Nurse Education Today 45 (2016) 225–229

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Assessment of cultural competence in Texas nursing faculty

Collen Marzilli, PhD, DNP, MBA, RN-BC, CCM, APHN-BC, CNE, Assistant Professor
The University of Texas at Tyler, Braithwaite Building 2170, 3900 University Blvd., Tyler, TX 75799, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Cultural competence [CC] is an essential component of nursing education and nursing practice yet
Received 27 April 2016 there is a gap in the research evaluating CC in faculty and how to practically develop this skillset for faculty mem-
Received in revised form 2 August 2016 bers.
Accepted 16 August 2016 Objectives: To explore CC in faculty as evaluated with the Nurses' Cultural Competence Scale [NCCS] and apply the
findings to the Purnell Model of Cultural Competence [PMCC] to guide professional development opportunities
Keywords:
for faculty members.
Purnell model of cultural competence
Nursing
Design: This was a concurrent mixed-methods study.
Health Setting: Faculty members teaching in Texas nursing programs were recruited for the study. Quantitative data was
Culture collected using an online survey tool and qualitative data was collected over the phone.
Values Participants: 89 Texas faculty members completed the quantitative strand and a subset of 10 faculty members
Nursing education completed the qualitative strand.
Nurses' cultural competence scale Methods: Descriptive statistics were used to examine the quantitative data and Strauss and Corbin's methodology
guided the evaluation of the qualitative data. These two strands were used to support the results.
Results: Faculty in Texas are moderately culturally competent. The qualitative findings support the application of
the PMCC to the areas identified by the NCCS.
Conclusion: The PMCC may be applied to the application of culture and values in nursing professional education as
supported by the NCCS. Recommendations are to include the PMCC as a structure for the creation of professional
development opportunities for faculty.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Cultural competence [CC], which is acting in a manner that acknowl-
edges the cultural background of another individual and tailoring the at-
titudes and behaviors of the individual providing care towards the
culturally diverse individual (Marzilli, 2014), is of paramount impor-
tance to address health disparities in the United States (U.S.). As U.S.
CC education needs to be integrated into the nursing curriculum, it is
important to understand the level of CC in faculty members as they
are responsible for teaching this important skill. Applying this under-
standing to Purnell's Model of Cultural Competence [PMCC] provides
opportunities for faculty development to better prepare nurse educa-
tors to advance their own cultural competency and model this behavior
for students. By framing faculty understanding of culture and faculty de-
velopment sessions in the PMCC, pedagogically faculty members may
be better prepared to understand and address this for students.
Faculty members' perceptions of CC are not well-documented.
Therefore, the purpose of this mixed-methods study was to deter-
mine the level of CC in pre-licensure faculty in Texas and explore fac-
ulty perceptions of what it means to be culturally competent while
E-mail address: cmarzilli@uttyler.edu.
applying these findings to the PMCC. The research question was: In
pre-licensure faculty members, what is their level of CC and their
perceptions of CC?
Ultimately, faculty are paramount in teaching necessary skills. Con-
sidering the challenges related to fear in the general public (Cook,
2015), faculty members should understand their own level of cultural
competency, seek opportunities to improve this, and actively model
and teach these skills to students.
2. Background/Literature
2.1. CC in Nursing Education
CC in nursing education has been studied through qualitative meth-
odologies like interviews. Studies have identified many resources for
the development of CC, such as experiential learning (Harris et al.,
2013; Harrowing et al., 2012; Gillund et al., 2013; Kratzke and Bertolo,
2013; Michael et al., 2012). These studies, while essential to the body
of knowledge regarding CC in students do not provide quantitative
data to evaluate or identify means to improve CC in nursing students.
Campinha-Bacote (2006) found that nursing students who expressed
a desire to be culturally competent achieved a higher level of CC than their
peers who did not express such a desire (Fitzgerald et al., 2009).

http://dx.doi.org/10.1016/j.nedt.2016.08.021
0260-6917/© 2016 Elsevier Ltd. All rights reserved.
226 C. Marzilli / Nurse Education Today 45 (2016) 225–229
Quantitative studies found that knowledge gained in an immersion envi-
ronment or a classroom setting was essential to increasing CC
(Michajlyszyn et al., 2012. Wilson et al. (2010) found that providing
knowledge through a CC workshop had lasting benefits.
2.2. CC in Faculty
Faculty members are role models for pre-licensure nursing students
(Felstead, 2013). Warner and Esposito (2009) studied the impact that ed-
ucators can play in role-modeling desired behaviors and found this was
an effective method of instruction. Montenery et al. (2013) explored
how faculty transfer their CC knowledge to the educational setting so
that nursing students can learn positive behaviors and relate them to pa-
tient care. It is essential that they possess an awareness of the examples
they provide to students in providing culturally competent care and skills
(Morton-Miller, 2013). While research has supported the role of faculty in
developing student nurse CC, limited studies explore the purposeful un-
derstanding of how faculty members convey this knowledge. Some stud-
ies even show that faculty members are not adequately prepared in CC
(Kardong-Edgren, 2007; Kardong-Edgren et al., 2005; Sealey et al., 2006).
2.3. Purnell's Model of Cultural Competence
The PMCC was originally designed as an organizing framework to teach
undergraduate students about CC. The realization that the model is a grand
theory and has applications outside of nursing education extended its use
to frame culture and CC for all involved in the care of persons from diverse
backgrounds. The wholistic nature of the PMCC (Purnell, 2005) is appro-
priate for professionals in all disciplines to address ethnocentric behaviors,
a lack of cultural awareness, and cultural insensitivity.
The PMCC has at its core a dark circle representing what is still un-
known about culture and CC. Framing the dark circle are 12 domains com-
prising culture. Four outer circles represent from inside to out, person,
family, community, and global society. The 12 cultural domains of the
PMCC are: overview/heritage, communication, family roles and organiza-
tion, workforce issues, biocultural ecology, high-risk behaviors, nutrition,
pregnancy, death rituals, spirituality, health-care practices, and health-
care practitioners. Along the bottom of the circular model is a lightning
bolt showing the transition from unconsciously incompetent, consciously
incompetent, consciously competent, and unconsciously competent as
practitioners dynamically interact with the characteristics of culture
(Purnell, 2005).
The PMCC provides a framework for health care providers as they ex-
plore culture didactically and practically while caring for individual pa-
tients, families, groups, or communities. The model frames
circumstances and factors that shape worldview and provide an insight
into culture. This serves to highlight what is necessary within the context
of culture for a particular patient so that appropriate care can be planned
to improve the health of all clients within the context of their culture
(Purnell, 2005).
The PMCC can also be used to assess CC and plan for revisions in cur-
riculum as pedagogical decisions are made. The model can be used as an
assessment to understand CC in students (Hayward and Charrette,
2012) and faculty, and it is an effective resource for faculty in organizing
curricula so that students are taught the fundamental aspects of culture
(Hudiburg et al., 2015). Faculty professional development sessions in CC
are well suited to follow the PMCC framework.
3. Methods
3.1. Design
A convergent parallel mixed-methods design was used to examine
CC in faculty. A quantitative strand measured CC. A qualitative strand
explored faculty perceptions of CC.
3.2. Sample and Participant Selection
A convenience sample of 89 faculty in Texas was recruited through
the Texas Organization of Baccalaureate and Graduate Nursing Educa-
tion (TOBGNE) and the Texas Organization for Associate Degree Nursing
(TOADN) Listservs, which, together, comprise a listing of all nursing
program deans and directors in Texas. Inclusion criteria were: full-
time faculty; employed by a university or college in Texas; and teaching
nursing students. Full time faculty teaching in both an undergraduate
and graduate programs were included. A subset of 10 participants was
recruited for the qualitative interviews.
3.3. Setting
The quantitative surveys were administered online through a link in
the email sent to the listservs. The survey was open for a two-week pe-
riod. Interviews were conducted by telephone.
3.4. Assessment and Measures
CC is conceptually defined as acting in a manner that acknowledges
the cultural background of another individual and tailoring the attitudes
and behaviors of the individual providing care towards the culturally di-
verse individual (Marzilli, 2014). A decision was made to use define CC
operationally with the Nurses' Cultural Competence Scale [NCCS]. This
instrument was selected due to its ease of use and budgetary con-
straints, and it can be applied to the PMCC. The NCCS is a 41-item survey
with four subscales (cultural awareness - 10 items, cultural knowledge -
9 items, cultural sensitivity - 8 items, and cultural skills - 14 items)
(Perng et al., 2007). Each subscale uses a five-point Likert scale to mea-
sure the participant's response: 1 = totally disagree, 2 = 25% agree,
3 = 50% agree, 4 = 75% agree, and 5 = 100% agree. Total scores range
from 41 to 205 with higher scores indicative of a higher level of CC.
The NCCS was originally written in traditional Chinese and evaluated
by four experts; it has been translated into English. Several studies sup-
port the reliability and validity, with a reported Cronbach's α between
0.78 and 0.96 and a reliability between 0.79 and 0.89 of the Chinese ver-
sion (Lin, 2013; Perng et al., 2007; Perng and Watson, 2012). The En-
glish version has shown to be promising as it has been piloted in
English, and results are pending for the validity and reliability associated
with the English version.
The NCCS assesses the PMCC. The subscales of awareness and sensi-
tivity relate to the four outer rings of the PMCC; global society, commu-
nity, family, and person. The subscales of knowledge and skills assess
and inform the 12 inner domains of the PMCC; health care practitioners,
overview, communication, family, workforce issues, biocultural ecology,
high-risk behaviors, nutrition, pregnancy, death, spirituality, and health
care practices. Along the bottom of the model is the lightning bolt
representing the continuum through which cultural competency oc-
curs, and this is represented in the change of the NCCS score depending
on when the nurse completes the assessment. This was also reflected in
certain qualitative discussions.
Qualitative data were obtained through semi-structured interviews
based on open-ended questions. These questions were intended to so-
licit information from the participants regarding their cultural encoun-
ters, existing knowledge, and feelings associated with CC. The
qualitative interview also examined their desire related to CC.
3.5. Procedures
Through the TOBGNE listserv, nursing deans and directors received
an email asking them to forward the information to their faculty mem-
bers. The email contained an IRB statement and a link to the online sur-
vey. Participation was entirely voluntary with no benefit, reward, or
coercion, and anonymity was in place for all participants completing
the quantitative strand. Following the quantitative questions, faculty
 C. Marzilli / Nurse Education Today 45 (2016) 225–229
members were taken to a separate survey and asked if they would be in-
terested in participating in the qualitative strand of the study.
Those opting into the qualitative strand were asked to provide their
name and contact information for participation in an interview. These
participants were contacted, and an interview was arranged and com-
pleted following submission of a signed informed consent.
3.6. Data Analysis and Strategy
Quantitative data were imported into SPSS version 20 (IBM, Inc.,
Armonk, NY, USA). The first part of the research question which deter-
mined the level of CC of participants, was analyzed using descriptive
statistics. Means and standard deviations were calculated for each of
the four CC subscales and the overall level of CC. Descriptive statistics
were also used to evaluate the level of CC in each faculty member.
The second portion of the research question examined the percep-
tions of CC in the faculty member and was evaluated using the constant
comparative method. Trustworthiness was maintained by having a sec-
ond researcher review, code, and analyze the data for comparison with
the PI's coded data. Theoretical constructs were independently conduct-
ed and mutually agreed upon. Additionally, triangulation, member
checking, and keeping a field journal were used to ensure trustworthi-
ness. Inspired by the work of Corbin and Strauss (2008) qualitative anal-
ysis procedures, themes were identified. Constructs and examples of the
constructs were used to support each theme. The themes were related
back to the PMCC. The subscales of awareness and sensitivity relate to
the four outer rings and the subscales of knowledge and skills assess
and inform the 12 inner domains.
4. Data/Results
4.1. Sample Characteristics
89 participants comprised the final sample. The sample was primar-
ily female, white, educated at the MSN level, with a mean age of 55.
Most spoke English as a first language, and the majority had experience
traveling abroad.
4.2. NCCS Score
Descriptive statistics were used to analyze the level of CC and the
four NCCS subscales. Total NCCS scores ranged from 81 to 197. The
NCCS total and subscale scores follow: NCCS Total (162.3 ± 21.7),
Awareness Subscale (41.5 ± 7.2), Knowledge Subscale (33.8 ± 6.5),
Sensitivity Subscale (32.8 ± 5.3), and Skill Subscale (54.3 ± 9.2). The
mean, standard deviation, percent, minimum score, and maximum
score for each subscale and the total NCCS instrument is presented in
Table 1.
Participants' CC scores as measured with the NCCS were moderate.
Texas faculty scored lower on the skills and knowledge subscale but
scored slightly higher in the awareness and sensitivity subscales. This
finding is consistent with the literature (Mahabeer, 2009; Molewyk
Doornbos et al., 2014). Considering the application to the PMCC, this
supports that faculty members may be more aware of CC and sensitive
to the needs of the culturally diverse in terms of the components of
the PMCC known as global society, community, family, and person as
Table 1
NCCS and subscales mean and percent.
Minimum score Maximum score
Awareness subscale 10 50
Knowledge subscale 9 45
Sensitivity subscale 8 40
Skill subscale 14 70
NCCS total with outlier 41 205
As shown in Table 1, the NCCS and subscales with minimum, maximum, mean, and mean as a percent of total possible points.
227
this area of the NCCS is scored higher. The important thing to note is
that while awareness and sensitivity are higher, the skills and knowl-
edge subskills are lower, corresponding to the inner domains of the
PMCC. This points to a weakness in faculty members' ability to know
what to do and the tools in which to address the needs of the culturally
diverse patient as they journey through the CC continuum moving from
unconsciously incompetent, consciously incompetent, consciously com-
petent, and unconsciously competent.
4.3. Qualitative Findings
Key experiences related to distinct cultural differences were viv-
idly embedded in the thoughts shared by participants. Faculty mem-
bers recalled experiences with a particular patient or situation that
highlighted the knowledge needed to provide care.
Findings from the interview process were framed within the do-
mains of the PMCC as a means to link the qualitative findings to the the-
oretical framework and to the quantitative data collected through the
NCCS as referenced in terms of the PMCC. The qualitative data was relat-
ed more closely to the 12 domains of the PMCC that is seen in the NCCS
as representative of the subscales of knowledge and skills, an area that
scored lower in the quantitative data.
The domain of communication includes the major components of
language as well as contextual use, volume and tone, spatial distancing,
and non-verbal communication. One participant described needing so-
cial space when conversing with a Hispanic individual. She felt that her
personal space was being encroached upon so she proceeded to step
back, and each time she stepped back, the other person would step for-
ward. The participant told that she had learned previously about the
issue of personal space with the Hispanic culture, but that knowledge
did not guide her actions until she had the actual experience.
The domain of family roles and organization provides knowledge for
health care providers as they seek to understand gender roles, attitudes
towards the elderly, social status, extended family, and alternative life-
styles. A participant shared the story of caring for a Roma patient and
being surprised by the family structure. “Gypsies really do not recognize
immediate family members as we do or as other cultures do… the entire
family is the tribe.” The participant described the experience as interest-
ing and challenging, and associated the experience with providing cul-
turally competent care.
Workforce issues include acculturation, autonomy, and language
barriers. A participant told of interactions with faculty colleagues
when selecting a course textbook. The participant noted the importance
of having pictures of minorities and diverse people in a textbook but
found this was not a selling point to anyone else. A colleague remarked
with shock, “Does that matter?” The participant noted “It really struck
me that people's world views are different. They can look right at you
but they see through you, especially people of color, and if you cannot
see people, you are not really culturally competent.” This was not an ex-
ample of caring for a patient from a different cultural background, but it
illustrated how differences can occur between two culturally diverse
people.
The domain of biocultural ecology includes medically necessary
things like how drugs are metabolized based on biological variation, ge-
netics, and heredity. A participant remarked, “… Our students work in [a
large, metropolitan area] when they graduate so that is very
Mean (S.D.) Mean as a % of total possible
41.5 (7.2) 83%
33.8 (6.5) 75%
32.8 (5.3) 82%
54.3 (9.2) 78%
162.3 (21.7) 79%
228 C. Marzilli / Nurse Education Today 45 (2016) 225–229
multicultural as far as the work staff and patient population because
[the city] itself is very diverse.” This participant expressed that the expe-
rience caring for this diverse population provided students with the
skills to be culturally competent and understand the biological differ-
ence in patients.
The domain of high-risk behaviors includes tobacco, alcohol, recrea-
tion drugs, physical activity, and safety. A participant noted that caring
for homosexual men was challenging because it was unclear how to ad-
dress their sexual behaviors in conducting a history. The participant felt-
ill prepared to address these without being perceived as judgmental.
Nutrition is a domain that includes how food is perceived, rituals, defi-
ciencies, limitations, and health promotion all related to food. A participant
recalled caring for a patient and being offered a beverage. The participant
had learned about providing culturally competent care to Hispanic pa-
tients and the importance of social exchange before initiating care.
Pregnancy includes fertility practices, pregnancy beliefs, birthing
practices, and care during the post-partum period. A participant recalled
caring for a pregnant, Hispanic female patient with a hemoglobin level
that was “not compatible with life.” The patient needed her husband's
approval for transfusion because it was related to her pregnancy.
The domain of death rituals also includes bereavement. A participant
was providing post-mortem care. The participant could not recall the
patient's exact culture but was struck by the differences in the death
practices between the patient's and her own and described the experi-
ence as “different or conflicted with what I might have done.”
Spirituality includes religious practices, prayer, understanding the
meaning of life, and spirituality and health. A participant told of the
challenge of caring for a Hmong patient. She did not understand exactly
what the patient needed from a religious standpoint, and described the
process was noted as “confusing and scary” because it was very out of
the ordinary. The participant felt they should be doing something to ad-
dress the patient's spiritual needs, but did not know what interventions
should be taken.
The domain of health care practices also includes traditional prac-
tices, transplantation beliefs, self-medication, mental health barriers,
and magico-religious beliefs. A participant shared the experience of pro-
viding care to an Arab woman in a battered women's shelter. The partic-
ipant remembered having to research the best way of providing
culturally competent care to better craft an appropriate plan of care.
This was something the participant did not know how to address, and
the time spent researching appropriate health care practices, specifical-
ly related to the idea of mental health. To address the health care needs,
the nurse was able to locate another Arab woman that had experienced
similar circumstances to help the patient cope.
The domain of health care practitioners includes perceptions of prac-
titioners, folk practitioners, and gender and health care. One participant
remarked, “Back in the 80s there was some mention of cultural differ-
ences, but it was not the emphasis or focus.”
5. Discussion
The data from this study support that faculty participants were mod-
erately culturally competent. Faculty members serve as role models for
students (Klunklin et al., 2011; Reju et al., 2014), and they need a com-
prehensive understanding of culture, CC, and their own perceptions of
the skills, knowledge, awareness, and sensitivity involved in caring for
culturally diverse patients. This is coupled with research that supports
that the actions of the faculty shape the students (Strouse and
Nickerson, 2016). If nursing, as the most trusted discipline in the U.S.
(Jones, 2015; Saad, 2015), is to truly address the care culturally diverse
patients' need, nurses must not only be sensitive and aware of cultural
needs, but have the skills and knowledge to correctly address those
needs so that patient-centered care is provided to all patients
(Kohlbry, 2016). When faculty are able to model culturally competent
behaviors, students receive the best didactic and practical instruction
in culturally competent nursing (Ume-Nwagbo, 2012). The moderate
CC quantitative findings related to the outer rings of the PMCC, global
society, community, family, and person supports the qualitative find-
ings that faculty members are aware and sensitive to the domains relat-
ed to CC in the PMCC but do not identify a high level of knowledge or
skills necessary to provide culturally competent care. This supports spe-
cific professional development sessions for faculty members to better
support and prepare students.
The qualitative findings suggest that the faculty have an awareness
of eleven of the twelve domains in the PMCC within the context of the
patient, family, community, and global society. The qualitative findings
showed that the participants focused on specific memories caring for
patients from diverse backgrounds. They referenced their own memo-
ries for their experience in caring for a patient of a particular cultural
background which is consistent with the literature that supports expe-
rience with various aspects of culture as an important aspect of provid-
ing culturally competent care. The domain of Overview/Heritage was
not present in the participant interviews because this represents a de-
mographic aspect of culture that faculty members do not consider to
be essential to the discussion of culture.
Based on this level of understanding expressed in the qualitative
findings, it does not support that faculty have a mastery level of under-
standing of the domains in the PMCC or CC. From these findings, it is
noted that the deficit in specific knowledge and skills can be addressed
through professional development sessions for faculty. By structuring
professional development education around the 12 domains, faculty
can further develop their knowledge and skills related to nursing care.
It should be noted that the interview process did not obtain any discus-
sion of CC professional development since nursing school and is an op-
portunity to develop sessions specifically for faculty.
The concept of CC is more than just a set of behaviors that the faculty
member will complete. CC is an important tool that nurses can use to
help reduce health disparities (Cupelli, 2016; Roberts et al., 2014;
Starr et al., 2011). It is important to consider that teaching styles largely
vary, and delivering culturally competent care in the health care setting
does not necessarily mean the faculty member will effectively teach the
concepts. However, the role of faculty members as a role model cannot
be underestimated as an important tool for teaching students CC skills
(Klunklin et al., 2011; Reju et al., 2014; Strouse and Nickerson, 2016).
The strength of the study is in the mixed-methods design and qual-
itative and quantitative data strands that support the other. However,
this study relies on interviews and self-reported assessment of the in-
strument. Self-reported data has the potential to show bias as the partic-
ipants strive to select that which may be more enticing to the
researcher. It is also important to consider that the sample cannot be
representative of all Texas pre-licensure faculty (Cicolini et al., 2015).
6. Conclusion
Professional development offerings should be made available to facul-
ty to provide specific education on knowledge and skills essential to CC.
The PMCC is the theoretical framework utilized in this study, and based
on the data results, framing the professional development sessions in
line with the 12 domains of the PMCC may be an effective tool to help de-
velop the sessions about CC skills for faculty members as they model these
skills to students. This curriculum may be offered to faculty in any number
of settings and formats, including workshops, seminars, conferences, and
infographics for busy nurse educators. CC training should focus on each of
the 12 domains with specific attention to the domain of Overview/Heri-
tage. Future studies should evaluate how students perceive the effective-
ness of CC education from their faculty members.
Acknowledgements
The author was a participant in the 2015 NLN Scholarly Writing Re-
treat, sponsored by the NLN Chamberlain College of Nursing Center for
the Advancement of the Science of Nursing Education.
 C. Marzilli / Nurse Education Today 45 (2016) 225–229
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