Ramona Benkert

Psychometric Evaluation of the Cultural Competence Assessment Instrument Among Healthcare Providers

Background: The relevance of healthcare provider cultural competency to the achievement of goals for reduction in extant health disparities has been demonstrated; however, there are deficits with regard to cultural competency measurement. Objectives: To examine the test-retest reliability of the cultural competence assessment instrument (CCA) among hospice providers, and to examine the reliability and validity of the CCA among healthcare providers in nonhospice settings. Method: Test-retest reliability of the CCA was assessed using a sample of 51 hospice respondents who completed the CCA at two time points. The internal consistency reliability and construct validity of the CCA for healthcare providers in nonhospice settings were evaluated using a convenience sample of 405 healthcare providers. Results: The CCA demonstrated adequate test-retest reliability (r = .85, p = .002) in hospice providers over 4 months. Among healthcare providers in nonhospice settings, the CCA had an internal consistency reliability of .89 overall (.91 and .75 for the two subscales). Construct validity was supported by principal axis factor analysis, which showed two factors with item loadings above .40, explaining 56% of the variance. Mean scores of the CCA were significantly higher for providers who reported previous diversity training compared to those who had not. Discussion: Findings for the psychometric properties of the CCA supported its potential as an instrument for measuring provider cultural competence. Knowledge gained will be useful for developing future research studies and specific cultural competence intervention approaches for healthcare providers that may decrease health disparities.

Development of a cultural competence assessment instrument

This article describes initial testing of an instrument designed to provide evidence of cultural competence among health care providers and staff. The Cultural Competence Assessment (CCA) instrument was based on a model describing cultural competence components (fact, knowledge, attitude, and behavior). Content and face validity were confirmed through expert panel review, subject feedback, and field-testing. The CCA was administered to an interdisciplinary health care team in a community hospice setting. Preliminary findings suggest that the CCA performed well. Internal consistency reliability for the scale was 0.92. Construct validity by factor analysis demonstrated that 25 items had loadings above 0.42. Construct validity was supported with a significant correlation to the widely used Inventory for Assessing the Process of Cultural Competence among Health care Professionals (IAPCC). Validity also was supported by significant differences between individuals with different educational levels and prior diversity training. The CCA is a promising tool to measure cultural competence in populations with a wide range of educational levels and backgrounds.

Culturally Congruent Care Putting the Puzzle Together

This article presents the 3-D puzzle model of culturally congruent care, defines the levels and constructs employed by this model, presents some assumptions, and lays out some basic propositions as a foundation for further work. There are many extant frameworks and theories of culture and cultural competence in nursing and health care; the model presented here draws heavily from prior work and is an attempt to present a synthesis of concepts and processes in a new way. The ideas presented here build particularly on pioneering work in transcultural nursing by Leininger. Leiningers work specifically focuses on the use of qualitative methods to understand the ways in which culture influences nursing care from an emic, or insider, perspective. The 3-D puzzle model extends Leiningers work to include concrete articulations of constructs relevant to design and implementation of intervention strategies for teaching and measuring competency among nurses and other providers.

African American Women’s Coping with Health Care Prejudice

African American clients have reported racism and prejudice in health care; yet there is limited documentation of the strategies used to cope with these experiences. This study describes African American women’s perceptions of prejudice in health care and the strategies used to cope with the experiences. This qualitative study used the constructivist perspective of interpretive interactionism for paradigmatic and methodological guidance. Participants were 20 women ranging from age 26 to 74 years with 50% having a high school education. Individual interviews consisting of five areas were conducted with three instruments measuring ethnic identity, socioeconomic status, and general demographics. The analyses provide two themes: experience with the “White health care system” and strategies for coping with the prejudice, which included getting angry, learning to unlearn, being assertive, and walking away. Consistent with the discussions of race in the United States, racism in health care has become a subtle entity that infuses health care relationships.

Testing a multi-group model of culturally competent behaviors among underrepresented nurse practitioners†

Diversifying the health professional workforce and enhancing cultural competence are recommended for decreasing health disparities. We tested a structural equation model of the predictors of culturally competent behaviors in a mailed survey of three groups of underrepresented nurse practitioners (n = 474). Our model had good fit and accounted for 29% of the variance in culturally competent behaviors. Life experiences with diversity had direct effects on awareness/sensitivity and behaviors, and diversity training had a direct effect on behaviors. Cultural awareness/sensitivity mediated the relationship between life experiences with diversity and culturally competent behaviors; all paths remained after controlling for covariates. For unique experiences that contribute to workplace diversity, life experiences with diversity, and diversity training are important for culturally competent behaviors.

Hypertension Outcomes In an Urban Nurse-Managed Center

Purpose To assess the quality of hypertension (HTN) care in an urban nurse‐managed center (NMC) by chart audits of insured and uninsured (N= 52) African Americans who were managed by nurse practitioners. Data Sources A chart audit form was developed by the authors that merged Health Plan Employer Data and Information Set (HEDIS) criteria with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria. Conclusions There was near comparable hypertension control among the two groups. No difference was found in systolic blood pressure (BP) control; however, the uninsured group had a slightly greater average diastolic BP compared with the insured group. There was no significant difference in the number of HTN medications or the number of risk factors. A significant difference was found in the number of NP visits per year between the two groups; the uninsured group averaged 3.2 more visits per year.

Impact of academic nurse-managed centers on communities served

Purpose: This paper presents findings from six community focus groups that addressed the impact of academic nurse‐managed centers (ANMCs) on the overall community being served as well as the quality of care provided in the centers. Data sources: Experts in focus group methodology from a public health institute conducted the six focus groups at ANMCs from four universities in the Midwest. Discussions were guided by nine questions presented to each group. All groups were tape‐recorded and transcribed. A total of 37 participants were recruited from the ANMCs and included patients and families, advisory board members, and local community organizations. Conclusions: Four themes were identified across the six focus groups: valuing patient‐centered care, which included two subthemes—continuous specific provider and specific aspects of care; quality of care; increasing access to care/addressing the safety net; and evidence of outreach. Implications for practice: Findings from these focus groups verify that community members do “get it” in terms of the unique aspects of ANMCs. Participants were able to articulate the differences between nurse‐managed care and other types of ambulatory primary care. The unique strengths of nurse practitioners were repeatedly articulated as well as the centers’ outreach into the community.

Violence exposure and optimism predict task-induced changes in blood pressure and pulse rate in a normotensive sample of inner-city black youth

Objective: This investigation examined the association of violence exposure (home and neighborhood) and optimism to task-induced changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate (PR). Methods: Drawn from a larger investigation, the convenience sample for this study consisted of 172 normotensive black youth (mean age = 11.5 years, standard deviation = 1.3). Violence exposure and optimism were self-reported by participants, and task-induced changes in SBP, DBP, and PR were measured with an automated monitor during two sequentially administered digit-forward and digit-backward tasks. Results: Hierarchical regression analyses revealed that violence exposure was inversely related to task-induced changes in SBP (p = .010) and DBP (p = .005). Optimism was not an independent predictor of blood pressure or PR changes (p-s > .32). The final step of these hierarchical analyses indicated that the effects of violence exposure and optimism interacted to predict task-induced changes in SBP (p = .013) and PR (p = .003). Follow-up regression analyses indicated that violence exposure was inversely related to task-induced changes in SBP among participants high in optimism and was positively associated with PR reactivity in participants low in optimism. Conclusions: The youth in this study have intact mechanisms for buffering blood pressure responses to violence exposure, especially those who are more optimistic about their future—a person factor whose moderating effects might wane with advancing age. HTN = primary hypertension; SBP = systolic blood pressure; DBP = diastolic blood pressure; PR = pulse rate; M = mean; SD = standard deviation; SE = standard error; mm Hg = millimeters of mercury; kg/m = kilograms/meter.

Comparison of Nurse Managed Health Centers With Federally Qualified Health Centers as Safety Net Providers

Nurse Managed Health Centers (NMHCs) provide a critical safety net function in their communities, yet they often remain invisible and challenged in terms of financial sustainability. This paper presents a comparison of demographics and financial status of NMHCs and Federally Qualified Health Centers (FQHCs). The comparison is based on four years of annual NMHC national survey data that includes 42 NMHCs overall and the 2008 FQHC data in the Uniform Data System. Findings indicate that NMHCs and FQHCs serve very similar diverse populations yet funding and revenue differences were significant. NMHCs tend to rely more on grants and donations from the private sector as well as contracts while FQHCs have access to considerable federal support that is cost based when serving the underserved. In addition, NMHCs are challenged by the array of state, federal and third party insurers’ regulations that often disadvantage nurse practitioners as primary care providers.

Tuberculosis education for nurse practitioner students: where we are and where we need to go.

Tuberculosis (TB) has reemerged as a public health concern. This study tested the reliability and validity of an instrument examining self-efficacy in providing TB care, beliefs about educational preparation, and knowledge about TB among nurse practitioner students from diverse programs. A one-time self-report instrument was distributed during a final clinical course. Rasch analysis was used to assess the instruments reliability and validity. Most of the 92 respondents were from family nurse practitioner programs and had received TB education via lecture. Students were moderately knowledgeable on TB content and had a moderate level of perceived self-efficacy. They valued TB education as it related to both their current program and their clinical practice. The instrument had excellent reliability (alpha = 0.96 to 0.98), and it appears to be an effective measure to help faculty understand student knowledge and confidence in the care of individuals with TB.