different knowledge and motivation
base compared to nurse leaders who are not AONE-members. Another potential future research
could explore the influence that the perceived cultural competence of nurse leaders has on the
cultural competence of the nursing teams they manage. The findings of this study supported that
the transfer of knowledge, often from ethnic and minority co-workers, improves the cultural
competence of nurse leaders. Further, the importance of modeling and leading by example was
identified as a component of nurse leader motivation. It would be interesting to learn, in future
research, how the cultural competence of the nurse leaders, as well as their skill and dedication to
modeling and leading by example, impacts the cultural competence of their nursing team. Yet
another potential future research study could focus on the impact that specific demographics
have on the perceived cultural competence of nurse leaders and the nursing teams they lead.
Beyond the scope of this study, future researchers could further explore the impact of
demographics, such as respondent age, race, education, and geographic location, to explore the
impact on cultural competence. Lastly, as noted in Chapter 1 of this study, another identified
stakeholder group (not primary stakeholder group) was hospital and health care CEOs. Signing
the national Pledge to Eliminate Health Care Disparities was identified as a way these leaders
could demonstrate their commitment to reducing health care disparities. An interesting future
research initiative would be exploring the connection between organizations who have signed
this national pledge and their clinical staffs’ cultural competence.
Conclusion
Health care disparities for racial and ethnic minority patients are a serious issue in the
U.S. health system. Although socio-economic status is a primary cause of these disparities, in
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reality there are many other contributing factors. Even when socio-economic status is held
constant, disparities are still present. Solutions to address these disparities can be approached
from various vantage points, including education, outreach, and policy. Improving the cultural
competence of care providers, including nurses, is just one potential improvement area. In the
practice environment, nurses constitute the largest percentage of hospital staff and serve as the
primary provider of patient care in the U.S., so their impact on the delivery of culturally
competent care is significant (BLS, 2015). The role of nurse leaders, and their influence on the
nursing teams they lead to deliver culturally competent care, is critical. Identifying and closing
gaps in knowledge, motivation, and organizational influences is a necessary step to improving
cultural competence.
Although improving caregiver cultural competence is an important strategy to reduce
health care disparities, the emerging concept of culture humility is broadening the possibility of
providing optimal patient care to all individuals. To fully understand each patient’s unique needs
and attributes, clinicians must demonstrate compassion that comes from their hearts (Chang,
Simon, & Dong, 2012). Beyond teaching cultural competence, it is important to encourage and
support self-reflection and self-awareness of one’s own culture and framework and the further
development of compassionate care, with the goal of understanding each unique individual better
(Yeager & Bauer-Wu, 2013). This broadens education from learning from the head, to learning
from the head as well as the heart.
The implication of this study is to add to the scholarly body of knowledge aimed to
improve the cultural competence of clinicians, decrease health care disparities, and improve the
health of individuals and communities. The findings of this study may be useful for nurse leaders
to implement strategies and plans within their own organizations to increase their level of
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153
cultural competence, as well as the cultural competence of the nursing teams they lead.
Improving the cultural competence of these clinicians and leaders can have a significant impact
on reducing disparities of care for racial and ethnic minorities. The study findings may also
encourage other researchers to explore further the impact of cultural competence on the delivery
of equitable care to all individuals.

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APPENDIX A
RECRUITMENT LETTER
My name is Susan Gergely and as a doctoral student in organizational change and leadership at
the University of Southern California, I invite you to contribute to a study that explores the
influences that affect providing culturally competent care to patients of all races and ethnicities.
Your participation will include completing a brief 15-question online survey, plus six
demographic questions, and potentially being invited to participate in an individual interview.
You are eligible to participate in the study because you currently serve in a nursing leadership
role at a hospital and are a member of the American Organization of Nurse Executives (AONE).

Your involvement in this study is voluntary; the alternative is not to participate. If you decide to
participate, you will be given an information sheet about the study, complete an online survey,
and potentially be asked to participate in an individual interview. The online survey should take
approximately ten minutes and the individual interview will take approximately 30 minutes. All
participants who complete the survey and provide their contact information will be entered into a
drawing for a $50 Amazon gift card; five gift cards will be awarded.

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APPENDIX B
INFORMED CONSENT/INFORMATION SHEET
University of Southern California
Rossier School of Education
Waite Phillips Hall
3470 Trousdale Parkway
Los Angeles, CA 90089

INFORMATION/FACTS SHEET FOR EXEMPT NON-MEDICAL RESEARCH

HEALTH DISPARITIES AND THE IMPACT OF CULTURAL COMPETENCE

You are invited to participate in a research study conducted by Susan Williamson Gergely under
the supervision of Dr. Kimberly Hirabayashi at the University of Southern California. Your
participation is voluntary. This document explains information about this study. You should ask
questions about anything that is unclear to you.

PURPOSE OF THE STUDY
The study is being conducted by a graduate student from the University of Southern California as
part of the dissertation process. The purpose of the study is to explore the various influences that
affect nurse leaders, leading their teams, in providing culturally competent care to patient of all
racial and ethnic backgrounds.

PARTICIPANT INVOLVEMENT - SURVEY
If you agree to participate in this research study, you will be asked to take an anonymous online
survey that will take approximately ten minutes complete. You are not required to answer any
questions that you do not want to answer. During the survey, if you decide to skip a question you
will click “next” to move to the next question. Your participation will remain confidential and
information that you share will not contain any identifiers linked to you or your responses.

PARTICIPANT INVOLVEMENT – INTERVIEW
As part of this study, you may also be asked to participate in a semi-structured individual
interview that will last approximately 30 minutes and be conducted via Skype. Six participants
will be randomly selected from all interview volunteers who meet the study criteria. Guided
questions will be used in these interviews and follow-up questions may be included. The
interviews will be recorded. You do not have to answer any questions that you do not want to
answer. If you do not agree to be recorded, you will be unable to participate in the study.

ALTERNATIVES TO PARTICIPATION
Your alternative is not to participate in this study.

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166
PAYMENT/COMPENSATION FOR PARTICIPATION
You will not be compensated for participation in the survey or interview. If you decide to
participate in the survey, you will have the opportunity to be entered into a drawing to win a $50
Amazon gift card. Five gift cards will be awarded. The drawing for the gift cards will be
conducted at the end of the survey period and the winners will be notified via email. The
information you provide for the drawing will be separate from the survey that you complete.

CONFIDENTIALITY
Your participation will remain confidential and information that you share will not contain any
identifiers to you. The researcher on a password-protected computer in a secure office will store
the data collected in the online survey. The data files will be destroyed two years after the
completion of the survey.

The individual interviews will be facilitated by the researcher via Skype. Only the professional
transcriber and the researcher will have access to the audio recordings. The transcripts will
remain confidential, be stored on a password-protected computer in a secure office of the
researcher, and will be destroyed after they are transcribed.

The members of the research team and the University of Southern California’s Human Subjects
Protection Program (HSPP) may access the data. The HSPP reviews and monitors research
studies to protect the rights and welfare of research subjects. When the results of the research are
published or discussed in conferences, no identifiable information will be used.

INVESTIGATOR CONTACT INFORMATION
If you have any questions or concerns about the study, please contact the following individuals:
Principal Investigator Susan Williamson Gergely via email at sgergely@usc.edu or faculty
advisor Kim Hirabayashi, PhD at hirabaya@usc.edu.

IRB CONTACT INFORMATION
University Park Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los
Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu

HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

167
APPENDIX C
SURVEY ITEMS
Although there are varied definitions of cultural competence, for this survey the following
definition will be applied:

Cultural competence is defined as the ability of health care systems and providers to deliver care
to patients with varied and diverse values, beliefs, and behaviors, while meeting the patients’
social, cultural, and linguistic needs (Health Research & Educational Trust [HRET], 2011).

The following responses are based on a five-point Likert scale (Strongly disagree, Disagree,
Neither agree or Disagree, Agree, Strongly agree). Please respond with your level of agreement
for each of the following statements:

1. Racial and ethnic minority patients in the United States receive lower quality of care, which
results in reduced health outcomes. (K-factual)

2. The cultural context of each patient’s treatment is influenced by the individual, family, and
community. (K-conceptual)

3. Health care disparities that stem from language barriers can be reduced through improved
procedural knowledge of the nurses on how to effectively communicate with patients for
which English is not their primary language. (K-procedural)

4. It is important that nurses dedicate time to reflect on their own knowledge and level of
cultural competence in providing care to patients of all racial and ethnic minorities. (K-
metacognitive)

5. Prejudice and bias, including both conscious and unconscious bias, affect the quality of care
that patients receive. (K-metacognitive)

6. It is important for me to lead my staff in providing culturally competent care. (M-EVT)

7. I am confident in my ability to lead my staff in providing culturally competent care. (M-self-
efficacy)

8. I receive clearly defined goals and objectives from my organization’s senior leadership and
governance body to improve the level of cultural competence of my nursing staff. (O)

9. My organization’s strategic plan includes guidelines for incorporating cultural and linguistic
competence into nursing operations. (O)

10. My organization’s chief executive officer and governance body holds leaders accountable for
improving the level of cultural competence of their staff. (O)
HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

168
11. My organization values and places importance on improving the level of cultural competence
in delivering care through the allocation of resources and education to the nursing staff. (O)

12. Cultural competency training is required at my organization for new staff orientation. (O)

13. Cultural content areas are included as a required component of annual nursing education at
my organization. (O)

14. Quality improvement projects that are aimed at improving the quality of care provided to
diverse patient populations are in place at my organization. (O)

15. My staff has adequate access to language assistance services, to aid in such functions as
interpreting for patients for which English in not their first language. (O)

Key:
(K) – measures knowledge influence
(M) – measures motivation influence
(O) – measure organizational influence

Demographic questions:

1. How long have you been in a nursing leadership role?
 0-1 years
 2-5 years
 6-10 years
 11-15 years
 16-20 years
 Over 20 years

2. What is your licensed bed count?
 Less than 100
 100-300 beds
 301-499 beds
 500-999 beds
 1,000 – 4,000 beds
 More than 5,000 beds

3. What is your current level of responsibility?
 Chief Nursing Officer/Chief Nursing Executive
 Clinical Staff
 Director
 Manager
 Other, please specify:____________

HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

169
4. What is your gender?
 Female
 Male

5. What is your ethnicity?
 African American
 Asian
 Hispanic or Latino
 Native American
 White
 Other
 Unsure/Prefer not to answer

6. What is your highest level of education attained?
 Associate degree
 Bachelor’s degree
 Master’s degree
 Doctoral degree
 Other

HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

170
APPENDIX D
INTERVIEW PROTOCOL
1. Can you define what providing culturally competent care means to you? (K)
 How did you learn about cultural competence? (K)
 Why did you think it was important to learn about? (M)

2. Can you tell me a little about your understanding of health care disparities for racial and
ethnic minorities and the impact they have on patient care? (K)
 Where did your knowledge of disparities come from?
 How does this knowledge lead your clinical practice? How does it affect your
leadership influence? (K)
 Is having this knowledge important to you as a clinician? If so, why is it important? If
not, why is it not important? (M)

3. Tell me your thoughts on the relationship between the cultural competence of nurses at your
organization and the level of disparities in serving racial and ethnic minorities? (K)
 What role do you believe bias, both conscious and unconscious, plays in the level of
care the nurses at your organization provides to patients? (K)

4. How do you lead the nursing staff in your organization to provide culturally competent care?
(M)
 To what extent do you feel this is an important aspect of your role? (M)
 What do you do to expand your nursing team’s knowledge of cultural competence?
(K)

5. How confident are you in your ability to lead your staff in providing culturally competent
care? (M)
 If confident, where did that confidence come from? (M, K)
 If not confident, why do you think you are not confident? What resources would help
you become more confident? (M, O)

6. How, if at all, does your organization’s leadership communicate the organization’s vision and
goals for providing culturally competent care? (O)
 Do you believe the staff has a clear understanding of this vision and goals? (K)
 What impedes the team from reaching these goals? (K, M, O)

7. How, if at all, are leaders in your organization held accountable, by perhaps meeting specific
metrics, for improving the level of cultural competence of their staff? (O)
 What sort of metrics are measured and monitored?
 Can you describe how this accountability or lack of accountability affects the leaders’
performance evaluations?

HEALTH CARE DISPARITIES AND CULTURAL COMPETENCY

171
8. Can you describe the kind of resources your organization provides to the nursing staff to
improve their level of cultural competence? (O)
 Do you think that these resources are effective in improving their knowledge and
application of providing culturally competent care? (K, O)
 What additional resources would be beneficial?

9. What, if any, continuing education is either provided or required by your organization to
improve the cultural competence of the nursing staff? (O, K)
 Is there a specific program that is most effective? What makes it effective? (O, K)

10. Is there anything else you would like to share or add?

Key:
(K) – measures knowledge influence
(M) – measures motivation influence
(O) – measures organizational influence

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Asset Metadata

Creator Williamson Gergely, Susan (author)

Core Title Health care disparities and the influence of nurse leader cultural competency: an evaluation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 08/28/2017

Defense Date 07/26/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag cultural competence,health care disparities,nurse leader,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Datta, Monique (committee member), Embrey, Karen (committee member)

Creator Email sgergely@usc.edu,sgergely@ymail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-424324

Unique identifier UC11265826

Identifier etd-Williamson-5690.pdf (filename),usctheses-c40-424324 (legacy record id)

Legacy Identifier etd-Williamson-5690.pdf

Dmrecord 424324

Document Type Dissertation

Rights Williamson Gergely, Susan

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA