INTRODUCTION:

Nursing education across countries including Thailand in the 21^st century has been violated after experiencing rapid changes in ethnic diverse customer population. Thailand as an example, the growing number of migrant workers as well as a predominantly Muslim population all over Thailand may affect the way we deliver our care and the quality of care they receive. According to Bangkok Today Press in July, 2009, it is estimated that 637,493 foreign laborers registered as workers in Thailand (Nitisiri, 2009). However, the real number must be higher, perhaps, more than double if non-registered laborers and foreign residents are included. Although the Thai demographics have not shifted as some developed countries, multi-cultural population could have some impact on health care and health care professionals.

For example, minority people as immigrants may feel less willing to seek contact with majority people who are health care providers and less comfortable when in contact with them. The clients may not be comfortable with western medicine which competed to their attitudes and beliefs. Furthermore, the under-privileged foreigners, their socio-economic status and disparities in insurance coverage impact their access to care and use fewer health care resources. Interviews were conducted with representative of foreign workers to find out about foreign patients’ reaction to the delivery of health care services by doctors who are culturally and ethnically different from them. According to the interview, most clients prefer to be treated by doctors who share their ethnic and cultural backgrounds and present no language or communication barrier. Unfamiliar ways of life, cultures, thoughts, attitudes and belief system between health care professional and clients influenced the quality of care. The ethnic disparities in health care (e.g. unequal treatment and health outcomes) continue to persist in Thailand as well as other countries.

In addition to the above phenomena, the advent of violence in the southern border provinces has emerged the significant cultural issue. My experience of living, visiting, and sharing with local health care staff and administration officers who working in Muslim communities helps point out that many conflicts arose as a result of different ways of thinking. Many hospitals have to be therefore on alert and taking precautionary measures as well as to provide services, facilities and activities which specially designed to conform to local culture such as halal food, prayer’s room, annual group circumcision, and other religious ceremonies in connection with birth and death. So, the cultural competence among health care professionals can no longer been ignored since ethnic conflicts and violence exist particularly in southern Thailand.

As far as we concern, fundamental differences among people arise from nationality, ethnicity, and culture, including from family background and individual experiences. This could affect health beliefs, practices, and behavior on the part of both patients and providers, and also influence the expectations that the patient and the provider have of each other (King, Sims, and Osher, 2006). It is suggested that health care providers need to look at cultures to gain an understanding of clients’ behaviors that differ from their own. Cultural competence can help the health care providers determine what would be the best health plan strategy for that particular client (Marcinkiw, 2003). One place to start in preparing health care providers to be cultural competence is in the education setting. Five institutes of health professions such as medical schools, nursing schools, schools of pharmacy, schools of public health, and schools of dentistry have participated in the mission to develop curricula to improve cultural skills for health personnel in Thailand.

From the previous review of the undergraduate curriculum structure and contents from 5 purposive selected schools, it was found that all nursing curricula did not explicitly demonstrate the bridge between theoretical contents and practice related to culture, religion, Thai wisdom or local wisdoms. Moreover, there was no system to assess and evaluate students’ competency in cultural care or cultural nursing (Songwathana et al., 2005). Based on the findings of several focus group discussions with nurses and community leaders in 3 southern Thai provinces, the major issues related to the delivery of care included the lack of cultural awareness of the values, customs, and norms of minority/ethnic population, lack of cultural specific knowledge and language barrier. The study also suggested an urgent need to provide adequate training or integrate cultural competency in the nursing courses. Subsequently, the 3-year study was conducted which aimed to develop a model of integration for improvement of cultural competence among nursing students at Faculty of Nursing, Prince of Songkla University. This paper defines the term “cultural competency” and strategies to prepare or develop cultural competence in Thai nursing students. A model for cultural competence integrated in nursing curricula for preparing Thai nursing students will be then highlighted including the future challenges for health professionals in addressing culturally competence care.

Cultural competency: the definition:

From the literature review, many scholars provide the definition of cultural competence. The most widely used definitions of cultural competency are presented. For example, it is a dynamic process in which the nurse continuously strives to achieve the ability to work within the cultural context of an individual, family, or community from a diverse cultural/ethnic background (Campinha-Bacote, 1999). Another simply definition includes the ability to recognize an essential to value people differences and preferences, and the self-awareness to respect and try to understand patients from whom we differ (Flores, 2000). So, it encompasses of being confident in oneself and comfortable with others from not only ethnicity and race, but also gender, age, income, education, sexual orientation, ability, and faith (Kumas-Tan, Beagan, Loppie, MacLeod, and Frank, 2007).

From the above definitions, it can be adopted for workable definitions which provide direction for Thais. In addition, every country holds its own uniqueness in culture, values, and approaches among various cultural groups which require a deep understanding in the context before implementing any strategies for teaching culturally competent care. Reflected from several workshops, study visits at Thai-Burmese borders, Thai-Muslim communities and interviewed hospital staff, representatives of foreign workers (e.g., Burmese and Cambodian), local administrative officers and NGO people, a cultural competency is defined. It is a process of gaining ability in cultural attitude, knowledge, and cultural skill efficiently to interact and care for people who are different in cultural backgrounds. The important component is attitude because it is originated from our heart. All informants agreed that understanding human culture and empathy should be more focus. They should not be egocentric or stereotypes others. In addition, the culture is not simply assumed as ethnicity or race, but several factors influenced people in that culture, such as language, customs, values, beliefs, religion, and social groups.

For conceptual framework, fundamental differences among people arise from nationality, ethnicity, and culture, including from family background and individual experiences. This could affect health beliefs, practices, and behavior on the part of both patients and providers, and also influence the expectations that the patient and the provider have of each other. It is suggested that health care providers need to look at cultures to gain an understanding of clients’ behaviors that differ from their own. Cultural competence can help the health care providers determine what would be the best health plan strategy for that particular client and achieve the holistic care (Marcinkiw, 2003).

Figure 1: The study framework

Cultural competency: the teaching strategies:

Regarding to the previous studies and experiences in working with a predominantly Muslim population as well as migrant workers in southern Thailand, main strategies which help nurse educators to prepare nursing students to develop their cultural competency at some degree are presented (Songwathana et al., 2008).

1. Increasing an understanding and awareness of self and other values through cultural self assessment:.

The extra-curricular activities were set up for the junior students. At least two sessions of group meeting were designed to facilitate nursing students in addressing their own values and beliefs as well as others. Students also learnt how to define the culture, cultural competence, and discuss recognition of cultural differences. Although several tools to measure cultural competence are available, most are conducted in developed world. A cultural competency self assessment with a modified one (for Thai) should be used to describe the level of cultural knowledge, awareness and skill.

2. Exposing the reality of cultural diverse groups through direct experiences:

The one day-workshop or study visit arranged for meeting with community resources persons such as local or religious experts in diverse cultural groups was offered. A one- hour lecture and two-hour experience on interview and observation in the specific or interested group population were designed. Students were assigned to work as a small group to learn at different topics. This enables students to incorporate cultural competence while communicate with people who speak in different language/ dialect, or who do not speak Thai. The debrief session was provided before and after completing each activity. Following the clinical practice, students were assigned to approach a diverse patient population. This activity was to offer them direct

experiential learning. Daily note or reflective writing was encouraged on a regular basis.

3. Facilitating individual and group interaction through media or scenario related to cultural sensitive issues and possible conflicts in health care system:

The media and scenario were occasionally used due to limited resources. The useful knowledge have led students to share and discuss about cultural differences, conflicts and reflect the nurse’s role and action. The article related to cultural issues in working with Muslim and migrant workers were also provided for students to share personal comments and professional experiences.

Cultural competency: the model of integration:

A model for integration of cultural competence training in nursing education for preparing Thai nursing students is presented here. It is derived from my direct experiences and lesson learnt from other health professionals as an exemplar work.

1. Recruiting institution and leadership support such as vice chancellors, deans, department chairs, faculty’s academic committee

2. Identifying the willingness of current faculty members to develop and teach content related to culture and cultural care

3. Identifying course coordinators who are willing to integrate training content within existing curriculum

4. Organizing faculty development workshop and providing resources and training tools (e.g. textbooks, teaching tools, assessment tools, videos) to address contents related to culture and cultural care

5. Revising the current curriculum if necessary to allow for orientation related activities to teaching cultural diversity, in the core or elective courses (both in classroom and practicum course).

6. Encouraging both faculty and students to perform continuous self-evaluation of their learning of a cultural competence care

Sequential patterns of content related to culture, cultural competency must be provided. For example, the students will learn about cultural competency throughout the program. The course which is required in each semester will comprise of a minimum of 1-hour lecture and 2-hour lab/practice in one of three approaches as appropriate. In the first year, the cultural knowledge and awareness related to the definition of culture and recognition of cultural differences should be focused. The second year, it should be focused on incorporating cultural competence into communication with diverse population or client groups including a person who does not speak Thai. The more students expose to diverse groups, the greater they will develop cultural knowledge, awareness and sensitivity which become cultural competence (Campinha-Bacote, 1999). The third and forth year, students should learn and use cultural understanding to identify patient problems, nursing intervention and improve patient education. Experiential learning could help students to practice what they have learnt in class. Several questions related to culturally specific health care beliefs should be posed and discussed, for example, how students would approach a situation in which a client had a health belief that is different from their own. A discussion, shared opinion and strategies would facilitate students to become more aware of any personal biases or stereotypes they have had and learn how to interact using better approach when negotiate or work with their clients in a positive way.

The cohort study conducted by Songwathana, et al. (2008) was aimed to describe and compare Thai nursing students competence for caring of culturally diverse clients. 228 nursing students (121 second year of BSN, 107 fourth year of BSN) in the Bachelor nursing program from Faculty of Nursing, Prince of Songkla University were participated in a survey. Focus group discussions were also conducted as additional method. Data were obtained using a self-report questionnaire developed from Campinha-Bacote (1999) consisting 5 parts, namely cultural awareness, cultural knowledge, cultural skill, cultural encounter and cultural desire. Three experts examined for content validity and the reliability of cultural knowledge was obtained by KR-20 of 0.73 and the reliability of other four parts by alphacoefficients of 0.89. Data were analyzed using descriptive statistic and simple content analysis. Findings revealed that nursing students gain a moderate level of cultural knowledge. Although the post score of cultural awareness and skills was a high level compared to a pre test, there was no significantly difference. Due to the short term evaluation, the results suggest that teaching and delivering culturally competence care are challenging and requiring further studies to develop an effective model by using richness of the clinical setting with real-world clients and their cultural needs.

Cultural competency the future:

An expansion the faculty’s capacity for teaching multicultural content and preparing nursing students cultural competence, some considerations must be addressed.

Firstly, both educational institutes and affiliated healthcare organizations should share the same vision with highly commitment. The alliance of providers, researchers, educators, communities, and health care authorities must address the identified issues within a national health care system as well as a health care professionals training. Secondly, faculty members should have at least cultural awareness which could further facilitate and motivate students to develop their own cultural capability. Advanced training for faculty development, textbooks, media resources and other support must be provided for student exposure to field experiences. The grant, awards, incentives should be offered to promote and encourage those who involved and participated in making cultural competence care in progress and reflecting optimum outcomes. In addition, the expert faculty in the cultural diversity and assessment methods should be recruited. Finally, the designed educational courses of study could be made more interesting by referring to current situations so that students will be able to see how culture interact with other parameters. In addition, the course and curriculum assessment to ensure the educational outcomes which embodies cultural sensitivity and client-center care must be required.

CONCLUSION:

Educating nursing students about cultural competence in terms of cultural knowledge, awareness and skill may help to bridge the gaps between provider and client relationships. Nursing students must be prepared through the existing courses or additional training in order to exercise cultural competence effectively in their clinical practice. The main components of cultural specific care must include: knowledge of multicultural with respect to the communities they serve, a non-judgmental and respectful attitudes towards all clients, competency in working with diverse population groups. The results suggest that multiple approaches of teaching and learning through direct experiences and media for preparing nursing students are necessary and requiring cultural specific content rather than in general. It is now apparent that rigorous research is needed to test the effectiveness of nursing educational model for fostering cultural competence care as well as to evaluate the outcomes of prepared nurses in the workplace. Although cultural conflicts and violent situations continue to exist in some parts of the world including in 3 southern Thai provinces, nursing professional remain the frontline of patient care. The future for eliminating health disparities and creating peaceful environment would have never been brighter. It is up to us as health professionals to “work together” and “carry the torch to light up the suffering” for next generations.

ACKNOWLEDGMENTS:

I would like to acknowledge all people in the Faculty and team who gave me inspiration and much support in writing this paper as well as the research funding support from Rockefeller.

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Received on 16.03.2013 Modified on 22.04.2013

Asian J. Nur. Edu. and Research 3(2): April.-June 2013; Page 111-115