Nurse Education Today 30 (2010) 314320

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Improving cross-cultural care and antiracism in nursing education:

A literature review
Jacqui Allen *
School of Nursing, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia

a r t i c l e i n f o s u m m a r y

Article history: Purpose: To appraise through literature review the available research evidence to guide teaching and
Accepted 12 August 2009 learning regarding cross-cultural care for nursing students. Cross-cultural education of nurses with a
focus on both culture and antiracism is one way of promoting ethical and effective cross-cultural health
systems for people from culturally diverse backgrounds. Although cross-cultural care has long been
Keywords: recognised as necessary to nursing education there is no clear consensus regarding how it is to be taught
Culture or which theoretical perspectives should underpin this teaching.
Antiracism
Findings: Current literature supports the effectiveness of cross-cultural teaching interventions in promot-
Nursing education
Literature review
ing cultural competence and in facilitating attitudinal and belief changes in nursing students. The liter-
ature further suggests that racism persists in some students following participation in cross-cultural
education and that there is a paucity of theory, teaching interventions and evaluations addressing anti-
racism.
Conclusions: Cross-cultural education alone is insufcient to combat racism. Cross-cultural education
focused on both cultural competence and antiracism is necessary to promote effective cultural care in
nursing students.
2009 Elsevier Ltd. All rights reserved.

Introduction Papadopoulos, 1999; Nairn et al., 2004). Moreover, effective

Cultural diversity is increasing in Western societies (Lim et al.,
2004; Tulman and Watts, 2008). Past research has identied that
people from culturally diverse backgrounds experience poorer
health outcomes than their Anglo western counterparts due to dif-
ferences in their ability to access health services, including lan-
guage and cultural barriers, and due to institutional racism
where organisations fail to provide culturally and linguistically
appropriate services to people of different cultural backgrounds
(Johnstone and Kanitsaki, 2008; Narayanasamy and White, 2005).
Promotion of cross-cultural care and antiracism are vital to socially
just health care systems. Appropriate cross-cultural education of
nurses with a focus on both culture and antiracism is one way of
promoting ethical and effective health systems.
Nurse scholars recommend that nurse educators/academics
plan their teaching regarding culture from a sound theoretical base
in order to adequately prepare students for practice in cross-cul-
tural care (Hughes and Hood, 2007; Lim et al., 2004). A number
of nurse scholars emphasise the need for cross-cultural care to in-
clude approaches focused on both culture and antiracism (Campe-
sino, 2008; Papadopoulos, 2006; Duffy, 2001; Gerrish and
cross-cultural care encompassing both culture and antiracism are
explicit expectations of the nursing profession and general public
(Johnstone and Kanitsaki, 2008).
However, cross-cultural care and antiracism remain controver-
sial with no clear consensus regarding how they should be taught
or which theoretical perspectives should underpin this teaching
(Campesino, 2008). Although culture and antiracism are recom-
mended and expected components of undergraduate nursing cur-
ricula (Hagey and Mackay, 2000), they do not feature strongly in
current nursing education and are indeed absent from many uni-
versity nursing courses (Pinikahana et al., 2003). These gaps in
teaching and learning could be addressed by strengthening cul-
ture and antiracism in undergraduate nursing courses to promote
nursing students learning of the complexities of cross-cultural
care provision. A structured review of the literature was under-
taken to appraise the available empirical research evidence to
guide teaching and learning for undergraduate nursing students
regarding culture and antiracism.
Why culture and antiracism? Denitions and theoretical issues

Cross-cultural education for nurses is the focus of this paper

* Tel.: +61 3 9244 6960; fax: +61 3 9244 6159. therefore nursing theories of culture with their emphasis on cul-
E-mail address: jacqui.allen@deakin.edu.au ture and health are considered rather than theories within other

0260-6917/$ - see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2009.08.007
 J. Allen / Nurse Education Today 30 (2010) 314320
social science disciplines. The most prolic nursing theory of cul-
ture, transcultural nursing, was developed and pioneered in the
1950s and 1960s by the North American nurse anthropologist
Madeleine Leininger to equip nurses with ways to provide cultur-
ally meaningful and helpful care (Kanitsaki, 2003; Leininger, 2002;
Leininger and McFarland, 2002). Transcultural nursing is con-
cerned with comparing differences and similarities between cul-
tures regarding caring values and life practices to predict care
needs of individuals and promote culturally tting care. In this ap-
proach, culture is dened as attitudes, values, beliefs and life prac-
tices learned and shared by people in a particular social group
which are passed on down generations affecting individuals think-
ing and actions (Leininger and McFarland, 2002). Leininger (2002)
emphasises culture specic care which refers to nurses under-
standing of caring actions, health care information and knowledge,
including folk healing practices, particular to each culture in order
to provide care matching a persons health care needs. More
recently developed models within the transcultural nursing
paradigm include the process of cultural competence model
(Campinha-Bacote, 2002) and the Giger and Davidhizar transcul-
tural assessment model (Giger and Davidhizar, 2002). These mod-
els similarly focus on cultural competence dened as meaningful
and helpful care for people from different cultural backgrounds
founded in knowledge of specic cultural beliefs, attitudes and
practices.
Other nurse scholars (Campesino, 2008; Duffy, 2001; Naray-
anasamy and White, 2005; Culley, 2001) argue that transcultural
nursing approaches do not adequately challenge discrimination
experienced by minority cultural groups such as ethnocentrism,
cultural biases, and overt and covert discrimination due to racial
difference; racism, accounting for poor health outcomes. According
to these critics of transcultural nursing, nurses knowledge of par-
ticular cultures and ability to t care to meet the needs of people
from diverse cultures, although a necessary foundation, is not suf-
cient to address discrimination in health care.
Culley (2001) further argues that transcultural nursings focus
on the essence of particular cultures limits culture to a static entity
and reduces understanding of peoples behaviour to prescribed cul-
tural norms. This promotes cultural stereotyping with the risk of
discrimination and it fails to account for individual and family dif-
ferences within cultural groups. Transcultural nursing is further
criticised as unable to explain other factors inuencing health in
particular structural social and political factors underlying racism
(Culley, 2001). Nursing education is therefore challenged to create
culturally competent practitioners who are able to negotiate and
adapt their care to diverse peoples without stereotyping. Nurses
require skills in the acquisition of meaningful information about
the person, family or community receiving their care rather than
relying on their own assumptions about a particular culture (Cul-
ley, 2001; Gunaratnum, 2001).
Papadopoulos (2006) has developed another important theory
of cross-cultural care; the Papadopoulos, Tilley and Taylor model.
In this model, transcultural nursing is focussed on cultural diversi-
ties and similarities in health, and underlying societal and organi-
sational structures. Papadopoulos (2006) considers that promotion
of cultural competence, the ability to undertake effective health
care given peoples cultural beliefs and values, is the aim of includ-
ing culture in nursing curricula. Accordingly, cultural competence
is both a process inherent to effective nursing care provision and
an outcome (Papadopoulos, 2006). In the Papadopoulos, Tilki and
Taylor model, cultural competence results from development of
four intersecting domains: cultural awareness (self-awareness,
cultural identity, awareness of ethnocentrism and stereotyping),
cultural knowledge (anthropological, sociological, psychological
and biological knowledge), cultural sensitivity (empathy, commu-
nication and relating skills) and cultural competence (assessment
315
and clinical skills, and challenging and addressing discrimination
in nursing and health care).
The need for a review
Following a search of the literature, several reviews were iden-
tied regarding the effectiveness of varying education and training
programs addressing culture and antiracism in nursing. However,
with exception to one review (Nairn et al., 2004); inclusion of the-
oretical issues noted in the preceding section is limited.
A review by Beach et al. (2005) including trained and training
health professionals from nursing, medicine and allied health
found strong support that cultural competence education enhances
the knowledge of health professionals and good support that this
training assists in changing their attitudes and skills. This review
further noted poor methodological quality in these studies sug-
gesting a need for improved study designs and methods. A recent
systematic review by Chipps et al. (2008) replicated these ndings
in relation to the effectiveness of cultural competence training for
health professionals in community-based rehabilitation settings.
One review (Nairn et al., 2004) was identied which considered
the literature in relation to both cross-cultural care and antiracism
teaching for nursing students. This review discussed conceptual
difculties regarding denitions of cross-cultural care and antirac-
ism, including the tension between both approaches for some
nurse educators who direct their educational programs at either
cross-cultural care or antiracism. These authors note the impor-
tance of teaching both cross-cultural care and antiracism.
These reviews are enlightening in regard to the effectiveness of
education focused on the development of cross-cultural care,
including cultural competence, and antiracism in health profes-
sionals (Beach et al., 2005; Chipps et al., 2008; Nairn et al., 2004).
However, the reviews by Beach et al. (2005) and Chipps et al.
(2008) do not provide a separate analysis of the effectiveness of
cross-cultural approaches to training in specic health disciplines
or for undergraduate students. It is therefore difcult to know
how these ndings would apply more specically to particular
health professionals undergoing their formative training such as
undergraduate nursing students. A further consideration in regard
to these reviews (Beach et al., 2005; Chipps et al., 2008) is the
inclusion of varying denitions of culture and cultural compe-
tence which are not based in clearly articulated theoretical frame-
works rendering it difcult to know precisely what denes
culturally competent care. Moreover, the review by Nairn et al.
(2004) included commentary and theoretical debate and did not
focus solely on evaluation studies appraising teaching interven-
tions addressing culture and antiracism in undergraduate nursing
students. Therefore, a focused structured review of the evaluation
literature was undertaken to improve understanding of the com-
plexities of cross-cultural care and antiracism education in nursing
students including consideration of any evaluated theories of
culture.
Review question and aims
How can best practice educational theories and strategy/ies
guide teaching and learning to promote cross-cultural care and
antiracism in nursing students?
Additionally, this review aimed to identify:
 Types of teaching strategies regarding cross-cultural care and/or
antiracism.
 Any evaluated theories of culture and racism related to nursing
education.
 The methodological quality of the published literature.
 Outcomes of teaching interventions.
316 J. Allen / Nurse Education Today 30 (2010) 314320
Methods
Search strategy
A focused search of the literature was conducted to nd pub-
lished material in relation to the target domains: educational strat-
egies and teaching interventions promoting cross-cultural care and
antiracism. Key terms used in these searches included: nursing/
student nurses/undergraduate nurses/baccalaureate nurses and
education/training in combination with culture, cross-cultural
care, transcultural nursing, multicultural care, cultural compe-
tence, cultural sensitivity, racism, ethnocentrism, and evaluation.
Publications were retrieved through searches of: CINAHL, Psy-
chinfo, and Medline. Studies were retrieved from January 1980 to
September 2008. The reference lists in retrieved articles were
searched by hand for additional publications resulting in a sub-
stantial increase in the number of studies included in the review.
Inclusion criteria
For inclusion, a study was required to nominate nursing stu-
dents as principle participants including those undertaking an
undergraduate degree or baccalaureate program within a univer-
sity or other educational institution. Numerous diverse educational
programs focused on culture and cross-cultural care are reported
in the literature including classroom based strategies, those fo-
cused on reection on practice and attitudinal change. Varying the-
oretical perspectives are also reported in the literature. Although
the current review is concerned with nursing theories of cross-cul-
tural care inclusion criteria are purposely broad to enable consid-
eration of any teaching strategy or empirically evaluated
theoretical perspective. Varying evaluation designs and methods
are reported in the literature therefore studies utilising either
quantitative and/or qualitative evaluation designs or methods
were included.
Additional inclusion criteria were dened according to prag-
matic necessity; therefore studies were required to be written in
English. As the search strategy employed within this review would
only identify the published literature, ndings are interpreted
within this context as the best available evidence.
Studies excluded from the review
A number of studies did not meet the inclusion criteria. These
studies included those which described culture and cross-cultural
care within education and training programs with no structured
formative/descriptive evaluation or structured outcome evaluation
reported (e.g. Lindquist, 1990). A number of other studies evalu-
ated study abroad programs (e.g. Callister and Cox, 2006) these
Table 1
Study characteristics.
Author/s Date
Alpers and Zoucha 1996
Anderson 2004
Bengiamin, Downey and Heuer 1999
Felder 1990
Hagey and MacKay 2000
Hughes and Hood 2007
Koskinen, Abdelhamid and LicPhil 2008
Lim, Downie and Nathan 2004
Napholz 1999
Sargent, Sedlak and Martsolf 2005
Tulman and Watts 2008
Wendler and Struthers 2002
Williamson, Stecchi, Allen and Coppens 1996
were not included as cultural immersion programs were not a fo-
cus of the current literature review.
Coding scheme
A coding scheme was devised to capture key characteristics of
interest. These comprised: study characteristics, intervention char-
acteristics, sample characteristics and design characteristics. All
data were coded as per the coding scheme and are presented in ta-
bles to follow.
Findings and discussion
Findings and discussion have been combined to maximise inte-
gration of results with the literature and theoretical issues identi-
ed at the outset of the review. In total, 14 publications met the
selection criteria reporting on 13 separate data sets. Two publica-
tions reported on the same data set (Brennan and Cotter, 2008;
Tulman and Watts, 2008). To ensure independence of data, only
the study by Tulman and Watts (2008) is presented in the ndings.
Studies meeting the selection criteria are marked with * in the Ref-
erence List. Table 1 presents study characteristics for all inclusion
papers.
Retrieved studies were published between 1990 and 2008. Only
ve studies were published between 1990 and 1999 indicating
increasing research interest in evaluating cross-cultural education
for nursing students since 2000. Of the 13 published studies, ten
were undertaken in the USA and one in Canada. Only one study
was identied in Europe and Australia respectively suggesting
greater research interest in empirical evaluation of the effective-
ness of cross-cultural education among nursing students in North
America.
Table 2 presents sample, evaluation design characteristics and
outcomes for all retrieved studies.
Transcultural nursing features strongly in these published eval-
uations of educational interventions. Of the 13 papers, eight (Al-
pers and Zoucha, 1996; Anderson, 2004; Bengiamin et al., 1999;
Hughes and Hood, 2007; Lim et al., 2004; Sargent et al., 2005; Tul-
man and Watts, 2008; Wendler and Struthers, 2002) report theo-
retical paradigms underpinning teaching interventions according
to transcultural nursing. No studies were retrieved which empiri-
cally evaluated other models of cross-cultural nursing and educa-
tion discussed in the introduction such as the Papadopoulos,
Tilley and Taylor model (Papadopoulos, 2006). One paper reports
on the effectiveness of a simulation experience (Koskinen et al.,
2008). A number of papers do not clearly nominate a theory under-
pinning teaching interventions (Felder, 1990; Hagey and Mackay,
2000; Napholz, 1999; Williamson et al., 1996). Two of these stud-
ies report on the effectiveness of culture and cross-cultural care
Journal title Country
Journal of Cultural Diversity USA
Journal of Nursing Education USA
Journal of Cultural Diversity USA
Journal of Nursing Education USA
International Journal of Nursing Studies Canada
Journal of Transcultural Nursing USA
Diversity in Health and Social Care Finland
Nurse Education Today Australia
Journal of Nursing Education USA
Nurse Education Today USA
Journal of Professional Nursing USA
Journal of Professional Nursing USA
Journal of Community Health Nursing USA
Table 2
Sample characteristics, study design, outcomes.

Author/s N Sample Sample characteristics Course Evaluation design Measures Theoretical paradigm Teaching/learning Outcomes
selection and intervention
source
Alpers and 63 Self-selection, Mean age of 26 years, Undergraduate Quasi- Cultural Self-Efcacy Transcultural nursing,  Intervention group The intervention group reported:
Zoucha University 91% female, senior nursing experimental/ Scale, Bernal and Leininger (2002) received cross-cultural greater understanding of
(1996) level nursing students independent Froman (1987) education African American life styles
groups and Hispanics beliefs
Nil validation  Control group received The control group reported:
evidence reported no cultural education greater understanding of
Asian folk health practices
Anderson 45 Self-selection, Mean age of 24, 38 Undergraduate Qualitative Qualitative survey Cultural competence,  Use of literary exemplar Students reported:
(2004) University females, 7 males, nursing survey single designed by Campinha-Bacote for class based teaching increased self-awareness
undergraduate nursing group pre/post researchers (2002) and discussion acknowledgement of
students teaching ethnocentrism
intervention acceptance of differences
recognition of the complexi-
ties of culture in the clinical
area
Anderson Quasi- Assessing your Nil signicant differences in

J. Allen / Nurse Education Today 30 (2010) 314320

(2004) experimental/pre/ personal responses to quantitative measures
cont post design transcultural health
care situations
Cultural Values
Questionnaire
Nil validation data
reported
Bengiamin 22 Self-selection, Age not reported, 18 Multiple Qualitative survey Qualitative survey Transcultural nursing,  Classroom based Students reported:
et al. University females, 4 males, courses single group pre/ designed by Leininger (2002) learning developing a more holistic
(1999) undergraduate nursing undergraduate post teaching researchers view of culture
students, some subject in intervention developing a broader view of
undergraduate medical cultural care culture to include diversity
students and allied developing an understanding
health students of alternative approaches to
health care
Felder (1990) 110 Self-selection, Mean age 22 years, 94 Undergraduate Quasi- Cultural Information Nil reported  Transcultural education Seniors reported signicantly
four females, rst year and nursing experimental/ Scale, Baker (1976) focus in curriculum better cultural knowledge than
universities nal year independent rst year students
undergraduate nursing groups
students
Cultural Diversity Nil differences were identied
Test (Dawson, 1982) between groups in attitudes
towards black American patients
Semantic differential
instrument (Morgan,
1984)
Reliability data
reported
Hagey and 41 Self-selection, Age and gender not Undergraduate Qualitative Interview schedule Not reported  Culture and diversity Participants reported:
MacKay University reported, nursing interviews (focus designed by integrated in the marginalised groups are silent
(2000) undergraduate nursing groups and one- researchers curriculum whites are privileged
students and 1 staff on-one interviews) whites are dominant
member racism is denied
Hughes and 218 Self-selection, Age and gender not Undergraduate Quasi- Cross-cultural Giger-Davidhizar Classroom based teaching, Students reported signicantly
Hood US College reported, diploma level diploma of experimental/pre/ evaluation tool Transcultural single semester subject: improved cultural competence
(2007) undergraduate nursing nursing post design (Freeman, 1993) Assessment Model, scores
students Validation reported Transcultural nursing,  Cultural awareness
Leininger (2002)  Knowledge of particular
cultures

317
(continued on next page)
 318
Table 2 (continued)

Author/s N Sample Sample characteristics Course Evaluation design Measures Theoretical paradigm Teaching/learning Outcomes
selection and intervention
source
Koskinen 103 Self-selection, Age not reported, 100% Undergraduate Qualitative survey Qualitative survey Not reported Simmulation/experiential Students reported:
et al. Polytechnic female, undergraduate single group pre/ designed by  Game-Barnga and BaFa gaining new insights into dif-
(2008) University nursing students, post teaching researchers BaFa ferent cultures
dental hygiene intervention changed thinking about
students culture
improved ability re future
intercultural relationships
Lim et al. 199 Self-selection, At least 81% were aged Undergraduate Quasi- Transcultural Self- Cultural self-efcacy Class-based teaching: Fourth year students reported
(2004) University 1731 years, At least nursing experimental/ Efcacy Tool, Jeffries theory, Jeffries (2000)  Transcultural nursing signicantly higher self-efcacy
84% female independent (2000) content across 3 year re cultural competence than rst
groups course years
First and fourth year Validation data
undergraduate nursing reported
students

J. Allen / Nurse Education Today 30 (2010) 314320

Napholz 66 Selection not Age and gender not Undergraduate Quasi- Ethnic Competency Not reported  One group received No signicant differences
(1999) reported, reported, junior level nursing experimental/ Skills Assessment, Ho, education re culture as between groups
University nursing students independent (1992) usual
groups Reliability data  One group received
reported additional consultation
with a content expert
in cross-cultural
nursing
Sargent et al. 209 Self-selection, Age range (rst years) Undergraduate Quasi- Inventory for Cultural competence  Cultural competence is Fourth year students reported
(2005) University 1735 years, age range nursing experimental/ Assessing the Process Campinha-Bacote infused throughout signicantly greater cultural
(fourth years) 2052 independent of Cultural (2002) undergraduate competence than rst year
years, female sample, groups Competence, curriculum students
undergraduate nursing Camphina-Bacote
students (1998)
Reliability data
reported
Tulman and 219 Self-selection, Age and gender not Undergraduate/ Psychometric Self-report-cultural Cultural competence Classroom based teaching: Final year students and Masters
Watts University reported, rst and nal postgraduate validation study, competence (Campinha-Bacote,  Cultural awareness students reported signicantly
(2008) year undergraduate single group post BICCCQ* 2002)  Attitudes/skills higher levels of cultural
nursing students, intervention Evidence of validation  Cultural competence than rst year
masters nursing comparisons reported communication students
students
Wendler and 51 Self-selection, Age and gender not Undergraduate Single group post Student satisfaction Transcultural nursing,  Online course in cross- Students reported high levels of
Struthers University reported, and survey survey not validated Leininger (2002) cultural health, focus satisfaction with the course
(2002) undergraduate and postgraduate on information re par- content
graduate nursing elective course ticular cultural groups
students and attitudinal change
of student participants
Williamson 56 Self-selection, Mean age 26 years, Undergraduate Quasi- Cultural Self-Efcacy Nil reported Classroom based: Students reported signicant
et al. University gender not reported, nursing experimental/pre/ Scale  Knowledge, skills, improvements in their
(1996) nal year post design Reliability data attitudes understanding of:
undergraduate nursing reported cultural concepts
students cultural patterns for particu-
lar ethnic groups
transcultural skills
*
BICCCQ, Blueprint for Integration of Cultural Competence in the Curriculum (Tulman and Watts, 2008).
 J. Allen / Nurse Education Today 30 (2010) 314320
infused into the curriculum of a three year nursing course (Felder,
1990; Hagey and Mackay, 2000).The remaining two papers (Na-
pholz, 1999; Williamson et al., 1996) report on a single subject fo-
cused on cross-cultural care.
Although four retrieved studies nominated cross-cultural care
educational interventions (Felder, 1990; Hagey and Mackay,
2000; Napholz, 1999; Williamson et al., 1996), they do not specify
antiracism as a central component of these interventions. Notably,
no studies were retrieved which explicitly evaluated theoretical
paradigms explaining antiracism or interventions targeting
antiracism.
A number of the reports utilising quantitative evaluation de-
signs found statistically signicant improvements between rst
and nal year nursing students cultural competence (Felder,
1990; Sargent et al., 2005; Tulman and Watts, 2008) and between
pre and post measures of cultural competence in single groups of
students following participation in cross-cultural education
(Hughes and Hood, 2007). One study investigating cultural self-
efcacy reported signicant improvements for nal year nursing
students when compared with rst year students (Lim et al.,
2003) and another study investigating differences between pre
and post measures in a single group of students found signicant
improvements in cultural self-efcacy following the educational
intervention (Williamson et al., 1996).
Some studies did not nd statistically signicant differences in
cultural competence pre and post teaching intervention (Anderson,
2004), or between an intervention group receiving additional con-
sultation with a content expert in cross-cultural nursing care and a
control group who received the standard cross-cultural education
(Napholz, 1999). The study by Alpers and Zoucha (1996) found no
statistically signicant differences on a measure of cultural self-
efcacy between an intervention group receiving cross-cultural
education and a control group of students who did not receive
cross-cultural education. According to these authors (Alpers and
Zoucha, 1996; Anderson, 2004; Napholz, 1999) design and mea-
surement issues confound their ndings. Anderson (2004) consid-
ers that measurement difculties account for the lack of signicant
ndings as a non validated measure was used. Validation of mea-
sures is considered vital to ensuring that a survey accurately cap-
tures the construct of interest (Anderson, 2004). Napholz (1999)
considers that the baseline status of the intervention and control
groups may not have been equal and past cross-cultural clinical
experiences of students in both groups may have confounded these
ndings. Although Alpers and Zoucha (1996) found no signicant
differences on cultural self-efcacy they did nd that the control
group reported greater understanding of Asian health practices
and the intervention group reported greater understanding of Afri-
can American life styles and Hispanic beliefs. They suggest that
these differences may be explained by different clinical experi-
ences and life experiences between students in each group. In total,
quantitative ndings support the effectiveness of cross-cultural
education on improving cultural competence and cultural self-
efcacy.
A number of retrieved studies undertook qualitative evalua-
tions of the effectiveness of cross-cultural care in nursing
students with positive ndings in regard to attitudinal change.
Koskinen et al. (2008) surveyed participants and found that
students reported gaining new insights into different cultures,
changed thinking about culture and improved ability to engage
in intercultural relationships following participation in simu-
lated experiences of being in another culture. Anderson (2004)
found student participants reported increased self-awareness,
acknowledgement of ethnocentrism, acceptance of differences,
and recognition of the complexities of culture following partic-
ipation in education focused on cross-cultural care. Bengiamin
et al. (1999) surveyed students following participation in
319
cross-cultural education and found that students reported
developing a broader and more holistic view of culture to incor-
porate diverse groups of people including those from different
socioeconomic groups and people at different life stages such
as older adults.
One qualitative study found that cross-cultural education across
the nursing curriculum did not result in antiracism among their
sample of students. Hagey and Mackay (2000) found student inter-
viewees expressed a number of beliefs suggesting covert racism;
for example white people are privileged and dominant, white cul-
ture is culture neutral and racism does not exist.
With exception to ndings by Hagey and Mackay (2000) quali-
tative ndings indicate that cross-cultural education can promote a
more holistic view of culture and diversity, and can facilitate in-
creased self-awareness regarding ethnocentrism and acceptance
of differences between people.
Quantitative and qualitative ndings from this review of the lit-
erature support the effectiveness of transcultural nursing (Leinin-
ger, 2002) and related teaching interventions in promoting
cultural competence in nursing students and also in facilitating
attitudinal and belief changes in regard to acceptance of different
cultures and acknowledgement of ethnocentrism.
The review ndings further suggest that there is an absence of
empirically evaluated theory and teaching interventions address-
ing antiracism and racism in nursing students. With exception to
the study by Hagey and Mackay (2000) none of the studies evalu-
ating the effectiveness of transcultural nursing on education ap-
praised racism among student participants. This means that it is
difcult to know how well these approaches to nursing education
address this challenging issue. Additionally, the absence of mea-
sures of racism/antiracism in retrieved studies means that it is
not possible to understand potential relationships between rac-
ism/antiracism and other attitudes and beliefs regarding culture.
The absence of racism/antiracism in these evaluation studies is
notable as nurse scholars emphasise the importance of including
antiracism and antidiscrimination in cross-cultural nursing educa-
tion (Campesino, 2008; Duffy, 2001; Nairn et al., 2004; Papadopo-
ulos, 2006; Culley, 2001).
Importantly, ndings from the qualitative study by Hagey and
Mackay (2000) identied covert racism among their student par-
ticipants although they had participated in cross-cultural educa-
tion within their nursing course. These ndings suggest that
education focussed on culture alone may not be sufcient to com-
bat discriminatory and racist beliefs among nursing students sup-
porting the view that cultural competence as dened within
transcultural nursing and related approaches may not be sufcient
to challenge and change racist beliefs and attitudes.
The methodological quality of retrieved studies indicates that
most have adopted a descriptive approach to evaluation. This is
consistent with past literature reviews with this focus (Beach
et al., 2005). Additionally, no studies were identied which utilised
an experimental research design, all 13 papers utilised quasi-
experimental or single group designs and survey methods. This
suggests that although a number of quasi-experimental studies
(Hughes and Hood, 2007; Lim et al., 2004; Williamson et al.,
1996) found teaching regarding culture is associated with im-
proved cultural competence and cultural self-efcacy cause to ef-
fect relationships cannot be claimed as other potential inuencing
factors cannot be excluded for example, students prior experi-
ences of cross-cultural care in earlier clinical placements. More-
over, all 13 retrieved papers reported self-selection of
participants minimising generalizability of ndings. Additionally,
some quantitative studies reported absent or minimal validation
evidence for measures employed. This means that it is difcult to
know how accurately these measures captured the phenomena
of interest.
320 J. Allen / Nurse Education Today 30 (2010) 314320
Limitations
There are a number of limitations to the current literature re-
view. The search strategy may not have identied all relevant liter-
ature in particular unpublished ndings. Therefore ndings
constitute the best available evidence. The selection criteria were
purposely broad to include diverse study designs, diverse teaching
interventions and varying theories of culture. This resulted in inclu-
sion of studies utilising descriptive methodologies. Review ndings
are therefore exploratory indicating a need for further research in
this important area of nursing education. Additionally, the broad fo-
cus of the review precluded any comprehensive synthesis of nd-
ings. For example, varying teaching and learning interventions
and outcomes of effectiveness were reported in the quantitative lit-
erature preventing any meaningful pooling of results.
Conclusion
This review has implications for curriculum developers and
researchers. Findings indicate transcultural nursing has been priv-
ileged in the evaluation literature as limited studies appraise alter-
native approaches. Although ndings support the effectiveness of
transcultural nursing in promoting cultural competence and attitu-
dinal change, the literature also indicates that interventions solely
focused on culture may not be effective in changing racism among
nursing students. Curriculum developers thereby need to include a
focus on culture and diversity, and social and political structures
underpinning racism and other forms of discrimination within
health care practices and systems.
Future research on cross-cultural and transcultural teaching
and learning interventions in nursing education needs to focus
on further developing theories of culture which conceptualise
cross-cultural care in terms of culture, diversity and antiracism/
racism in addition to other forms of discrimination. Application
of these complex relationships to teaching and learning among
nurses requires focussed research attention on cross-cultural care
as both process and outcome.
The literature indicates a need for nurses to be educationally
prepared for effective cross-cultural practice in increasingly cultur-
ally diverse communities. Counteracting the effects of racism and
other forms of discrimination are inherent to culturally competent
and appropriate care. Nurses require strong abilities in cross-cul-
tural care to lead socially just health systems into the 21st century.
Acknowledgement
The author would like to thank Professor Megan Jane Johnstone
for comments on an earlier draft of this paper.
References
Alpers, R., Zoucha, R., 1996. Comparison of cultural competence and cultural
condence of senior nursing students in a private southern university. Journal
of Cultural Diversity 3 (1), 915.
Anderson, K., 2004. Teaching cultural competence using an exemplar from literary
journalism. Journal of Nursing Education 43 (6), 253259.
Baker, A.,1976. Nursing students cultural knowledge of and attitudes toward black
American patients. Doctoral dissertation, University of Michigan. Dissertation
Abstracts International 37, 2768B.
Beach, M., Price, E., Gary, T., Robinson, K., Gozu, A., Palacio, A., Smarth, C., Jenckes,
M., Feuerstein, C., Bass, E., Powe, N., Cooper, L., 2005. Cultural competence. A
systematic review of health care providers educational interventions. Medical
Care 43 (4), 356373.
Bengiamin, M., Downey, V., Heuer, L., 1999. Transcultural healthcare: a
phenomenological study of an educational experience. Journal of Cultural
Diversity 6 (2), 6068.
Bernal, H., Froman, R., 1987. The condence of community health nurses in caring
for ethnically diverse populations. Image 19 (4), 201203.
Brennan, A., Cotter, V., 2008. Student perceptions of cultural competence content in
the curriculum. Journal of Professional Nursing 24 (3), 155160.
Callister, L., Cox, A., 2006. Opening our hearts and minds: the meaning of
international clinical nursing electives in the personal and professionals lives
of nurses. Nursing and Health Sciences 8, 95102.
Campesino, M., 2008. Beyond transculturalism: critiques of cultural education in
nursing. Journal of Nursing Education 47 (7), 298304.
Campinha-Bacote, J., 1998. The Process of Cultural Competence in the Delivery of
Healthcare Services: A Culturally Competent Model of Care. Transcultural
C.A.R.E. Associates, Cincinnati, USA.
Campinha-Bacote, J., 2002. The process of cultural competence in the delivery of
healthcare services: a model of care. Journal of Transcultural Nursing 13 (3),
181184.
Chipps, J., Simpson, B., Brysiewicz, P., 2008. The effectiveness of cultural-
competence training for health professionals in community-based
rehabilitation: a systematic review of literature. Worldviews on Evidence
Based Nursing 5 (2), 8594.
Culley, L., 2001. Nursing, culture and competence. In: Culley, L., Dyson, S. (Eds.),
Ethnicity and Nursing Practice. Palgrave, New York, pp. 109127.
Dawson, B., 1982. A study of knowledge and attitude toward culturally diverse
health concepts for ethnic people of color. Doctoral Dissertation, The University
of San Francisco, California. Dissertation Abstracts International.
Duffy, M., 2001. A critique of cultural education in nursing. Journal of Advanced
Nursing 36 (4), 487495.
Felder, E., 1990. Baccalaureate and associate degree student nurses cultural
knowledge of and attitudes toward black American clients. Journal of Nursing
Education 29 (6), 276282.
Freeman, T., 1993. Cross-cultural Interaction Score. Paper presented at
Communicating across Cultures for the Saint Louis Public Schools Inservice,
Saint Louis, MO.
Gerrish, K., Papadopoulos, I., 1999. Transcultural competence. The challenge for
nurse education. British Journal of Nursing 8 (21), 14531457.
Giger, J., Davidhizar, R., 2002. The giger and davidhizar transcultural assessment
model. Journal of Transcultural Nursing 13 (3), 185188.
Gunaratnum, Y., 2001. Ethnicity and palliative care. In: Culley, L., Dyson, S. (Eds.),
Ethnicity and Nursing Practice. Palgrave, New York, pp. 169185.
Hagey, R., MacKay, R., 2000. Qualitative research to identify racialist discourse:
towards equity in nursing curricula. International Journal of Nursing Studies 37
(1), 4556.
Ho, M., 1992. Minority Children and Adolescents in Therapy. Sage, London.
Hughes, K., Hood, L., 2007. Teaching methods and an outcome tool for measuring
cultural sensitivity in undergraduate nursing students. Journal of Transcultural
Nursing 18 (1), 5762.
Jeffries, M., 2000. Development and psychometric evaluation of the transcultural
self-efcacy tool: a synthesis of ndings. Journal of Transcultural Nursing 11
(2), 127136.
Johnstone, M., Kanitsaki, O., 2008. Ethnic aged discrimination and disparities in
health and social care: a question of social justice. Australasian Journal on
Ageing 27 (3), 110115.
Kanitsaki, O., 2003. Transcultural nursing and challenging the status quo.
Contemporary Nurse 15 (3), vix.
Koskinen, L., Abdelhamid, P., Likitalo, H., 2008. The simulation method for
learning cultural awareness in nursing. Diversity in Health and Social Care 5
(1), 5563.
Leininger, M., 2002. Culture care theory: a major contribution to advance
transcultural nursing knowledge and practices. Journal of Transcultural
Nursing 13 (3), 189192.
Leininger, M., McFarland, M., 2002. Transcultural Nursing Concepts, Theories,
Research and Practice, third ed. McGraw-Hill, New York.
Lim, J., Downie, J., Nathan, P., 2004. Nursing students self-efcacy in providing
transcultural care. Nurse Education Today 24 (6), 428434.
Lindquist, G., 1990. Integration of international and transcultural content in nursing
curricula: a process for change. Journal of Professional Nursing 6 (5), 272279.
Morgan, B., 1984. A semantic differential measure of attitudes toward black
American patients. Research in Nursing and Health 7 (3), 155162.
Nairn, S., Hardy, C., Parumal, L., Williams, G., 2004. Multicultural or anti-racist teaching
in nurse education: a critical appraisal. Nurse Education Today 24 (3), 188195.
Napholz, L., 1999. A comparison of self-reported cultural competency skills among
two groups of nursing students: implications for nursing education. Journal of
Nursing Education 38 (2), 8183.
Narayanasamy, A., White, E., 2005. A review of transcultural nursing. Nurse
Education Today 25 (2), 102111.
Papadopoulos, I., 2006. The Papadopoulos, Tilki and Taylor model of developing
cultural competence. In: Papadopoulos, I. (Ed.), Transcultural Health and Social
Care: Development of Culturally Competent Practitioners. Churchill Livingstone
Elsevier, London, pp. 725.
Pinikahana, J., Manias, E., Happell, B., 2003. Transcultural nursing in Australian
nursing curricula. Nursing and Health Sciences 5 (2), 149154.
Sargent, S., Sedlak, C., Martsolf, D., 2005. Cultural competence among nursing
students and faculty. Nurse Education Today 25 (3), 214221.
Tulman, L., Watts, R., 2008. Development and testing of the Blueprint for Integration
of Cultural Competence in the Curriculum Questionnaire. Journal of Professional
Nursing 24 (3), 161166.
Wendler, M., Struthers, R., 2002. Bridging culture on-line: strategies for teaching
cultural sensitivity. Journal of Professional Nursing 18 (6), 320327.
Williamson, E., Stecchi, J., Allen, B., Coppens, N., 1996. Multiethnic experiences
enhance nursing students learning. Journal of Community Health Nursing 13
(2), 7381.