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Lesley University 
30 Meilen Street 
Cambridge, MA 02138-2790 

For Reference 

Not to be taken from this room 




submitted by 


In partial fulfillment of the requirements 

for the degree of 

Doctor of Philosophy 


September 10 



As the demographics of the United States change to include a more diverse 
population, occupational therapy practitioners will be faced with the challenge of 
working with clients and colleagues who are culturally different than themselves. It is 
imperative that practitioners develop the characteristics and skills necessary to 
provide culturally competent care. 

The development of cultural competence must begin in occupational therapy 
educational programs, and educational outcomes must be assessed. This study 
examines the perceptions and meaning of cultural competence and culturally 
competent care as described by occupational therapy students in their final year of 
occupational therapy education. The purpose is to determine whether students who 
have received education that included diversity and multicultural content see 
themselves as developing cultural competence. 

Using Moustakas' (1994) phenomenological methodology, I interviewed and 
analyzed the words of twelve students from two major Universities in the Boston 
area. Study participants were asked to describe their experiences with, and 
perceptions of, cultural competence and culturally competent care. 

The study findings indicate that although these students recognize 
characteristics of cultural competence similar to those found in the literature, they also 
perceived that becoming culturally competent is a choice, a volitional act; that 
knowledge is important, and that personal experience with cross-cultural interactions 
provides the most transformational learning; and that feeling comfortable in cross- 
cultural situations is an important outcome. In contrast with the literature, the majority of 
the study participants did not identify cultural self-awareness as a characteristic of 
cultural competence. 

Many implications for occupational therapy educators arise from these 
findings, including a need for increased faculty development, a need for 
teaching/learning strategiesthatfacilitatecultural self-awareness and increased 
knowledge of sociopolitical realities, a need for cross-cultural experiential 
opportunities, and a need for continued research in diversity and cultural competence. 


There are many people to thank for the support they have given me during 
this almost-seven-year process. First of all, I wish to thank the student participants of 
this study and the pilot study, who volunteered their time and graciously shared their 
thoughts, experiences, perceptions and stories. Without you, there would be no 

I also want to thank the numerous students I have taught over a nineteen-year 
academic career and who have taught me in turn. I learn from each of you every 
semester, and I am so grateful to be in a position where I can be a co-learner with 
you. A special thank you to those of you who have read parts of my research and 
have encouraged me in this study. 

To my doctoral committee, Claudia Christie, Diana Bailey, Judith Beth 
Cohen, and Mary Clare Powell, thank you so much for all the thoughtful questions, 
careful reading, and helpful feedback. The quality of this dissertation has been 
tremendously enhanced by your efforts. I truly appreciate your willingness to help 
me maintain the schedule for completion of this work. You were all great! 

My family; Mom, Heather, Andy, Dan, and Bette, have not only been 
tremendously supportive, but extremely patient with my lack of time for them. They 
have often had more confidence than I have regarding my completion of this project 
and my success. I love you all and give you thanks and kisses. I promise to have 
more time for play now. 

I also want to thank the three academic administrators at the University of 
Southern Maine; President Richard Pattenaude, Provost Joseph Wood, and Dean 
Betty Robinson, who have kept my feet to the fire, especially these past eighteen 
months. You have supported, pushed, cajoled, teased, goaded, and generally 
made nuisances of yourselves, but I recognize and appreciate that you have done 
this out of concern and support. I thank each of you for caring. 

To my special friends; Glen, Linda, Nancy, and Ray, including my faculty 
colleagues at Lewlston-Auburn College, especially Lisa, Chhs, Mary Anne, and 


Nancy, I want to say thanks for listening to my continuous chatter and moaning, and 

for ail your encouragement. Your friendships mean the world to me. 

My canine and feline friends have also sustained me. Thanks to Beau for 
being generally patient but for reminding me when it was time to play, and to 
Maverick for his daily vigil on my desk as I studied. You guys were always the 
constant companions in my often quite solitary pursuits. 

And finally, a very special thank you to the members of the doctoral writing 
group at Lesley University that I have been part of for the past four years. Suzanne 
Spreadbury, Mary Knight-McKenna , Susan Griffith, Sandras Barnes, Peggy Burke, 
and Amy Rutstein-Riley are very special women who have supported me In this 
process, lovingly and honestly critiqued my writing, encouraged me when I didn't 
think 1 had anything of substance to say, taught me how to be a better writer and a 
critique of writing, laughed and cried with me, and provided me not only with a 
community of learners, but a sisterhood of friends. Thank you all so much. I love 
each of you and could not have done this without you. 






Personal justification for the study 1 1 
Occupational therapy and the need for 

culturally competent practitioners 1 3 

Cultural competence in research and education 1 4 

The research question and study design 1 6 

Purpose of the study 1 7 



Why cultural competence? 1 9 

Cultural competence defined 21 

Attributes of cultural competence 24 

Self-awareness 24 

Knowledge 26 

Skill 29 

Methods of training/education for cultural competency 31 

Nursing education 33 

Social work education 39 

Counseling psychology education 42 

Occupational therapy and cultural competence 51 

Occupational therapy research about cultural competence 54 

Research about cultural competence in other health related fields 56 

Some overarching thoughts and ideas in the literature 




Social work 






Research about specific attributes of cultural competence 


Research about culturally competent care (CCC) 


Research about client perceptions of culturally competent providers 


Analysis and discussion of research methodologies 


Self-report scales 


A look at qualitative research and what it offers 







Conceptual framework of the model 


Phenomenology and voice 




Preparation for the study 


Writing the prospectus/proposal 


The pilot study 


Determining the sites and participants 




Data collection 


Method of analysis 




Reduction and elimination 


Clustering andthematizing 


Individual textural description 


Individual structuraldescription 


Composite textural and structural descriptions 



Textural - structural synthesis 


Critique of the Research Methodology 




Individual textural descriptions 


LF: Participant #1 


JM: Participant #3 


Individual structural descriptions 


LF: Participant #1 


JM: Participant #3 


Thematic analysis 


Theme One: Attitudinal levels that lead to cultural 







Openness to difference 






Theme Two: Characteristics of a culturally competent person 


Attitude of willingness 


Being knowledgeable 




Active engagement 




Client-centered care 


Compromise and change 


Theme Three: Outcomes of culturally competent 



Collaboration and connection 


Greater understanding of one another 



Positive feelings/ feelings of comfort 


Composite textural description 


Composite structural description 


Textural-structural synthesis: The essence of cultural 








Discussion of findings and implications 


Willingness: The volitional aspect of cultural competence 






Personal Causation 




Levels of willingness 


Nonref lective willingness 




Committed willingness 




Learning through experience 


Developing a sense of comfort 


Summary of the implications for educators 


Limitations and value of the study 








Appendix A 

Dissertation prospectus 


Consent form 



Appendix B 

Interview protocol 214 

Cover letter 217 

Appendix C 

ParticipantQuestionnaire 219 



Personal Justification for the Study 

I am a White, middle class, occupational therapy educator who has been 
teaching White, middle class students in a predominantly White women's profession 
for the past eighteen years. More than a decade ago, as a result of my examination 
of feminist and critical theory as part of my master's degree work, I became aware of 
the changing demographics of this country and the oppression of non-dominant 
groups. I began to think about the meaning of this for me as an occupational therapy 
educator, and wondered about the meaning for occupational therapy students and 
practitioners. As a result, for several years now, I have studied, read about, planned 
courses and delivered content related to culture and diversity as part of an 
occupational therapy curriculum. Much of the course work in my doctoral program has 
been focused on issues of diversity. I have incorporated my new knowledge into 
the classes I teach in an attempt to Increase students' awareness of diversity and 
culture and its implication for occupational therapy practice. This has been exciting 
work. I have learned a tremendous amount from the students I have taught, 
especially about myself as an educator. 

Many of the undergraduate students I taught were the first in theirfamily to 
attend college. The majority of them were White and held traditional world views . It 
was fulfilling to see them begin to question their values and beliefs and begin to look 
at the world in a more open and questioning manner. It felt good to hear them use 
more inclusive language and begin to develop effective communication skills. 
Although the graduate students I now teach have more experience in the world, 
many of them are also new to the ideas and concepts embedded in diversity 
education. I have been pleased to watch them apply these concepts to 
occupational therapy cases. 


As my doctoral studies continued, my interest in diversity began to focus on 

tlie development of cultural competence which led me to coauthor a book with an 
African American woman on the subject (Wells & Black, 2000). This fascinating 
process required me to delve into the literature on the subject and helped me to 
reflect on compelling issues such as the social construction of Whiteness, power and 
privilege, and multicultural pedagogy. Additionally, my coauthor and I found 
ourselves negotiating and working through issues of race and privilege as we 
worked together to compete the book. For example, Shirley sometimes speaks 
and writes in a style known as BlackEnglish. It was difficult for me to approach her 
with this at first because I was aware of and sensitive to my privileged position. 
However, we did talk about it and she certainly agreed that I should edit any 
grammatical errors that I saw. During this discussion, we both referred to Lisa Delpit's 
(1995) work regarding the importance of giving every group of people the skills to 
be successful in the dominant society. I learned a tremendous amount during the 
three years of writing and t)ook production, and realize that I now have even more 
questions than when I began this process. Some of these are listed below. 

Because I have a vested interest in providing the best possible education for 
my students, I have often wondered about the impact of diversity content on the 
students who take my courses. How effective were my efforts? Even though 
course evaluations were often positive, and students often commented on how 
much they had learned, I began to wonder whether I was truly facilitating the 
development of cultural competence in the students I teach. I knew I was increasing 
content on diversity and culture, but was this actually moving students towards 
cultural competence? I've questioned how meaningful it is for a White teacher to 
teach about diversity to a White student population. How can I truly impact students' 
perceptions and understandings when I am part of the dominant sociocultural group 
and share that world view? Continued study in this area has led me to accept my 
place as a White teacher of diversity. Teaching about and reflecting on White 
privilege is now an emphasis in my courses. I believe that students construct their 
own knowledge based on their life experiences and social location. How, then, can I 


be sure of what they are learning? Do they even understand what cultural 

competence means? 

During this period of questioning and research, It came to me that students' 
voices were missing. They were often not included in the research studies I had 
examined during my literature review, nor had Shirley Wells and I included them in 
our book (Wells & Black, 2000). I began to wonder how students actually talk about 
and experience cultural competence. What does it mean to them? How do they 
describe a culturally competent person? Can they recognize culturally competent 
care? When they leave my classroom are they practicing culturally competent care? 
These are some of the questions that I bring to this research study. 

Occupational Therapy and the Need for Culturally Competent 


Occupational therapy is a health and human service profession which 
identifies humans as occupational beings. Occupations are the meaningful activities 
in which people engage that determine and are determined by their roles and 
identity. Using a client-centered approach, occupational therapy practitioners assist 
people with impairments to improve their occupational performance. They do this 
by recognizing a client's values and interests and collaborating on an intervention 
approach. A person's values, beliefs and interests are determined by one's 
sociocultural background, as are the occupationsor activities that are meaningful and 
in which one engages. One's cultural beliefs also determine how a person defines 
health and wellness, how she interprets and responds to the sick role, and how she 
interacts with health care personnel. 

Although the changing demography of the United States has resulted in an 
increased number of ethnically diverse and immigrant healthcare clients, people who 
are homeless and needy, and folks who more openly proclaim their sexual 
orientations (U.S. Dept. of Health and Human Services, 1 997), occupational therapy 
practitioners continue to be predominantly White, middle-class and heterosexual. 


This uneven distribution assures that many occupational therapy practitioners will be 

working with clients who are culturally different than they are and may come from a 
different soclocultural background and position in our society. In order to be effective 
in working with people from diverse cultural backgrounds, occupational therapists 
must be not only sensitive to difference, but also skilled in interacting with all people. 
They must be sensitive to their White privilege and competent in dealing with 
people from cultural backgrounds different from their own. In other words, they must 
be culturally competent. At a time in United States' history when there is more 
diversity in our population than ever before, with predicted significant growth of non- 
dominant groups over the next twenty years (US Dept. of Health and Human 
Services, 1 994), providing culturally competent health care is vital. Thus, there is a 
significant need for a study of this kind. 

Cultural Competence in Research and Education 

Cultural competence is a term that is seen more and more frequently in the 
fields of nursing, social work, and counseling psychology (see chapter 2), and is 
gaining precedence in other healthcare fields, Including occupational therapy. Over 
the past decade, a limited number of practice and research articles on cultural 
competence have appeared in occupational therapy journals (Dillard, Andonian, 
Flores, Lai, MacRae, & Shakir, 1992; MacDonald, 1998; Pope-Davis, Prieto, 
Whitaker, & Pope-Davis, 1993; Wells, 1996), and recently, a few books on the 
subject have been published (Bonder, Martin, & Miracle, 2002; Wells & Black, 
2000). This increased awareness and practice of cultural competence and culturally 
competent care has been supported by recently published national standards for 
cultural competence (US Dept. of Health and Human Services, 1999). But the 
question remains, "How does one become a culturally competent practitioner?" 

I agree with Zeller (1 995) when she states that "it is the responsibility of the 
educational institutions in the United States to nurture cultural sensitivity ... by 
providing students the opportunity to explore and examine other cultures as well as 


their own'" (p. 9). I believe this is especially true in health professions' education, 

where faculty not only facilitate the learning of specific professional content, but also 
seek to acculturate the students into the guiding philosophies of the professional 
organization (Curry, Wergin, & Associates, 1993). Some of these guiding 
philosophies in the profession of occupational therapy include a belief in inclusion 
and equality of all people (AOTA, 2000), and the centrality of client-centered care 
(Law, 1998). These professional precepts provide the foundational rationale to 
facilitate the development of cultural competence in occupational therapy students. 
Helping occupational therapy students develop cultural competence is a challenge 
for today's educational programs. Yet the expectation to do so is there. In the latest 
revision of the national standards for educational programs (American Occupational 
Therapy Association, 1 998) there are two standards which specifically address 
issues related to culture and diversity. 

* Standard B.I .7 (The student will) Demonstrate knowledge and appreciation of 

theroleof sociocultural, socioeconomic, diversity factors, and lifestyle choices 
in contemporary society, (p. 6) 

* Standard B.4.6 (The student will) Consider factors that might bias assessment 

results, such as culture, disability status, and situational variables related to the 
individual and context, (p. 7) 

There are numerous others that address understanding the "social condition" 
(B.1.8), "social factors" (B.6.3, B.7.2) and "social models" (B.6.5., B.7.1) that 
influence occupational choice and the delivery of occupational therapy practice 
(American Occupational Therapy Association 1 998). 

These standards are quite general, and do not specifically address cultural 
competence, yet they do assure that every occupational therapy student will at least 
be introduced to the concepts of culture and diversity. Typical of educational 
standards, they fail to indicate how that can or should happen. There is no 


standardized approach to teaching about these issues, and there are no specific 

expectations for student outcomes. 

As occupational therapy education programs continue to teach about 
diversity in an effort to foster cultural competence, it becomes increasingly important 
to research the results of that effort. Only a few occupational therapy research 
studies examine aspects of cultural competence (Bailey, 2000; Fonwell, 2000; 
Forwell, Whiteford, & Dyck, 2001 ) that actually ascertain how the students perceive 
of, understand and experience the phenomenon. Seeking answers in the 
occupational therapy literature has been frustrating because of the limited number of 
studies published. 

I, therefore, turned to the literature in other health fields, particularly nursing, 
social work, and clinical psychology. These were chosen, not only because of their 
similarity to occupational therapy, but also because these three professions have all 
contributed significantly to the literature on cultural competence. The information 
found in the following literature review was illuminating because the majority of the 
research studies were empirical designs where data was gathered through surveys. 
(See chapter 2). Very few studies ask students to describe in their own words or 
voice how they understand or experience cultural competence. I felt that this was a 
significant gap in our understanding of how students perceive of, experience, and 
understand the concept and how to apply it. 

The Research Question and Study Design 

The research question ! am exploring in this study is " How do occupational 
therapy students "voice" their perception, meaning of, and experience with culturally 
competent interactions and culturally competent care at the end of their academic 
experience?" As was stated earlier, the majority of research on cultural competence 
includes empirical quantitative studies that rarely ask for personal stories or 
narratives. Because I am interested in the experiences occupational therapy 
students have had with cultural competence, and the meaning of these experiences 


for these students, this study is designed as a phenomenological examination using 

methodology outlined by Moustakas (1 994). The purpose is to understand the 
"essence" of cultural competence and culturally competent care as perceived and 
described by occupational therapy students. 

Purpose of the Study 

My research question initially came from my desire to contribute to outcome 
research on occupational therapy education, particularly as it relates to culture and 
diversity. At the end of an occupational therapy academic program, how do 
students understand and experience the phenomenon and concept of cultural 
competence? This phenomenological study will contribute to the professional 
dialogue in occupational therapy on cultural competence. This qualitative analysis of 
students' perceptions will give insight into the experiences of students. Knowing 
how students make meaning of the concept and experience of cultural competence 
will help inform occupational therapy educators' teaching practices. This study will 
describe a) how some students perceive, understand and experience cultural 
competence, and b) determine if students' experiences and language reflect the 
manner in which the concept is developed in the literature. It is expected that this 
study will assist occupational therapy educators in creating more effective 
teaching/learning approaches regarding diversity, multiculturalism, and cultural 



The changing demographics of the United States continue to indicate a rise in 
the numbers of non-Whites while the numbers of poor and worl<ing poor have also 
increased. Additionally, the general population is increasingly aging, and people 
who live an alternate lifestyle are more and more open about their choices (U.S. 
Dept. of Health and Human Services, 1997). The explosion of diversity in our 
society has resulted in a rising awareness of the importance of cultural competence. 
In the social science and health professions' literature in particular, cultural competence 
is a concept that is increasingly investigated and written about. However, it is not 
easily defined. Not only does cultural competence mean different things to different 
people and disciplines, the components of cultural competence seem to be many 
and varied. Trying to understand the skills and characteristics that make up a culturally 
competent professional person can be confusing. Therefore, trying to validate, 
describe, operationalize and reconstruct those skills and characteristics through 
research can be difficult. 

This chapter will first discuss the necessity forcultural competence in health 
care, explore some of the definitions of cultural competence, and identify the more 
salient and currently agreed upon characteristics and skillsof aculturally competent 
person. Secondly, it will examine some of the methods found in the literature to 
educate for cultural competence. It will then examine cultural competence and 
occupational therapy, and finally will identify and analyze the research on cultural 
competence in healthcare, making a case for a qualitative analysis of this concept. 


Why Cultural Competence? 

"Cultural competence is increasingly being seen as important to quality of 
care" (Chin, 2000). Managed care has changed the way health professionals do 
business. Instead of having weeks and months to develop rapport with a 
client/patient, practitioners find themselves challenged by the task of providing the 
best possible service in an often too brief period of time. Both evaluation and 
intervention time frames have been shortened to sometimes include only a few 
days to a few weeks of reimbursable care. Chin (2000) reports that "Few 
demands have been made of managed care organizations to be more responsive 
to diverse groups in their policies and procedures" (p. 115). Despite these realities, 
health professionals, including occupational therapists, are exhorted to provide 
client-centered care as the most effective and best quality care. Client-centered care 
recognizes each client as a unique individual who contributes towards his/her own 
problem and goal definition as part of the intervention process (Canadian 
Association of Occupational Therapists, 1 991 ). In order to recognize and honor each 
client's unique nature, practitioners must be sensitive to and knowledgeable about 
that person's cultural beliefs and background, because these will impact his/her 
response to illness and wellness, and will define the sick role for that person. 
Therefore, client-centered therapists must develop cross-cultural skills; they must be 
culturally competent. 

Abney (1 996) argues for the importance of cultural competency when she 
states, "Cultural identification hasacrucial impact on an individual's response to 
traumatic stress. Thereforecultural identification must beconsidered carefully when 
addressing practice issues. . . It determines the individual's view and disclosure of 
the trauma, expression of symptoms, and attitude toward treatment and recovery" 

Abney (1 996) identifies the importance of practitioner cultural competence for 
theclient Othersspeaktothe importance forthe practitioner. Brislin, Cushner, 
Cherrie, and Yong (as cited in Lynch and Hanson, 1998) identify cross-cultural 


competence as important "to assist interventionists to a) feel comfortable and 

effective in their interactions and relationships with families whose cultures and life 
experiences differ from their own, b) interact in ways that enable families from 
different cultures and life experiences to feel positive [sic] about the interactions and 
the interventionists, and c) accomplish the goals that each family and interventionist 
establish" (Chapters, no page number). 

While making the case for the importance of cultural competence, several 
authors address the consequences of cultural incompetence. McPhatter (1 997), 
referring to the field of child welfare strongly states, "The current level of cultural 
incompetence can persist only at vast detriment to children, families, communities, 
the child welfare system, and society as a whole" (p. 274). She goes on to state 
that incompetently developed programs "often exacerbate the very problems they 
aim to ease," . . . "pursue erroneous targets, squander scarce resources, and help 
few" (p. 274). A report on Cultural competence practice and training: Overview 
(retrieved from the world wide web from\/lL/MOCPT1/htm. on February 22, 2000) discusses 
multiple consequences of the lack of cultural com petence. The author identifies the 

* Patient-provider relationships are affected when understanding of each other's 

expectations is missing. 

* Miscommunication 

* Patient may not follow instructions 

* Patient may reject the provider because of non-verbal cues that do not fit 


In all of these examples, quality of care Is compromised, perhaps even to 
the point of providing an unsafe environment for the client. Additionally, there is 
increased frustration in both the client and the provider, resulting in an unsatisfactory 
health care experience for all parties. These consequences may be avoided if 
practitioners work towards the development of cultural competence. 

Cultural Competence Defined 

In order to understand the meaning of cultural competence, we must examine 
the word culture. A definition I prefer, and have used in an earlier publication (Wells 
& Black, 2000, p. 279) is the following: 

Culture is the sum total of a way of living, including values, beliefs, standards, 
linguistic expression, patterns of thinking, behavioral norms, and styles of 
communication that influence the behavior(s) of a group of people that is 
transmitted from generation to generation. It includes demographic variables 
such as age, gender, and place of residence; status variables such as social, 
educational, and economic levels; and affiliation variables. 

This inclusive definition is not consistently found in much of the literature on 
cultural competence, however. The majority of papers and research studies appear 
to focus mainly on the characteristics of race and ethnicity when identifying cultural 

In researching the definition of cultural competence, it might be instructive to 
determine when the phrase was first coined. Early in the twentieth century the 
concept of cultural tolerance was used to describe the goals of working with and 
educating those who were culturally different from white Americans (LaBelle & 
Ward, 1 994). In the 1 960's, as a result of the influence of the Civil Rights 
movement and the community health and mental health movements, mere 
tolerance to difference was recognized as a limited concept, and cultural sensitivity 
was emphasized as a more effective attitude and goal when providing services to 
immigrants and non-English speaking minority groups and people of color (Chin, 
2000). It wasn't until the 1980's that the focus shifted from cultural sensitivity to 
cultural competence. Madeleine Leininger, a nurse-anthropologist who is known for 
the development of transcultural nursing, asserts that she was the originator of the 
construct and the term cultural competence (Leininger, 1 994). The term competence 


seemsto indicate the development of particular skills when interacting within cross- 
cultural situations. Chin (2000) states that although being sensitive to and knowing 
about the culture of others continues to be important, "this transformation to a skill 
focus resulted in efforts to operationalize those components necessary to achieving 
cultural competence at a system level" (p. 25). 

Competence is an apt term for this particular concept. Synonyms found in 
The Merriam Webster Dictionary (1 995) include "capable," "fit", and "qualified" 
(p. 1 07). This connotes that some people may have a certain capability to perform 
a particular task. Does this then mean that certain abilities make a person more 
qualified for a task? Does it mean that effective cross-cultural interactions occur only 
between people who are somehow more qualified than others? Hager and Gonczi 
(1 996) discuss an "integrated conception of competence." Within their discussion, 
"competence is conceptualized in terms of knowledge, abilities, skills and attitudes 
displayed in the context of a carefully chosen set of realistic professional tasks" (p. 
1 5). Given this conceptualization of competence, and combining it with the dictionary 
definitions, one can conclude that a person must hold particular knowledge, abilities, 
skills and attitudes regarding sociocultural issues in order to be "qualified" as 
culturally competent. 

According to Hager and Gonczi (1 996), it is precisely this Integrated view of 
competence that emphasizes not only the abilities and skills of a person, but also 
the personal attributes and attitudes of that person, that moves the concept beyond 
that of being purely skill-based. Many people can learn particular skills for a task, but 
Hager and Gonczi emphasize the importance of personal beliefs and attitudes for full 
competence (in any task) to occur. "Just as abilities or capabilities [are] necessary, 
but not sufficient for competence, so the performance of tasks is also necessary, but 
not sufficient for competence. Thus any satisfactory account of competence must 
include both attributes and tasks" (p. 1 6). They perceive the concept of competence 
as relational. "Competence is essentially a relation between abilities or capabilities 
of people and the satisfactory completion of appropriate task(s)" (p. 1 6). Many of 
thedefinitions of cultural competence found in the literature, however, don't 


necessarily seem to subscribe to the relational conceptual viewpoint of competence 

described by Hager and Gonczi. 

In the occupational therapy literature, cultural competence has been defined 
as people "moved from being culturally unaware to being sensitive to their cultural 
issues and how their values and biases affect racially different patients/clients" 
(Pope-Davis, Prieto, Whitaker, & Pope-Davis, 1993, p.839). It is also described as 
"the process of actively developing and practicing appropriate, relevant, and 
sensitive strategies and skills in interacting with culturally different persons" (AOTA 
MulticulturalTask Force, 1995). 

Within counseling psychology literature, Stanley Sue (1998, p 440) states 
that cultural competence "is the belief that people should not only appreciate and 
recognize other cultural groups but also be able to effectively work with them." 
Abney (1 993) writes, "cultural competency is the ability to understand, to the best of 
one's ability, the world view of our culturally different clients (or peers) and adapt our 
practice accordingly" (p. 41 1 ). Following a lengthy concept analysis of the term 
cultural competence. Smith (1 998) derives this definition from a study of the nursing 
and health care literature. "Cultural competence is acontinuous process of cultural 
awareness, knowledge, skill, interaction, and sensitivity among care givers and the 
services they provide" (p. 9). 

The definition most often quoted in the literature, however, comes from 
Cross, Bazron, Dennis, and Issacs in a monograph entitled. Towards a culturally 
competent system of care, vol. y, (1989). Cross et al. define cultural competence 
as a "set of congruent behaviors, attitudes, and policies that come together in a 
system, agency, or among professionals and enables that system, agency, or those 
professionalsto work effectively in cross-cultural situations" (p. 13). This definition is 
more in harmony with Hager and Gonczi's (1 996) relational concept of competency, 
particularly as Cross et al. emphasize the congruence of the attributes of cultural 
competence, and the manner in which they "come together" for effective care. 
Perhaps this definition is more often used because it is broader, moving the concept 
of cultural competency beyond individuals and into organizations and communities. 


It supports the examination of the climate of an organization and the policies that 

enhance or diminish aclimate of competency. 

In all of the definitions above, the concept of action is a common component 
of cultural competence. It is not always clear, however, what specific action is 
required. In the occupational therapy definition, practicing.. . strategies and s/f/7/s is 
underscored. Counseling psychology emphasizes effectively worl<[ing] with 
people or adapting our practice, while Cross et al. identify congruent befiaviors as 
an important aspect of cultural competency. According to these definitions, in order 
to be culturally competent, a person must actually do something. It is not a concept 
that is passive in nature. One wonders, therefore, what is it that a person or agency 
actually has to do to be recognized as culturally competent. What, exactly are the 
characteristics of cultural competency? How would we know a culturally competent 
person if we saw one? 

Attributes of Cultural Competence 

Although there are multiple theories within the literature, most authors agree 
thatthere are predominantlythree major characteristics or attributesof cultural 
competence: self-awareness/attitudes, knowledge, and skills (Kavanagh & 
Kennedy, 1992; Lynch & Hanson, 1998; Pedersen, 1988; Pedersen & Ivey, 1993; 
Wells & Black, 2000). 

Self -A wareness 

Individualswithcultural self-awareness critically know and understand 
themselves at a confident level that allows them to be vulnerable and to take risks in 
cross-cultural interactions. They also recognize the need for and seek out additional 
knowledge about groups that are different from themselves. Leonard and Plotnikoff 
(2000) refer to self-awareness as the "heart of cultural competence" (p. 51 ). 

According to Pope-Davis and Coleman (1997), "a desire to explore one's 


identity as a person who has been socialized in a culture, race, and ethnicity is 

characteristic of [those] who are committed to developing multicultural competencies" 
(p.9). Thiscritical self-examination allowsapersontocarefully study her culture, racial 
identity and world view, as well as the role she plays in a racialized world. She 
reflects on how she values and responds to people who differ from her in age, 
gender, class, sexual orientation, and ability. This process of self-discovery allows 
the practitioner not only a sense of self in a diverse world, but an openness that 
enhances her empathy with those from different cultural backgrounds. Analyzing 
oneself is not always easy, especially for those practitioners who hold characteristics 
of the dominant societal group; those who are white, upper-class, financially secure, 
able-bodied, heterosexual, and male. It necessitates recognizing and grappling with 
one's own unearned privilege (Mcintosh, 1988) and thinking about how that may 

Some believe that self-awareness is the necessary first step in the journey 
towards cultural competence (Chan, 1990; Harry, 1992; Lynch & Hanson, 1998; 
Weaver, 1 999; Wells & Black, 2000). Culturally aware individuals recognize their 
own culture and social location and know how it influences their values, beliefs, 
behaviors, and choices; they are comfortable with cultural differences between 
themselves and others; and they are sensitive to issues of culture in all interactions 
(WellsSt Black, 2000). In healthcare when working with clients from other cultures, 
"students must be able to acknowledge their own cultural backgrounds and not feel 
threatened by their own cultural identifications, especially when they differ with that of 
the clients" (Chau, as stated in Sowers-Hoag & Sandau-Beckler, 1996, p.43). 
Cultural self awareness "is the bridge to learning about other cultures" (Lynch & 
Hanson, 1998, p.55), and Gerrish and Papadopoulos (1999) suggest that "the 
starting point of any education programme should therefore be an exploration of the 
students' own cultural values, beliefs, and practices, including their own prejudices" 
(p. 1454). 

McPhatter (1 997) refers to this increased self-awareness as "enlightened 
consciousness." She believes that it is a fundamental transformational process that 


results in the "reorienting [of] one's primary worldview" ... "It often requires a radical 

restructuring of a well-entrenched belief system that perceives oneself and one's 
culture, including values and ways of behavior, as not only preferred but clearly 
superior to another's. The ultimate goal of this shift in mind-set is to create a belief in, 
and acceptance of, others on the basis of equality solely because of a sense of 
shared humanity" (pp. 262-263). McPhatter is not talking about simply completing a 
few self-awareness exercises. Rather, she emphasizes the gravity of this work, and 
the need for ongoing and sustained practice. "It should be apparent that this 
dynamic process cannot even begin in short-term or brief overtures into another's 
world. It must be a sustained effort motivated by a true desire to become accepting 
and comfortable in personal cross-cultural interactions and effective in providing 
services to clients whose cultural realities differ markedly from one's own" (p. 264). 

Although it was stated above that self-awareness may be the first step in the 
development of cultural competence, in actuality full self-awareness may develop as 
a result of gaining knowledge about others and the world in which one lives in a more 
interactive or transactive process. Although learning about oneself as a cultural being 
may result in an interest in learning about those who are different from oneself, the 
opposite sequence may also occur. Gaining knowledge about other groups of 
people may also facilitate greater self awareness. 


Knowledge is the second major characteristic of cultural competence, and 
can mean specific knowledge about the culture of one's clients (Pedersen & Ivey, 
1 993). It can also mean having an understanding of the sociocultural role of minorities 
in thedominant culture, and recognizing the barriers to healthcare access for many 
non-dominant groups (Wells & Black, 2000). It may mean learning the language of 
your clients (Lynch & Hanson, 1 998) or knowing which community agencies are 
supportive of your clients' needs. Being culturally knowledgeable also means 
having a clear and explicit understanding of your own field (Pedersen & Ivey, 1 993), 


the concept of client-centered practice, and the awareness of how you can effectively 

provide the best healthcare possible for all clients no matter what their culture. 

McPhatter (1 997) states that the following list provides a foundation for a 
"grounded knowledge base" necessary for cultural competence. 

1 . Knowledge of the history, culture, traditions and customs, preferred language or 

primarydialect, value orientation, religious and spiritual orientations, art, music, 
and folk or other healing beliefs of your clients 

2. Intimate familiarity about social problems and issues that have different impacts 

on minority group members. 

3. Knowledge of the clients' neighborhoods and communities in recognition of the 

importance of context as influential in a person's life 

4. Firm understanding of the dynamics of oppression, racism, sexism, classism, and 

other forms of discrimination 

5. Knowledge of health and social systems and their impact on disadvantaged 


6. Awareness of diversity of family structure and the often overlooked 

functionality of diverse family forms 

7. Knowledge of culturally relevant interventions employed within the professional 

structure (pp 266-270) 

McPhatter's list is broadly based, thorough, and overwhelming in its breadth. 
What it does not do, however is to give specifics on how one accrues this 
knowledge. Lynch and Hanson (1 998) suggest that four of the most effective ways 
to access cultural knowledge are, "1 ) learning through books, the arts, and 
technology; 2) talking and working with individuals from the culture who can act as 
cultural guides or mediators; 3) participating in the daily life of another culture; and 4) 
learning the language of the other culture" (p. 55). Interestingly, Lynch and Hanson 
do not stress the need for cultural immersion, but view participation within a culture as 
just one of many ways to gain cultural knowledge. 


Lynch and Hanson (1998) warn against memorizing lists that depict 

differences between various cultures as a way to gather information. Instead, they 
propose that practitioners "consider value sets that are common across cultures and 
view each as a continuum" (p. 57). In this way perspectives don't have to be 
polarized or mutually exclusive, and individuals may fall anywhere on the continuum. 
Lynch and Hanson also suggest seven cultural continuato explore when learning 
about clients or the cultural groups to which they belong. These include: 

1 . the family constellation continuum - which includes kinship networks and the 

amount of support offered 

2. the nurturance/independence continuum -which determines the values related to 

how long children are nurtured or encouraged to be independent 

3. the time continuum - how individuals or groups perceive time 

4. the traditional/technology continuum - which explores whether people look to the 

past, present, or future to determine what is important in life 

5. the ownership continuum - which looks at property rights 

6. the rights and responsibilities continuum - which considers equal rights and 

responsibilities and differentiated rights and responsibilities 

7. the harmony/control continuum - which explores whether people want to live in 

synchrony with their surroundingsand circumstances, orwhetherthey 
want to havecontrol over their surroundings and circumstances 

Lynch and Hanson (1 998) believe that if a practitioner can understand where 
a client falls on these continua, and if that same practitioner is aware of her own 
values in relationship to these continua (self-awareness), the opportunity for effective 
cross-cultural interactions within practice settingswill be enhanced and one will 
positively move towards cultural competence. However, as important as self- 
awareness and knowledge are, they are more or less meaningless unless one 
develops cross-cultural skills and behaviors. Culturally competent behaviors are the 
way that one's awareness and knowledge is applied. 



The third characteristic of cultural competence, cross-cultural skill, is most 
often described as effective communication skills. Pedersen and Ivey (1993, p. 18) 
discuss a three- stage developmental framework of competencies with skill-learning 
being the final stage. They state that culturally skilled [practitioners] can: 

1 . generate a wide variety of verbal and nonverbal responses appropriate to a 

wide range of cultures 

2. both send and receive verbal and nonverbal messages accurately and 

appropriately to or from culturally different people, and 

3. change the system or institution on behalf of a client when the individual is right 

and the system is wrong. 

These are fairly broad statements, and without specific examples, they do 
not clearly articulate observable skills. One skill defined by Stanley Sue (1 998), 
has been more thoroughly discussed. He uses the term 'dynamic sizing' to mean 
that "the therapist has appropriate skills in knowing when to generalize and be 
inclusive and when to individualize and be exclusive" (p.446). Sometimes specific 
knowledge about another culture results in stereotyping, where each person of that 
culture is recognized as having the same characteristics, traits or behaviors. 
Appropriate dynamic sizing "allows one to avoid stereotypes of members of a 
group while still appreciating the importance of culture" ... "the therapist is able to 
place the client in a proper context - whether that client has characteristics typical of, or 
idiosyncratic to, the client's cultural group" (Sue, 1 998, p. 446). 

Wells and Black (2000) are more pragmatic in approach when they discuss 
multicultural or cross-cultural skills. They state that skill "refers to acquiring as well as 
mastering strategies, techniques, and approaches for communicating and interacting 
with persons from different cultures." They go on to give specific examples such as 
"telephone behaviors, receptionist practices, client interactions that build trust, 
establish credibility, and help create culture-friendly environment" (p. 181). Skilled 
communication patterns include "articulating the problem, managing resistance and 


defensiveness, and recovering when mistakes are made" (p. 182). Cross-cultural 

skills that are vitalforeffective multicultural communication also include empathizing 
and understanding others' beliefs, assumptions, perspectives, and feelings. 

Lynch and Hanson (1998) develop these concepts even further. They 
suggest that effective cross-cultural interaction takes place when a practitioner 
understands whether the client is from a high-context or low-context culture and uses 
that knowledge with appropriate communication patterns. A high-context culture is 
one where group interactions and strong, cohesive interpersonal bonds, and 
emotions are valued, whereas low-context cultures value individualism, objective 
and analytical thinking (Bennett 1995). Lynch and Hanson (1998) describe the 
importance of being skilled in recognizing and engaging in nonverbal communication 
including the significance of eye contact and facial expressions, proximity and 
touching, body language and gestures (pp. 70-74). They also emphasize that 
cross-cultural skill includes listening to the client's perspective in an effort to seethe 
world the way the client does, and acknowledging and respecting cultural differences 
rather than minimizing them (pp. 74 & 75). 

The authors do summarize that learning these skills is not easy."Unfortunately, 
there are no shortcuts and there is no magic wand. Acquiring the skills is a lifelong 
process; however, desire, willingness to learn, and the potential outcomes for [clients 
and practitioners] alike make it a rewarding pursuit" (Lynch & Hanson, 1998, p. 84). 
McPhatter (1 997) points out that skill proficiency develops only through a systematic 
process. "Skill proficiency is not a haphazard process; it is focused, systematic, 
reflective, and evaluative. Continuing to use skills because we were trained that way 
or because we lack alternative skill proficiency is out of sync with the goal of achieving 
cultural competency" (p. 272). 

Each of the three characteristics discussed above is of vital importance in the 
development of cultural competence. Pedersen and Ivey (1 993) summarize it in 
this way. "If any of the three stages of awareness, knowledge, or skill is missing from 
their [practitioners'] training, difficulties are likely to arise. Ifthey neglect awareness, 
they are more likely to build on wrong or inappropriate assumptions. If they neglect 


knowledge, they may be inaccurate in tlieir description of a situation. If they neglect 

skill, they may well be changing the situation in counterproductive directions" (p. 1 9). 
Rather than viewing these attributes as sequential, Weaver (1 999) believes that 
these three components of cultural competence; self-awareness, knowledge, and 
skills, are interactive. She states, "none is sufficient in and of itself to bring about 
appropriate practice" She goes on to state that "striving for cultural competence is a 
long-term, on-going process of development" (p.218). 

An important point to emphasize from the above, is that becoming culturally 
competent is not an easy task. Rather, it is challenging, and may be a life-long 
process (Gerrish & Papadopoulos, 1 999; Harris & Cummings, 1 996) In fact, many 
characterize the journey towardscultural competence is arduous and complex (Lynch 
& Hanson ,1998; McPhatter, 1997; Weaver, 1999). It is a "developmental process 
in which one learns to recognize, value and adapt to diversity; assess one's own 
knowledge, attitudes and beliefs about others' cultures; and incorporate the patient's 
beliefs and practices into the health care encounter. Patients perceive services as 
being culturally competent when they are appropriate for their problems and helpful 
in achieving desired outcomes according to their explanatory belief models" (Dana, 
as cited in Kramer, Ivey, & Ying, 1999, p.20). 

Yet, as extraordinary as this task is, it must start somewhere. Recognizing the 
attributes of a culturally competent person is the first step. That knowledge then 
challenges occupational therapy educators with the question, how does one learn to 
become culturally competent? What type of training/education has been used 
successfully with students and others who wish to gain expertise in these multiple 
areas? Is a certain educational approach more effective than others? The next 
section of this chapter will address these questions. 

Methods of Training/Education for Cultural Competency 

Given the compelling need for a culturally competent work force in the health 
professions, it is not surprising that authors stress the development of effective 


education that will address these issues (Dyck, 1 991 ). Zeller (1 995) states that "it is 

the responsibility of the educational institutions in the United States to nurture cultural 
sensitivity ... by providing students the opportunity to explore and examine other 
cultures as well as their own'" (p. 9). This is especially true of health professions' 

Health professions' education is governed by accreditation councils which 
develop and maintain educational standards for each profession. Accreditation 
standards for many professions include statements regarding culture, diversity or 
multiculturalism but may differ in depth and specificity. From professions such as 
Rehabilitation Counseling that required no multicultural training in their standards even 
less than a decade ago, (Smart & Smart, 1 992), educational standards range to the 
very detailed. The American Physical Therapy Association standards include 
general statements such as "physical therapy graduates should consider social and 
cultural factors while collaborating with patients and their families" (Commission on 
Education in Physical Therapy Education as cited in Monahan, 1 997). This is similar 
to the very general standards found in the Essentials and Guidelines for an 
Accredited Occupational Therapy Education Program (The American Occupational 
Therapy Association, 1 998). In contrast, the social work profession, which has been 
grappling with the issue of diversity since the 1 950's, has developed specific 
accreditation standards which not only require multicultural training, but also ban ethnic, 
racial, and religious discrimination with respect to the selection of students, faculty, 
field instructors and other staff ; ban gender discrimination; support affirmative action 
and work toward social justice (McNicoll, 1999). 

The National League of Nursing has also mandated inclusion of content on 
cultural diversity within nursing curricula (Beverly, 1992), and in 1992, the American 
Academy of Nursing's Expert Panel on Culturally Competent Nursing Care made 
specific recommendations regarding strategies forteaching and guiding faculty and 
nursing students to provide cultural-specific nursing care. (Campinha-Bacote, 1 998). 
This emphasis is not surprising given the nursing profession's early emphasis on 
transcultural nursing (Leininger, 1978). 


But the profession from which much of the cultural competency literature is 

generated, Counseling Psychology, continues to struggle with appropriate 
standards. Sue, Arredondo, and McDavis(1992) reported that although 89% of 
counseling psychology education programs offer a multicultural course (p. 477), the 
educational standards at that time did not provide a clear mandate to do so. The 
authors identified a lack of multicultural statements in the standards and guidelines of 
the American Association for Counseling and Development, and offered a call for 
action that would add specific standards addressing these areas (Sue, Arredondo, & 
McDavis, 1992). 

Although professional mandates do not always translate into practice, over 
the past decade much has been written regarding the training and education for 
cultural competency. Multiple models delineate numerous approaches used to 
educate health professionals in an effort to facilitate cultural awareness, sensitivity, 
knowledge and skills necessary for effective practice within a diverse society. One 
strategy for organizing this array of information is to examine what approaches are 
being used within particular health professions. I will do so by reviewing literature 
from nursing, social work, and counseling psychology. These three professions 
were chosen to examine because of their significant body of literature on cultural 
competence. Occupational therapy will be examined in a separate section of this 

Nursing Education 

Nursing has been involved with multinational and multicultural groups as early 
as Florence Nightingale's involvement in Crimea and with the Australian aboriginals in 
the early nineteenth century (Hagey, 1 988). But it wasn't until 1 974 when 
Madeleine Leininger combined the concepts of nursing and anthropology to found 
the sub specialty oftranscultural nursing (Leininger, 1978) that the concept of culture 
became an area of study in the nursing profession. Almost two decades later, 
Andrews (1992) worried that these educational efforts had made little impact. She 


reported, "only a handful of nursing programs have Integrated cultural concepts Into 

the curriculum, despite considerable rhetoric about the Issue and the availability of 
guidelines to assist faculty" (p. 1 0). She goes on to say that the cultural terminology 
Is Incorporated Into currlcular documents and even some texts, but these concepts 
are not fully developed by authors or faculty. 

Perhaps one of the reasons the Integration of this material has been so slow 
Inforthcoming Isthattranscultural nursing has tended to look at culture from an 
observers point of view, rather than engaging the students and faculty In the self 
assessment necessary for cultural competence. Sims and Baldwin (1 995) state that 
"the predominant education model In nursing's literature focuses on teaching the 
exceptional and culturally different student" (p. 318). Although this approach in itself 
Is sometimes seen as racist, classist, and sexist, it is also believed to be a viable 
and effective way to learn about people different from oneself. Certainly the work 
by Spector (1 996) which provides continually updated information about different 
cultural groups and their health care practices and beliefs offers much needed 
information to the White health care practitioner who is yearning to understand more 
about her Vietnamese client. This knowledge is important in order to provide 
culturally competent health care. However, if not used carefully and with sensitivity, 
that information can be misused in a stereotypical manner, masking the unique 
identity of the client in a way that is indeed racist. 

Not all nurse scholars view curriculum inclusion of culture and diversity in the 
way outlined above, however. McGee (1 992) writes that it is "neither practical nor 
desirable to attempt to teach students about many different cultures. The aims 
should rather be on developing a set of principles that equip the nurse to care for 
people, not just of one culture but of many different ones" (p. 1 8). Lenburg and her 
colleagues (1 995) refer to this as a generic versus a specific approach to 
addressing cultural characteristics. The generic approach "focuses on universal 
categories that are used to describe various cultural groups, e.g. , world view, non- 
verbal communication, language, and family structure, using different cultures to 
illustrate variations. The specific approach, in contrast, focuses on one or more ethnic 


or immigrant groups, providing acultural description that includes cultural traits, 

behaviors, communication patterns, and the like" (p. 9). More currently, Gerrish and 
Papadopoulos (1999) state that merely knowing about other cultures is insufficient. 
"in order to provide effective health care in a multiethnic society, practitioners also 
need to understand the complex way in which historical, political, social, and 
economic factors interact and impact on the experiences of minority ethnic 
communities" (p. 1 454). They believe that in order to be culturally competent, 
practitioners must develop both generic and specific cultural competence. Gerrish 
and Papadopoulos go on to state that the starting point of any education program 
should be self-exploration and awareness. Recognizing the importance of 
evaluating one's own cultural values as part of becoming culturally competent has 
been identified by several authors in the nursing literature (Carpio & Majumdar, 
1991 ; Lea, 1994; Lynam, 1992; McGee, 1994; Tuck & Harris, 1988). 
Although there is developing agreement on this point and other aspects of culturally 
competent education, there is less agreement on the method to achieve these 
goals. The American Nursing Association (ANA) addressed inclusion of cultural 
content in nursing curricula in 1 986 by identifying four approaches that nurse 
educators might employ. 

1 . the concept approach refers to the integration of cultural concepts 

throughout theentire nursing curriculum ; 

2. the unit approach referstotheinclusionof cultural aspects of nursing care in 

a specific unit or units; 

3. the course approach refers to the offering of a specific course in which the 

emphasis is on the cultural aspects of nursing care; and 

4. the multidisciplinary approach refersto the team-teaching of cultural 

content by nursing faculty, anthropologists, medical sociologists, and 
others involved in health care. (Andrews, 1992, p. 13; McGee, 1992, 
p. 15). 
Although these guidelines provide a framework for faculty, Andrews (1 992) 
believes they "fail to provide sufficient depth for the majority of faculty using them" 


(p. 1 1 ). McGee (1 994) critically assesses the unit and course approaches, stating 

that although they may be the easiest way to implement curricular change without 
undue cost and effort, they can also be viewed as basically tokenist and potentially 
racist, as they often do not address in-depth issues such as prejudice or 
competence. The approaches listed above may give a broad overview of 
multicultural curricula, but the choice of content and teaching strategies is left to 
programs and faculty to determine. A selection of specific models and curricula 
related to diversity and cultural competence found in the nursing literature are 
discussed below. 

Despite McGee's (1 994) critique of the use of specific courses to teach 
cultural competence, Abrums and Leppa (2001 ) discuss the revisions they have 
made to broaden the meaning of cultural competence for students in a course 
entitled "Nursing Care and Cultural Variation." They use Friedman's theory of 
relational positionality "to help students recognize that everyone has a perspective 
through which they view the world as 'normal'; and that normal as defined by the 
dominant group can create situations of oppression for others" (p. 270). Relational 
positionality helps students to recognize that all people maintain many contradictory 
social positions at any one time. "For example, a middle-class Black woman who is 
privileged by class but not by race may be viewed as a member of the oppressor 
group by a poor Black woman struggling with the welfare system; [while] a gay, 
White, upper-class male may be privileged by race, class, and gender, but a victim 
in a heterosexist environment" (p. 271 ). Using this theory as a guide for teaching 
cultural content helps to "increase student self-awareness in relationship to issues of 
discrimination and oppression in health care" (p. 271 ) and stretches their thinking 
about people different from themselves. 

Taking a broader view of curriculum is Gigerand Davidhizar'sTranscultural 
Nursing Assessment Model (Davidhizar, Bechtel, SGiger, 1998; DavidhizarS 
Giger, 2001 ; Dowd, Giger, & Davidhizar, 1998). As part of this model, the authors 
developed a cross-cultural assessment tool in response to the need for an 
appropriate method to evaluate "cultural variables and their effects on health and 


illness behaviours" (Dowd, Giger, & Davidhizar, 1998, p. 120). Gigerand 

Davidhizar's model is built on the premise that health professionals must have 
access to culturally relevant information in order to deliver culturally sensitive and 
competent care. The assessment tool evaluates six cultural phenomena including 
"1 ) communication, 2) space, 3) social organization, 4) time, 5) environmental control, 
and 6) biological variations" (Dowd, Giger, & Davidhizar, 1998, p. 121). This 
popular approach has been addressed in numerous articles and in a textbook 
entitled Transcultural Nursing: Assessment and Intervention (Giger & Davidhzar, 
1 999), and according to the authors, was designed for use by other health 
professionals as well (Davidhizar, Bechtel, & Giger, 1 998). In contrast to this 
approach, McGee (1 992) states that "the concept of assessing 'culture' as an 
element separate from the psychological, sociological, and other domains is aform 
of bias in itself, highlighting the idea of culture as a problem created by 'them' - ethnic 
people - who are different from 'us' - the dominant culture" (p. 56). 

Within their model, Davidhizar and Giger (2001 ) emphasize the importance 
of the concept approach outlined by Andrews (1 992) above, stating that "while 
there is specific focus on the phenomena in specific courses, all faculty assume 
responsibility for integrating culture as athread throughout individual courses in the 
curriculum" (p.283). They emphasize the need for integrating culture throughout the 
curriculum "to achieve educational outcomes related to cultural competency" (p. 284). 

Two other models or educational projects found in the nursing literature are the 
MELTING project by Sookhoo, Adams, and Anionwu (2000), and Project Cultural 
Competence (Jones, Bond, & Mancini, 1998). MELTING Is an acronym for 
multiethnic learning and teaching in nursing, and the goal of the MELTING project is 
'1o identify resources and strategies for teaching and learning culturally competent 
care" (p. 41 ). This is a three-phase project that will culminate in the production of 
teaching and learning resourcesthat will facilitate learning about the needsof ethnically 
diverse people. The investigators will attempt pot only to add to the knowledge 
base of nursing students and faculty, but also "to enable nurses to acquire and 
develop skills which help them care for patients in a culturally sensitive manner" (p. 


41 ). Although the information about this project was somewhat limited, nowhere did 

it mention the facilitation of self-awareness for either faculty or students. 

Similar to the MELTING project in goals (the development of knowledge and 
cross-cultural skills) but very different in process is Project Cultural Competence 
(Jones, Bond, SMancini, 1998). This collaborative project combined the resources 
of three major community systems: education, health care, and the business sector 
of the community (Dallas, TX) in an effort to develop cultural competence among 
health care providers. There are two major learning components of this project. 
They include a "short-term continuing education cultural immersion program 
consisting of language and culture learning experiences in Cuernavaca, Mexico" 
(p.282) and a nurse exchange program between a local hospital system and the 
Instituto Mexicana Seguro Social Hospital in Cuernavaca. The University of Texas 
at Arlington School of Nursing provides didactic cross-cultural academic programs 
and a "Travel, Study, Learn program that sponsors the 1 -week-long immersion 
experience in Mexico. The hospital system provides Spanish lessons, and health 
care personnel that take advantage of the University immersion experience as well 
as the nurse exchange program, while the community system provides housing and 
resources for the nurse exchange program . While evaluations of this project have 
been extremely positive, the authors recognize that this is only one approach to 
dealing with cultural competency training, and is biased towards learning about 
another culture and the development of basic cross-cultural skills. They state that 
"these initial, one-time, short-term immersion experiences teach individuals how to 
study culture and thrusts them into a life-long learning process about other cultural 
groups.. .[However], these initiatives are essential but also not sufficient to meet the 
health workplace needs" (Jones, Bond, & Mancini, 1998, p.286). They go on to 
state that multiple and varied training initiatives are necessary to develop a truly 
culturally competent healthcare work force. 

As one reviews these various educational approaches in nursing, it becomes 
apparent that very few of the models are comprehensive in that they do not educate 
for all of the cultural competency attributes of self-awareness, knowledge and skills. 


The following section will determine whether the social work profession is more 

successful in meeting this goal. 

Social Work Education 

Because of social work's commitment to social justice and equality, and their 
history of involvement in multicultural issues, one would expect a consistent 
academic approach to these issues. However, Kadushin and Egan (1997) 
discovered that although increasing diversity in the health care environment is a 
recognized trend, only 51 % of social work schools surveyed in their study (N = 94) 
had course units that focused on multicultural issues. Despite the limited number of 
education programs that include diversity issues in their curricula, many have 
developed successful strategies and models for inclusion. 

Lee and Greene (1999) discuss the importance of a social constructivist 
framework in their recent article. Constructivism adheres to the belief that learning is 
internal and that "the human mind plays an active role in organizing and creating 
meaning - in literally inventing rather than discovering reality" (p. 21 ). They continue, 
"In this process of socially constructing reality, individuals interpret, assign meaning, 
and create assumptions about themselves, other people, and their environment that 
provide the foundation for their knowledge of the world" (p. 22). The authors 
believe that one's cultural background plays a critical part in one's reality and how one 
co-constructs with others. They theorize that a constructivist approach to learning 
would assist students in developing a "culturally sensitive perspective of openness 
and acceptance to their clients' diverse cultural systems" (p. 26). The teaching 
framework for this approach consists of three components: an overview of 
constructivism ; an exploration of culture and self; and a social constructivist approach 
to the help-seeking process of clients which is centered in practice. Lee and Greene 
(1 999) conclude that this approach has its limitations but is one way to provide 
students with a theoretical basis for developing a culturally sensitive perspective of 
openness and acceptance of diversity. 


Another curricular approach found in the social work literature isthe Inclusionary 

Cultural Model described by Nakanishi and Rittner (1992). This model allows 
students to learn about culture from their own cultural experience. Students examine 
their own cultural heritage and values and compare these to those of the dominant 
culture and their own classmates. The final stage of the process is to introduce 
didactic material on various cultures. Nakanishi and Rittner (1 992) developed this 
approach in order to "soften the exclusionary boundaries between cultural groups 
and allow students to become more open to a more etic approach to learning about 
and interacting with people of different cultural backgrounds" (p. 33). This model 
allows students to learn about culture from the familiar-their own culture. This 
personal approach to learning about culture maintainsthe students' interest, 
providing a learning experience that is not just theoretical, but makes meaning for 
them in a personal and effective way. The authors describe the Inclusionary Cultural 
Model as a "demonstrably successful teaching method" (p. 34). 

A Values-Based approach by Uehara et al. (1996) "draws on fundamental 
values undergirding the profession and practice of social work: social justice, equality, 
self-determination, and empowerment" (p. 614). The ultimate goal of this approach 
is social transformation which occurs through reflection and collaboration. Self 
reflection is important because the person must "be constantly aware of how her or 
his own values, beliefs, behaviors, and customs may distort communication and 
promote domination. Therefore, constant introspection or self-reflection . . . is critical" 
(Ueharaetal.,1996, p.615). 

It is interesting that a common theme through the above three approaches is 
the vital need for self-knowledge and self-reflection. As has been stated earlier, self- 
awareness is a very important component of cultural competence. However, unless 
combined with cross-cultural knowledge and skills, it is ineffective for cross-cultural 
practice. Ronnau (1 994) and Sowers-Hoag and Sandau-Beckler (1 996) offer more 
comprehensive views of multicultural education in social work. 

Ronnau (1 994) identifies and discusses five strategies forteaching cultural 
competence. These include: 


1 . Introduce students to key definitions pertaining to cultural awareness and the 

culturally competent professional. Within this category, Ronnau includes an 
emphasis on self-awareness and the importance of a commitment to the 
development of cultural competence. Additionally, students must recognize and 
accept the fact that significant differences do exist between people of different 
cultures, and that those differences will Impact practice. Lastly, students must learn to 
gather more knowledge about a client's culture and to use this cultural knowledge to 
adapt their practice behaviors and develop new skills to meet the needs of their 

2. Provide resources about the cultures to be discussed. Ronnau supports the use 
of cultural profiles but emphasizes the Importance of using them with caution. 
Although such resources do provide basic knowledge about cultural groups, If 
misused, they can also perpetuate stereotypes. Students must also be taught that 
each client is unique, and there is as much diversity within a specific culture as there is 
between cultures. 

3. Ask students to be cultural guides. This strategy is most effective if there is 
diversity within the class. Class members are asked to volunteer for this role to 
assist their classmates to learn about other cultures. "Cultural guides are asked to 
provide samples of food, music, art and language which are important to them and 
represent their culture as they view it" (Ronnau, 1 994, p. 35). It is stressed that no 
one person can accurately represent an entire culture, but classmates can represent 
their own personal backgrounds. 

4. Inform students about and encourage them to attend cultural awareness actl\^'ties 
that are occurring on campusandin surrounding communities. Announcing these 
events in class reminds students that cultural awareness Is valued, is an ongoing 
process, and requires active Involvement. 

5. Integrate multicultural contentthroughoutthecourse(s). "Multiculturaleducation 
cannot be achieved by means of a few classroom activities. Becoming multicultural 
has to be seen as a process rather than a state of being" (Ronnau, 1 994, p. 36). 
Becoming culturally competent is an ongoing and prolonged process that will not 


occur as a result of a few classroom exercises. However, an effective integrated 

course can increase student awareness, whet the appetite for more knowledge, and 
begin the development of cross-cultural skills. 

Although somewhat limited in skill development, Ronnau's strategies 
provide a more comprehensive approach to teaching cultural competence than seen 
in the nursing literature. Sowers-Hoag and Sandau-Beckler (1 996) propose another 
comprehensive approach which is guided by their philosophy that "Developing 
cultural competence is adynamic process of growth through ongoing questioning, 
self-assessment, knowledge and skill building starting with the students' level of 
current competence, and supporting enhancement of their abilities" (p. 39). What is 
unique about the model suggested by Sowers-Hoag and Sandau-Beckler (1996) 
is that multicultural content is integrated throughout a multi-course generalist 
curriculum that culminates in the fieldwork experience. Using a case example, the 
authors demonstrate how knowledge and skills learned in a variety of courses could 
be applied to the case, emphasizing the breadth and depth of cultural awareness, 
knowledge and skills. They discuss the importance of an "ethnic sensitive field work 
program" where students "can apply the culturally relevant knowledge and skills 
acquired in the classroom curriculum" (p. 49) but acknowledge the complexity of and 
the need for careful planning for the development of appropriate field sites. In 
conclusion, they exhort the Council on Social Work Education Commission on 
Accreditation to strengthen the educational standards beyond the level of 
"understanding diversity" to the development of cross-cultural skills necessary for 
culturally competent care, and also suggest that all doctoral social work programs 
"consider the inclusion of learning objectives . . . designed to promote culturally 
competent educators" (Sowers-Hoag & Sandau-Beckler 1996, p. 53). 

Counseling Psychology Education 

"Although the counseling profession's recent attention to multicultural issues is 
to be lauded, there is no clear consensus as to what constitutes a good multicultural 


training program" (Ponterotto, Rieger, Barrett, & Sparks as cited in Sue, 1997, p. 

1 75). This lament continues to be heard in counseling psychology despite the 
plethora of research and articles regarding diversity, cultural competence, and 
culturally competent care. Some of the confusion may result from the multiple ways 
that the term "multicultural" is defined within the profession. Some use a broad 
definition which includesfactors such as age, ethnicity, gender, place of residence, 
socioeconomic and educational levels, nationality, and religious and sexual 
orientation. Pedersen and Ivey (1 993) believe that all of the above are aspects of 
culture, and therefore are included in all counseling relationships. "Culture is not 
treated as an exotic or specialized aspect of counseling but rather as the heart and 
soul of any and all counseling relationships" (p.viii). 

Others believe that this broad definition is so inclusive that issues related to 
racism might be lost (Sue etal., 1992) or impossible to investigate (Helms, 
1 994). Helms points out that different competencies may be required to effectively 
counsel non- White clients. It is by no means clear that the same competencies 
required to deliver effective services to clients for whom racial-group membership is 
central are equally appropriate for clients for whom other social identities (e.g. , 
gender, age, or religion) are more central. (Helms, 1994, p. 163). 

The more narrow view of multiculturalism in counseling psychology has 
traditionally incorporated the four major ethnic groups in the United States in a culture 
specific orientation. Proponents of this definition believe that non-White groups not 
only have different sets of values and beliefs from that of the White population, but 
many have experienced "or been the targets of discrimination and racism. Issues of 
oppression, racism, and identity have to be acknowledged" in the counseling 
interaction. (Sue, 1997, p. 178). 

Despite the controversy over the definitions of culture and multiculturalism in 
this field, many training programs do exist. An early, and well-known monograph by 
Cross, Bazron, Dennis, and Isaacs (1 989), identified a program to develop cultural 
competence in professionals, agencies and systems. The authors talked about a 
developmental continuum within which cultural competence occurs, that ranged from 


cultural destructivenessto cultural proficiency. They identified the various levels in 

the following manner. 

* Cultural Destructiveness: This most negative end of the continuum is 
represented by attitudes, policies and practices that are destructive to cultures and 
the individuals within the culture. For example: agencies and institutions that promote 
cultural genocide; The Indian Child Welfare Act; the KKK; Neo Nazis and other racial 
superiority groups. 

* Cultural Incapacity: People or groups lack the capacity or will to help non-majority 
clients or communities. The system remains extremely biased, believes in the racial 
superiority of the dominant group and assumes a paternal posture towards the 
disadvantaged. They may exhibit discriminatory hiring practices, apply resources 
disproportionately, and maintain stereotypes. 

* Cultural Blindness: Services are provided with the express philosophy of being 
unbiased. They function with the belief that color or culture make no difference and 
that all people are the same. It ignores cultural strengths, isolates those who are 
different, blames victims for their problems, and encourages assimilation. 

* Cultural Pre-Competence: This level exhibits positive movement. People and 
agencies are committed to civil rights and desire to deliver quality services. They 
falsely believe, however, that the accomplishment of one goal or activity fulfills their 
obligation to minority communities, or they may engage in token hiring practices. 

* Cultural Competence: People and agencies demonstrate acceptance and respect 
for difference; they expand their cultural knowledge and resources; engage in 
continuous self-assessment regarding culture, make a variety of adaptations of 
service models; seek advice and consultation from ethnic and culturally different 
communities; provide support for staff to become comfortable working in cross- 
cultural situations; and commit to policies that enhance services to diverse clientele. 

* Cultural Proficiency: Agencies hold culture in high esteem; seek to add to the 
knowledge base by conducting research, developing new therapeutic approaches 
based on culture; publish and disseminate the results of demonstration projects; hire 
staff who are specialists in culturally competent practice; and advocate continuously 


for cultural competence throughout the system. (Cross etal., 1989, pp. 13-17). 

Although the authors emphasize that systems can evaluate their level of 
competence by comparing their activities to this developmental list, they also go on 
to identify how cultural competence can be achieved at the policymaking level, the 
administrative level, and at the practitioner level. As do most education/training 
programs in counseling psychology (McRae & Johnson, 1991 ; Sue, 1997), the 
emphasis on Individual development of cultural competence by Cross et al. (1 989) 
focuses on attitudes/self-awareness, knowledge, and skills. 

Similar to multicultural education programs in nursing and social work, Sue 
(1997) reports that "In general, counseling training programs have done better in 
helping trainees with beliefs and attitudes and knowledge than they have in skills 
development" (p. 184). A decade earlier Johnson (1987) recognized this by 
identifying a need to move trainees from "knowing that" cultural differences exist, to 
"knowing how" to effectively conduct therapy with diverse clients. McRae and 
Johnson (1 991 ) add, "There is no one training model that seems to encompass all 
the necessary components in a way that can be evaluated as effective" (p. 1 32). 
It is interesting that McRae and Johnson stated the above when the staff of a 
National Institute of Mental Health training project developed the Development 
Model of Culture-Centered Training in 1981 (Pedersen& Ivey, 1993). This model 
provides a framework of competencies that can be used "to evaluate and measure 
competencies in individual counselors, to identify problems in agencies or 
organizations, to organize training workshops or develop course materials on 
multiculturalism, and even prepare to work with aculturally different client in direct 
service" (p. 23). These competencies do fall into the three areas of awareness, 
knowledge and skill, which Pedersen and Ivey conceptualize as three 
developmental stages that flow from one to another in sequence. "The importance 
of building on the sequence of stages toward informed and intentional multicultural 
skill is the focus of this three-stage developmental model" (p. 24). The authors 
emphasize the importance and balance of all three components in effective culture- 


Following this approach, Johnson (1982) developed the Minnesota 

Multiethnic Counselor Education Curriculum (MMCEC) that attempted to include the 
development of all three of the components. The program "provided expertise 
from psychologists representing specific ethnic groups . . ., focused interviews with 
clients from each ethnic group, and experiential exercises that allowed trainees to 
practice and apply the knowledge learned" (McRae & Johnson 1 991 , p. 1 32). 
Johnson later went on to develop a graduate course that incorporated the 
philosophy of the MMCEC. 

One well-known model that builds specifically on the skills area is the "triad' 
model developed by Pedersen in the mid-1970s (Pedersen, 1977). This model 
has been refined and used extensively in counselor training sessions (McRae & 
Johnson, 1991 ; Pedersen & Ivey, 1993; Sue, 1997). "The training model requires 
asimulated cross-cultural counseling interview between acoached client-antl- 
counselorteam from one culture and acounselortrainee from adifferent culture" 
(Pedersen, 1 977, p. 480). The anti-counselor takes the part of the client in the role - 
played interview by representing the problem from the client's cultural viewpoint, 
and subversively attempts to point out cultural mistakes made by the counselor 
trainee. Thismodel workson fourskill areas which Include: articulating the problem, 
anticipating resistance, diminishing defensiveness, and recovery skills (Pedersen, 

Another approach to multicultural education in counseling psychology is the 
Systemic Multicultural Curriculum Model by Vazquez (1997). Vazquez decries the 
one-course approach to multicultural education as insufficient to develop cultural 
competency. Additionally, by having one faculty member responsible for the 
multicultural course, others may feel relieved from the responsibility of having to 
address the issues in class until they are challenged to do so. Vazquez identifies the 
latter faculty as "multiculturally impaired individuals" (1 997, p. 1 61 ). 

Rather than the one-course approach, Valquez describes the process of 
developing a systemic approach as the Multicultural Journey (p. 163) which begins 
with consensus from the faculty on the identity of the program's culture. It moves 


then to identifying the goals and aspirationsof the program, including the target 

(implementation of the goals with a specific audience) and scope (the extent of 
coverage of content in relation to different groups). The context of the multicultural 
journey is next addressed. This includes the structure of the program and the 
interpersonal relationships involved. It Is here that issues of social power and 
(in)equality are explored. Valquez states that programs must go through 'dramatic 
changes' to accomplish this systemic approach (1 997, p. 1 78). The type of 
changeshespeaksofconstituteatransformation of the traditional curriculum. Others 
(Midgette & Meggert, 1991 ; Reynolds, 1997) agree with this approach. Reynolds 
(1 997) also believes that the single-course approach is inadequate, stating "These 
courses are not enough. A systems-based approach is necessary in order to create 
mental health service delivery that effectively meets the needs of traditionally 
underserved and underrepresented clientele" (pp. 211-212). Although perhaps 
ideal, an approach such as this would be very difficult to accomplish. It involves 
significant time, energy, financial resources, and a commitment from the entire faculty 
to be part of the multicultural training team. 

Another common educational/training approach in the counseling psychology 
literature is the use of particular tools to facilitate learning. Reynolds (1 997) writes of 
the Multicultural Change Intervention Matrix (MCIM), Leong and Kim (1 991 ) 
introduce the Intercultural Sensitizer (IS), the Culture-Specific Rating Scale (CSRS) 
is discussed by Nwachuku and Ivey (1991), Ponterotto (1997) developed the 
Multicultural Competency Checklist, and Ramsey (1 994) uses the Personal Cultural 
Perspective Profile (PCPP) to develop multicultural competence. Although several 
of these tools are used to develop the three major competency areas of awareness, 
knowledge, and skills (Leong & Kim, 1991 ; Ponterotto, 1997; Ramsey, 1994), each 
is unique in its approach. 

Leong and Kim (1 991 ) state that the "basic premise of the Intercultural 
Sensitizer is to provide the trainee with an active experience from which she or he 
can learn the important behaviors, norms, values, perceptions, attributions, and 
customs of another culture" (p. 115). They accomplish this by employing a booklet 


which can be used as a self-directed learning tool, that contains several critical 

incidents of cross-cultural interactions. Flanagan (as cited in Leong & Kim, 1991 , 
p. 1 1 5) defines a critical incident as "any observable human activity sufficiently 
complete in itself to permit inferences to be made about the person performing the 
act." "The critical incidents of the IS are selected to represent critical problems and 
keycultural differences of the target or focal group. . . By discussing a series of 
incidents and their alternative explanations, trainees begin to learn the beliefs and 
valuesofthetargetcultural group" (Leong & Kim, 1991, p. 115). 

Another tool that examines specific cultures is the Culture-Specific Rating 
Scale (CSRS) (Nwachuku & Ivey, 1991) developed specifically for use with the 
Af rican-lgbo culture. This 20-item instrument "provides a baseline of how the culture 
conceptualizes a problem and its mode of solution." . . . "some advantages - the 
target culture is generating the problem and the theory, rather than an external 
source" (p. 1 08). The authors state that this tool could be adapted for use with other 
cultures as well. 

Moving from looking at other cultures to looking more closely at self, the 
PCPP developed by Ramsey (1994) is a 14 item cultural continua which 
emphasizes the concept of personal culture in a way that helps counselors 
recognize personal biases and potential areas of conflict in cross-cultural interactions. 
Additionally, the purpose of this tool is to help counselors recognize that culture is not 
external to themselves, and helps to combat cultural group stereotyping (p. 283). 
The remaining two tools identified above, the Multicultural Competency Checklist 
(Ponterotto, 1997) and the Multicultural Change Intervention Matrix (Reynolds, 
1 997) are used to support not only individual, but organizational change. Reynolds 
believes that multicultural change will not occur or be sustained without organizational 
commitment, although she cautions that "transforming an academic department into 
an environment that truly integrates the values and beliefs of multiculturalism is a 
challenging task" (p. 21 5). She suggests that a systematic approach that is facilitated 
by the use of the above tools to "examine the underlying organizational structure of 
the program and social justice issues" (p. 21 5) is the best approach to effect lasting 


change. It appears that the use of particular teaching tools results in a more limited 

educational program, one that does not assist a learner in developing all three 
attributes of cultural competence. 

One final educational model identified in the counseling psychology literature 
is the Multicultural Immersion Experience (Pope-Davis, Breaux, & Liu, 1997). The 
authorsarguethatmany cross-cultural exercises and simulations used in training may 
have the opposite effect of reducing prejudice because of the brevity of the 
experiences. They cite a 1993 study by Bruschke, Gartner, and Seiter that 
examined student outcomes to a popular classroom simulation game. "They found 
the simulation increased students' ethnocentrism and dogmatism" and "attributed the 
outcome to a lack of time to adjust following the culture shock" (Pope-Davis, Breaux, 
& Liu, 1 997, p. 233). As a result of this and other studies, the authors believe that 
the most valuable experiential exercise in cross-cultural training would be one of 
longer duration involving direct contact with a targeted culture. 

Such an experience would enhance traditional educational methods, such 
as role-playing, and make the immediacy of the multicultural experience a 
reality. Individuals would have the opportunity not only to test and evaluate 
what they have read and learned about different cultural groups, but to 
experience how these cultural groups define and experience themselves 
on a daily basis" (p. 235). 

The Multicultural Immersion Experience (MIE) was developed to be part of 
an academic course and would be completed over a semester. It is designed in 
three phases. During Phase 1 . students identify a cultural group in the university or 
community that differs from themselves, to become involved with or immersed in 
the activities of that cultural group over the course of the semester. During this phase, 
students write a short autobiography that includes issues of oppression, race, class, 
and gender. They then tie this personal history to the group with which they are 
interacting and begin to explore how the differences in culture may impact the 
counseling relationship. The immersion experience itself is Phase 2. Students enter 
this group as an active participant, not an observer. They are required to maintain a 


journal during this phase that examines their cognitive and affective experiences and 

an honest assessment of their feelings of discomfort or anxiety. Classroom 
discussion is used to explore these feelings and the experiences of the students. 
Phases includes a class presentation or a roundtable discussion that includes invited 
members of each cultural group. Debriefing occurs following this exercise. A final 
assignment for the course includes a reflection paper which allows students to 
examine how the experience has changed them. 

The expectation with this comprehensive model is that students will not only 
develop Increased self-awareness and knowledge of another cultural group, but will 
also develop effective and lasting cross-cultural skills necessary for cultural 
competence (Pope-Davis, Breaux, & Liu, 1997). 

Despite the years of development of these multiple educational models and 
programs however, many authors describe the outcomes of these efforts as limited. 
Within the social work literature, Fong and GIbbs (1 995) address the "disparity 
between the stated goal [of developing cultural competence] and its implementation 
in training programs and continuing education" (p.1). Authors from the field of clinical 
psychology were echoing this lament throughout the eighties and nineties (Midgette 
& Meggert, 1991; Sue, 1981 ; Sue, Arredondo, & McDavis, 1992) with Quintana 
and Bernat stating "normative data from counseling psychology programs indicated 
that most programs are providing training that lead to, at best, multicultural sensitivity, 
but very few appear to be providing training that prepares practitioners to be 
multiculturally proficient' ( cited in Ponterotto, 1997, p. 113). And in the nursing field 
Gerrish and Papdopoulos (1 999) are concerned that "many educational 
programmes fall short of promoting the development of transcultural competence" 
(p.1454), supporting Andrews' (1992) earlier statement, 

A serious conceptual problem exists within nursing in that nurses are 
expected to know, understand, and meet the health needs of culturally 
diverse people, without any formal preparation for doing so. Although 
progress has been made in the integration of cultural concepts into nursing 


care, the progress has been disappointingly slow and education for nurses 

has been sketchy, brief, and nonspecific" (p. 7). 

What can the field of occupational therapy learn from these accounts? The 
following section examines the development of culture and cultural competence 
within the profession of occupational therapy. 

Occupational Therapy and Cultural Competence 

Occupational therapy (OT) has lagged behind many other health professions 
when examining issues of diversity and culture. One somewhat eariy (and isolated) 
article by Sanchez (1 964) spoke to the relevance of considering cultural values of 
clients in the development of OT programs. Although there were limited attempts to 
address these issues found in the literature prior to the civil rights movement of the 
late sixties and early seventies, some works began to appear at that time (Boles, 
1971 ; Committee on Basic Professional Education, 1969; Paulson, 1975; Utiey, 
1 974). By the latter half of the seventies, language within U.S. society had changed 
to include the term minorities. This was reflected in occupational therapy titles such 
as "The Involvement of Occupational Therapy with Minority Groups" (Pinto, 1 978). 
The 1 980's saw an increased number of articles and reports on diversity in the 
occupational therapy literature. Articles reflected studies on African American 
children's performance on standardized tests (Martin, 1 986), the role of grandparents 
in Hispanic families (Raphael, 1 988), and an increased awareness of the need for 
cultural sensitivity (McCree, 1989; Barney, 1989 a & b). In 1987, one publication. 
Occupational Ttierapy in Healtti Care, devoted an entire monograph (Vol. 4, Issue 
I) to cross-cultural analysis of treatment approaches. This monograph was an 
important addition to the occupational therapy literature as it allowed numerous 
authors to explore issues of cross-cultural care within a single forum , emphasizing 
their importance and timeliness. 

Changes in occupational therapy education also began to reflect the impact of 


diversity. In 1 991 , multicultural and diversity components were added to the 

Essentials and Guidelines for an Accredited Occupational Therapy Educational 
Program (American Occupational Therapy Association, 1 991 ). These standards 
were written to "ensure that allfuturepractltioners will appreciatecultural differences 
and be aware of the impact of these differences on client-therapist interactions" 
(Wells & Whiting, 1 998, p.2). The new standards became mandates for the 
inclusion of multicultural and diversity issues in every occupational therapy curriculum 
in the United States. 

The national organization also began to respond. For the first time, minority 
issues became an independent goal of the American Occupational Therapy 
Association (AOTA) Strategic Plan (1990-1991). Association policies were 
developed that addressed the recruitment and retention of minority individuals, 
inclusion of ethical and cross-cultural concerns and issues in all appropriate AOTA 
documents and publications, and the use of gender neutral language (Wells & 
Whiting, 1 998). In 1995, the theme of the AOTA Annual Conference was 
"Diversity: Our Journey Together". All of these events were important in the 
development of a national examination of diversity, but in my view, the most 
important and effective structural change wasthe establishment in 1991 of the 
Minority Affairs Program (MAP) as part of the Public Relations Department of the 
American Occupational Therapy Association. 

The Minority Affairs Program (MAP) was initially developed to increase the 
recruitment of minority students to the profession. However, as the needs of the 
profession changed in response to member and societal shifts, the MAP grew and 
developed as well. The name of the program was changed to the Multicultural 
Affairs Program in 1994, and it expanded its purpose. 

Over the next several years, multiple efforts were made by the MAP, not 
only to recruit more diverse members to the organization, but to also "serve as a 
clearing housefor information on issues relating to diversity and multiculturalism" 
(Wells & Whiting, 1998, p.33). The second director of the program, Shirley Wells, 
stated that a major goal of the MAP was to provide a sounding board for and to 


help meet the needs of the diverse members of the AOTA (personal 

communication, October 22, 2000). The OT Practice article by Wells and Whiting 
(1998) summarizes the many and varied accomplishments of this program in its 
seven years of existence. Unfortunately, due to downsizing as a result of budget 
cutsand structural changes, the Multicultural Affairs Program and its director were 
terminated in 1 998 and some of the tasks of the MAP were distributed among other 
AOTA staff members and programs. 

However, the work of the MAP, coupled with a heightened awareness of the 
importance of issues related to culture, multiculturalism and diversity resulted in an 
increased exploration of these issues in the occupational therapy literature. The 
examination of the impact of culture on one's choice of occupational activities has 
changed the way occupational therapy practitioners work with consumers. Virtually all 
of the emerging models of practice that focus on occupational performance address 
the concept of culture and the importance of evaluating and being sensitive to the 
cultural context of the client (Christiansen & Baum, 1997; Dunn, Brown & McGuigan, 
1994; Kielhofner, 1997; Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996; 
Schkade & Schultz, 1 992). Diversity has been defined in broad terms that include 
not only racial and ethnic characteristics, but also gender, age, ability, sexual 
orientation, and class (Wells & Black, 2000), and there has been more interest in 
the area of cultural competence. 

Although Sayles-Folks and People (1 990) implored the need for cultural 
sensitivity training for occupational therapists, the term cultural competence was not 
seen in occupational therapy literature until the early 1 990s. Dillard, Andonian, 
Flores, Lai, MacRae and Shakir (1992) described practice within a diversely 
populated mental health setting in San Francisco as culturally competent care. The 
authors stated that the purpose of the article was "to introduce the concept of cultural 
competence and discuss the importance of culture for occupational therapy in mental 
health settings" (p. 721 ). The article was descriptive, defining culturally competent 
practice and then describing several programs instituted at the institution which 
reflected that practice. Other descriptive articles such as this addressed minority 


women who are disabled (Wells, 1991), Native Americans (DeMars, 1992), older 

adults from diverse cultures (Barney, 1991), "minority patients" (McCormack, 1987) 
and Hmong children (Myers,1992), while an entire monograph addressed OT 
across cultures (Merrill, 1 992). Dyck (1 991 ) issued a challenge to the entire 
profession to consider the importance of multiculturalism and occupational therapy. 
She stated that although individual therapists had begun to respond to 
demographic changes within our client population, in order for change to be effective 
it needed to be a "shared responsibility. Clinicians, educators, researchers, 
professional bodies and ethnocultural communities all have a role to play in retooling 
the knowledge base that guides practice, professional education, and the 
organization of services" (p. 224). 

MacDonald and Rowe (1 995) responded to Dyck's challenge (1 991 ) within 
the educational arena by describing a curriculum of "transcultural occupational 
therapy" that includes currlcular infusion of cross-cultural concepts, as well as an 
individual mentoring program for minority students. A few years later, MacDonald 
(1998) wrote about an application of Well's (1996) model of multicultural 
competency at the College of Occupational Therapists in York, Great Britain. Well's 
model was later refined and described in a book published by the American 
Occupational Therapy Association (Wells & Black, 2000). Another descriptive 
account of the use of educational models to establish (multi)cultural competence was 
offered by Horger and McGruder (1 995) at the Annual Occupational Therapy 
Conference held in Denver, Colorado. And more recently, Bailey (2000) describes 
an infusion model within an OT educational program to increase students' awareness 
and appreciation of cultural diversity. 

Occupational Therapy Research about Cultural Competence 

Descriptive reports have increased in the occupational therapy literature, but 
reported research on cultural competenceorcross-cultural care is limited. Within this 
meager literature, however, both qualitative and quantitative studies are published, 


many of which have been done outside of the United States. Khamisha (1 997) 

surveyed occupational therapists working in Glasgow to determine their cultural 
awarenesswhenworklngwithclientsof Indian subcontinent origins. Therapists self- 
rated their awareness as quite low (p. 1 7). A similar study done in the Netherlands 
by Kinebanian and Stomph (1992), was carried a step farther. The authors used the 
information from the study to "develop eight educational tools for use within the [OT] 
schools." In Australia, Westbrook, Skropeta, and Legge (1 991 ) examined the 
experiences of therapists with ethnic clients and concluded that "There is clearly a 
need for both educational and continuing education programmes to focus on the 
difficulties encountered by ethnic clients if they are going to meet their communication 
and emotional needs" (pp. 257-258). 

Scott (1997) explored the perceptions of cross-cultural practice by British 
occupational therapists. Using phenomenological, qualitative inquiry, herfindings 
indicated that"cross-culturallearning and understanding of theclient'sillness 
experience are facilitated when therapists adopt a truly non-directive, or client- 
centered approach to care . . . which requires an attitude of seeing clients as unique 
persons with the right to live according to their own viewpoint" (p. 93). Whiteford 
and Wilcock (2000) conducted a 3-year qualitative study with occupational therapy 
students in Aukland, New Zealand "about their learning, development of skills and 
competencies for intercultural practice" (p. 325). This article focused only on the 
concepts of occupation and independence as part of the data gleaned from the 
study. The participants concluded that independence is a "therapist centered, 
predominantly Western cultural construct" (p. 331 ) that must be carefully considered 
in a culturally sensitive, client centered intervention approach. 

Within the United States, Pope-Davis, Prieto, Whitaker, and Pope-Davis 
(1 993) examined the "self-reported multicultural competencies of occupational 
therapists" (p. 839) using quantitative inquiry. Results suggested that "there is a 
clear difference in perceived multicultural competencies among those therapists who 
have a higher level of education, have worked with patients of color, have taken 
multicultural course work, or have attended multicultural seminars or workshops" (p. 


842). The authors also correlated responses with the cultural competencies of 

awareness, skills, and knowledge identified earlier in this chapter and with afourth 
competency of relationship. Working with patients of color most strongly correlated 
with the competency area of awareness; skills and knowledge were most closely 
correlated with exposure to multiple kindsof education dealing with multicultural 
issues; while the competency of relationship showed an absence of any correlation 
with the variables. 

Kim (1996) examined the impact of cross cultural practice on cultural 
competence in an empirical study similar to that of Pope-Davis et al. (1 993). Using 
the Multicultural Counseling Inventory (Sodowsky, Taffe, Gutkin, & Wise, 1994), her 
findings "revealed statistically significant correlations between cross-cultural practice 
and the overall level of multicultural competence" (p. 54). Additionally, further 
analysis indicated that cross-cultural practice "was asignif leant factor affecting the 
levels of Awareness and Knowledge" (p. 55). 

The above section indicates only limited research on cultural competence in 
the occupational therapy literature. However, much abounds in other health related 
fields. As we examine many of these studies, the basic questions to be answered 
are; how does one measure cultural competency, its effectiveness, and create 
approaches to training and education, and what can occupational therapy learn from 
these studies? These questions will be addressed in the next section. 

Research about Cultural Competence in Other Health Related Fields 

When I began this paper I was under the impression that there was not much 
research being done on the topic of cultural competency. I formulated this 
impression by talking with psychologists and multiculturalists who told me there was 
little out there. Therefore, I was surprised to find as much in the literature as I did. 
Perhaps not surprisingly, most of the reported research seems to be happening in 
the counseling psychology field, with less found in other healthcare professions' 
literature such as that of nursing, or social work. What was surprising to me, however. 


was that the greatest majority of these studies were empirical, quasi-experimental 

designs with quantitative analyses. There seemed to be few qualitative studies. 
This will be discussed more thoroughly in the next section. 

Because research on cultural competency is quite disparate, it is somewhat 
difficult to determine how to organize the information in a way that makes it accessible 
to report and to analyze. Should it be categorized by discipline, by research 
methodology, by year, by content? After reviewing the literature several times it 
appears to fall naturally into several content categories. Therefore, I will examine the 
literature by reviewing the research on a) education and training techniques; b) the 
efficacy of specific cultural competency attributes; c) culturally competent care; and 
d) client perception of culturally competent practice. 

Some Overarching Thoughts and Ideas in the Literature 

Many researchers emphasize how difficult it is to do effective research related 
to multicultural competence. Sue (1 998) believes that because much of the work is 
related to race relations, "research into these issues will also engender many 
emotional responses" (p.444). Being emotionally involved in the research certainly 
influences the manner in which the study is planned, conducted, and reported, and 
often compromises any hope of objective analysis of the findings... if that is the 
researcher's goal. Even if a researcher feels that she has no emotional tie to the 
factors being studied, her unconscious and sometimes unexamined biases and 
world view will color the findings (Sue & Sundberg, 1 996). Helms (1 993) reports 
that White researchers in the area of counseling are the primary gatekeepers of 
cross-cultural research (p.242). This includesjournai editors and dissertation advisors 
who may provide a "constricted" study of cultural diversity issues because of the 
particular world view of the White researcher. Cauce, Coronado, and Watson 
(1 998) remind us that "how one designs and conducts research is at once a scientific 
and sociopolitical process" (p. 305). Some authors wonder if the subjective world of 
people of color can ever by understood by Whites (Stanfield, 1 993). For these 


reasons, it is imperative to seek a research approach that will allow for the 'voice' of 

the person of color to be heard most effectively. It is also vital that researchers 
carefully evaluate and present their own beliefs, values, and assumptions in order to 
diminish researcher bias or facilitate the assessment of their work by others. In 
response to these concerns, Meleis(1996) suggests criteria that (nurse) 
researchers could use to guide their research and to help determine the rigor and 
credibility of research studies related to cultural competence. 

Education/Training Research 

Most health professions academic programs today are guided by broad and 
non-specific standards developed by their accrediting agencies that require 
academic content related to diversity and multicultural issues (Darling, Greenwood, & 
Hansen-Gandy, 1998; Lenburg, 1995; MacDonald, 1998; Monahan, 1997; 
Trolander, 1 997). The literature indicates that academic programs have complied 
with these standards in a variety of ways, but that there seems to be little systematic 
approach to teaching multicultural content. (Babyar, Sliwinski, Krasilovsky, Rosen, 
Thornby, & Masefieid, 1996; Andrews, 1992; Kadushin & Egan, 1997). This may 
be due in part to the fact that there has been insufficient research to articulate and 
validate effective academic strategies. 

Within the plethora of articles that discuss adding multicultural content to health 
professions academic programs, only a small percentage actually focus on cultural 
competence and the characteristics or attributes of which it is comprised. As a result, 
many authors report that insufficient research has been done which examines various 
aspects of education that promote cultural competence (Allison, Echemendia, 
Crawford & LaVome Robinson, 1996; Lenburg, 1995; MacPhee, Kreutzer, & Fritz, 
1 994). The studies that have been reported, however, differ significantly based on 

Social Work 

Within the profession of social work, mainly anecdotal and descriptive 
studies or studies that were qualitatively rather than quantitatively analyzed were 
found in the literature. 

Several authors have written about and/or studied particular curricular models 
or teaching strategies that facilitate cultural competence in social work education. 
Manoleas (1 994) devised a curricular model that identified several outcome 
objectives for cultural competence. These were based on what he calls the 
"universal " yet "oversimplified" factors that relate to a person's knowledge, skills, 
and values. Although this model provides an opportunity for the evaluation of 
outcomes through research, Manoleas does not suggest how this might occur. 

Ronnau (1 994) identified five cultural competence teaching strategies and 
assessed their effectiveness in a descriptive study where students were asked to 
complete a short survey. From this he identified four major benefits of his program ; 
learned that the majority of the students felt more comfortable asking culturally 
sensitive questions; and that the students' knowledge about other cultures was 

Nakanishi and Rittner (1 992) describe and examine a particular classroom 
approach they named "The Inclusionary Cultural Model." This educational approach 
"combinesteaching traditional sociocultural theories with an experiential classroom 
component that enables students to move from an emic (Lum, 1 986) process of 
cultural self -definition to an etic (Lum, 1 986) perspective of acceptance and respect 
for the cultural systems of others" (p. 27). Although they did not provide a structured 
assessment of this model, anecdotal evidence of student transformation is 
"powerful." By experiencing cultural dissonance and lack of understanding first, "the 
didactic material about culture and minority statustends to bemuch more accessible" 
according to Nakanishi and Rittner (1 992, p. 34). The Inclusionary Cultural Model 
provides students "with an opportunity to examine how culture has influenced their 
behavior prior to examining how it influences the behavior, values, norms, and 


needs of others" (p. 34). This approach to multicultural education appears to have 

merit, but certainly requires more careful study in order to validate its effectiveness. 

Another approach to examining multicultural education isto review the skills 
and needsof the faculty who are presenting the content. In a qualitative study using 
grounded theory methods, Singleton (1 994) reviewed the comfort of faculty who 
teach content on racial oppression. Using Strauss' (1 987) approach, Singleton 
chose an exploratory, cross-sectional research design in which she interviewed 
eleven faculty members from four different urban, east coast schools of social work. 
The interviews were recorded and follow-up interviews were conducted as 
necessary. Singleton used open-ended questions to examine the concept of 
"comfort", and the transcripts of the tapes were coded for analysis. 

Her analysis established that "the decision to present or not to present 
oppression content is not a simple one... The processes through which social work 
instructors arrive at a decision regarding the presentation of oppression content can 
be delineated into three distinct paths: avoiding oppression terminology and 
minimizing oppression content, rejecting all content on oppression, and explicitly 
including oppression content" (p.1 6). She suggests further research, both survey 
and qualitative to further examine this phenomenon. 


The nursing literature seems limited in quantitative research studies but 
appears to have produced more of these than has social work. Lenburg and her 
colleagues (1995) report that research on education that promotes cultural 
competence is "sparse." She identifies articles that talk about research but do not 
report actual research projects or results, and descriptive reports of model programs 
or teaching-learning strategies (much like that found in the social work literature), but 
no actual research studies. Lenburg does indicate that there have been some 
descriptive studies published in the field of nursing, but that much more needs to be 
done. Andrews (1 992) reports that there is a heavy emphasis on qualitative 


research methods in many cross-cultural studies, and because of this nurse 

researchers often experience funding difficulties. She argues that the 
"counterproductive debate over quantitative versus qualitative methods should be 
ended. The choice between qualitative and quantitative research methods depends 
on the questions asked, and frequently a combination of methods enables the 
researcher to achieve the optimum results" (p. 13). 

Despite these comments, however, one study in the nursing literature that is 
often cited was done by Pope-Davis, Eliason, and Ottavi (1 994). This was an 
exploratory investigation to determine if nursing students were multiculturally 
competent. One hundred and twenty undergraduate nursing students were asked to 
complete the Multicultural Counseling Inventory by Sodowsky, Taffe, Gutkin, and 
Wise (1994) and a demographic questionnaire that had been developed by the 
investigators. Results were reported in descriptive statistics, and analyses of 
variance were completed on the demographic effects. What was discovered was 
that students with work experience "had significantly more self-perceived multicultural 
skill and knowledge but not more multicultural awareness . . . than students who have 
had no workexperience"(p.33). This finding has some interesting implications for 
(nursing) education if it means that students who are somewhat culturally unaware 
(mis)perceive that they are actually culturally competent. It also raises the question 
whether someone can actually be culturally competent if she does not have cultural 
self-awareness. Studies reported earlier in this chapter (Pedersen & Ivey, 1993; 
Weaver 1 999) indicate that that cannot happen. 

Another outcome study administered by Alpers and Zoucha (1996) 
examined cultural competence and cultural confidence in senior nursing students. 
Using the Cultural Self Efficacy Scale (CSES), two groups of students were 
evaluated; one group had received diversity course content and one had not. The 
CSES was developed to measure confidence and perceived competence in a 
nurse's knowledge and skill to develop culturally appropriate care to three specific 
ethnic/racial groups (p. 1 1 ). Interestingly, the group of students with no prior 
diversity training perceived themselves to be more confident and culturally 


competent than did the 'educated' group. The authors suggest that the latter group 

of students may have had just enough training to make them realize "that they do 
not know enough abouttranscultural nursing, health care beliefs, and practicesof 
specific ethnic groups" (Alpers & Zoucha, 1 996, p. 11 ). This resulted in diminished 
confidence in their abilities. Alpers and Zoucha summarize that a mere introduction to 
diversity content is clearly insufficient to develop cultural competence and confidence. 

Two additional studies that examined students' self reported cultural 
competency were conducted more recently by Napholz (1999) and St.Clair and 
McKenry (1 999). In Napholz's study an examination was made of the effects of the 
addition of an innovative cultural sensitivity intervention to a more traditional course 
that already incorporated cultural diversity in its content. The self -report instrument 
used in this case was the Ethnic Competency Skills Assessment (Ho, 1 992). 
Descriptive and multi variant analysis revealed somewhat inconclusive results in this 

St.Clair and McKenry (1 999) had more definitive findings from their study, 
however. Their study was designed to examine whether two- to three-week 
international student experiencesthat called for cultural immersion in acommunity 
diverse from their own would effect change "in the students' ethnocentrism, cultural 
sensitivity, and cultural self-efficacy" (p. 228). The study was completed over 2 
years with 1 different groups of students who volunteered to participate in 
international nursing experiences (N=80).They used atriangulated research design 
that incorporated both quantitative and qualitative analysis. St. Clair and McKenry 
examined cultural self-efficacy quantitatively by using Bernal and Froman's ( 1 993) 
Cultural Self-Efficacy Scale (CSES). Additionally, cultural competence was 
measured by the type of care the student nurses provided during these 
experiences, and was assessed qualitatively through participant observation, field 
note transcriptions, and of examination of journal entries. Scores from the CSES 
were analyzed using descriptive and multi variate analysis while a qualitative analysis 
was made of all 80 student journals. The investigators clearly articulated that this was 
not a qualitative study, but that the analysis of the journals "was completed to further 


explain the findings from the quantitative instrument, understand the students' 

perceptionsof the immersion experience, and Identify whether a cultural perspective 
change occurred "(using Mezlrow's [1 991] perspective transformation theory) 
(p.231 ). Later, the authors point out that although the quantitative findings did 
indicate a difference, it is only with the qualitative analysis that a researcher can learn 
what made the difference in the students. Significant findings from this study 
indicated that studying cultural diversity in school courses may facilitate "the 
development of cultural sensitivity and enlighten one about the concept of 
ethnocentrism, but without living in another culture, students have a limited ability to 
understand and overcome their own ethnocentrism" (p. 233-234). Students may 
have Initially described themselves as culturally aware and sensitive prior to the 
experience, ". . . however, they did not become aware of how their ethnocentrism 
affected their ability to become culturally competent providers until they were 
immersed in another culture" (p.234). 

These findings have important implicatlonsfor health professions' academic 
programs that attempt to facilitate cultural competence in their students. One 
question that St. Clair and McHenry ask is if the same results can happen in culturally 
diverse communities in the United States, or if they only occur with an International 


Studies from other disciplines have found evidence to support additional 
kinds of training/education. MacPhee, Kreutzer, and Fritz (1 994), from the. 
psvcholoav literature, report on the success of a study called the "Multicultural 
Curriculum Infusion Project". Faculty volunteers from eight departments of a college 
agreed to infuse multicultural content into their classes. The study focused on four 
human development courses that were " sequenced from sophomore to senior 
level, in terms of increasing emphasis on syntheses of research-based knowledge, 
theory, and the application to social policy issues" (p. 705). The authors employed 


a quasi-experimental design using an attitude pretest and post test that examined 

racial attitudes and attitudes toward poverty. Additionally, qualitative information was 
gathered through content analysis of student learning and process evaluations. 
Results of all of these measures indicate that infusion of multicultural and diversity 
content had a broad effect on students' attitudes toward outgroups (p. 71 2). 

In summary, the research methods used in studying education and training of 
culturally competent skills, though limited in volume, are quite varied. Studies range 
from anecdotal and descriptive reports to grounded theory qualitative analyses and 
quantitative descriptive or multivariate analysis. There are more quantitative studies 
in psychology than in social work or occupational therapy. Although nursing 
researchers have historically engaged in anecdotal, descriptive, and qualitative 
inquiry, more recently there has been an increase in empirical studies. 

Research about Specific Attributes of Cultural Competency 

Although there is some consensus that healthcare professionals who wish to 
become culturally competent must improve their self-awareness, knowledge and 
skills, there is limited research that examines the development of individual attributes 
of cultural competence. In 1 991 , D'Andrea, Daniels and Heck reported on a series 
of studies conducted with counseling psychology graduate students enrolled in 
multicultural counseling courses. In each study, the Multicultural Awareness- 
Knowledge-and Skills Survey (MAKSS) was used to evaluate the participants' 
perceptions of their development of these attributes. The MAKSS is a self- 
administered written test consisting of 60 items that are equally divided into three 
sub scales. Ninety-six students in three different classes from two different 
educational programs were evaluated. The MAKSS was administered at the 
beginning and at the end of each class to evaluate differences in outcomes as a 
result of class structure (one class met 1 XAweek for 1 5 weeks, 3 hours per class; the 
second met 2X/week for 6 weeks, 3 hours per class; and the third class was held in a 
weekend format with students attending for 5 hours on Fridays, and 9 hours on 


Saturdays over 3 weekends). Although there were no significant differences found 

between the three groups on the pre-test, post-test results indicated a significant 
difference between the mean ranks of each of the sub scales for all three groups. 
Results indicated that the courses each positively effected the participants' 
perceptions of their cultural competence attributes, and the time structure did not 
effect the results. Although all attribute areas improved, the lowest of the three was 
thatof multicultural skills. (D'Andrea, Daniels & Heck, 1991). 

Pope-Davis and Ottavi (1 994) examined the association of cultural 
competency attributes with demographic variables such as race and ethnicity. Using 
the Multicultural Counseling Inventory by Sodowsky et al. (1 994), 220 counselors 
responded to the 40 items which evaluated skills, knowledge, awareness and 
relationship. Descriptive statistics and analyses of variance were conducted on the 
data. Results indicated that ethnicity was the only demographic variable associated 
with difference in self-reported competencies. "Asian American and Hispanic 
counselors reported more multicultural counseling knowledge than did White 
counselors; African American, Asian American and Hispanic counselors reported 
more competence in multicultural awareness and relationships than did White 
counselors" (p. 653). Although the meaning of these results is unclear, the authors 
suggest an ongoing need for continued improvement in the training and practice of all 
counselors, and specifically "White counselors should be encouraged to work harder 
to increase and enhance their multicultural knowledge and awareness" (p. 654). 

Examination of the attributes of cultural competence is also found in 
intercultural competence research. "By far, the most frequent goal of intercultural 
competence research has been the identification of variables that could be used as 
predictors of effective intercultural performance, followed by empirical attempts to 
understand the correlates of differentially effective adaptations," state Dinges and 
Baldwin (1 996, pi 06). In a chapter that examines the research on cultural 
competence over a ten-year span, these authors favor the increase in the complex 
analysis of quasi-experimental empirical studies. 

In a significant literature review, Dinges and Baldwin (1 996) examined and 


reported on twenty-two separate research studies that had been done on some 

aspect of intercultural competence between the years 1 985 and 1 993. The focus of 
these studies fell within several distinct categories. The investigators examined 
aspectsof intercultural competence, dimensions of intercultural effectiveness, 
intercultural adjustment, the validity of tools and assessments that measure the 
above, or they tested previously identified behavioral skills considered to be 
important in facilitating intercultural effectiveness. The majority of the studies 
(eighteen out of twenty-two) were quasi-experimental in design. Some of the 
findings were as follows: 

In a study that examined the relationship between intercultural communication 
competence, knowledge of the host culture, and cross-cultural attitudes, Wiseman, 
Hammer, and Nishida (1 989 ) found that the degree of ethnocentrism in a person, 
was the strongest predictor of the culture-specific communication competence. 
Another study investigated the relationships between previous intercultural 
experience and self-perceived intercultural competence (Martin, 1987). Not 
surprisingly, sojourners with the most intercultural experience rated themselves 
higher in the skills of self-awareness and the ability to facilitate communication. 
Cui and Awa (1992) examined intercultural effectiveness of individuals, based on 
interpersonal skills, social interaction, cultural empathy, personality traits, and 
managerial ability. In afactor analysis which compared these traits to cross-cultural 
adjustment and job performance, the investigators found that personality traits 
(including patience, flexibility, empathy and tolerance) accounted for the highest 
amount of variance (24.4%) whereas cultural empathy (which included previous 
overseas experience, awareness of cultural differences, empathy for working style, 
and non judgmental behavior) had the lowest loading (6%) on the factor analysis . 
Interestingly, this seems to conflict with the findings of Martin's (1 987) study above, 
but this discrepancy may be due to the difference in design and analysis of the two 
studies. In some agreement with Cui and Awa (1 992), Olebe and Koester's earlier 
(1 989) study found that the three most important predictors of intercultural 
effectiveness were task roles, empathy, and respect. 


In summary, it is apparent that there is no general agreement on which "traits" 

provide the unequivocal basis for cultural or intercultural competence. Dingesand 
Baldwin (1996) believe that the move away from this kind of research is positive. 
"This past approach has resulted in composite-trait stereotypes that have 
contributed little more to the understanding of Intercultural competence and has 
probably been a major nonproductive diversion from more important research" 
(p. 120). 

Research about Culturally Competent Care (CCC) 

Much of the literature found regarding culturally competent care is written in a 
generalized, theoretical manner (Chin, 2000), or describes CCC with specific 
groups of people including African Americans (Giger, 2000), Appalachians (Purnell, 
1999), Sexual Minorities (Gonser, 2000), and Psychiatric Nurses (Mahoney & 
Engebretson, 2000). There were, however, several research studies that examined 
the results or outcome of culturally competent care with specific groups. 

A Canadian study examined CCC with culturally diverse clients with a history 
of sexual abuse (Austin, Gallop, McCay, Peternelj-Taylor, & Bayer, 1999). Survey 
research was done with 1 , 701 psychiatric nurses from four provinces (Alberta, 
Saskatchewan, Ontario, and Nova Scotia) to examine their attitudes, knowledge and 
competencies while working with this client population. The data was qualitatively 
analyzed by discovering emerging themes and exploring the commonality of 
themes across provinces. On the question that asked how they rated their ability to 
provide culturally competent care, four overall themes were identified that were 
present in all provinces and all nursing groups. These included: Culture is not the 
problem - some nurses felt incompetent working with the diagnostic problem 
regardless of the clients' culture; Culture is not an issue - some nurses did not 
acknowledge any implications arising out of cultural differences. Interestingly, these 
nurses rated themselves at the highest level of cultural competence (5 on a scale of 
1 to 5) ; Culture influences perspective and responses - many of these 


respondents believed that culture was always an issue, that It shapes perceptions 

and affects clients and treatment regardless of the presenting problem. Many of 
these nurses rated themselves at the midpoint (3) in cultural competence; and 
Culturally specific competence - some nurses felt more competent with specific 
cultures than they did with others (Austin et al., 1999, pp 14-17). Overall, only 4.6% 
of the respondents saw themselves as very competent. 

The authors question whether the 5-polnt Likert question is an accurate 
assessment of competence, particularly when those who self-assessed at the 
highest level (5) did not see culture as an issue. They wonder whether "it is 
possible that the 62.9% of nurses who rated themselves at levels 3 and 4 are so 
cognizant of the complexities of culturally competent care that they hesitate to claim a 
higher degree of skill?" (p. 1 8). Austin and her colleagues summarize the study by 
stating that the nurses surveyed recognized the importance of culturally competent 
care, but that they needed more knowledge and understanding of cultural norms and 
practices in order to proved the kind of care necessary. 

Another qualitative (grounded theory) study found similar results concerning 
the need for increased cultural knowledge about sexual minority males. (Schilder, 
Kennedy, Goldstone, Ogden, Hogg, & O'Shaughnessy, 2001) Forty-seven HIV 
positive males were interviewed and participated in focus groups that elicited 
information about their health care experiences. Participants reported that many 
health care providers did not recognize the gay, homosexual, ortransgendered 
culture, nor did they attempt to learn more about it. Positive experiences in health 
care occurred with a few culturally competent providers who could "identify and 
include the social and sexual identity of their patients, and were aware of inherent 
cultural values and beliefs" (p. 1657). 

Weaver (1 999) reported the results of a study of culturally competent 
helping practices with Native Americans. Sixty-two Native American social workers 
and social work students completed a survey on knowledge, skills, and values 
necessary for culturally competent service provision to Native American clients. 
Survey data was reviewed and categorized into themes which were then classified 


into the common attributes of knowledge, sl<ills, and values. Within the area of 

knowledge, themes included: 1 ) diversity, 2) history, 3) culture, and 4) contemporary 
realities. The skill area was broken into two major themes; a) general skills such as 
communication and problem solving, and b) containment skills which require social 
workers to refrain from speaking. 

Four major themes arose in the values area. These included : a) helper 
wellness and self-awareness, b) humility and willingness to learn, c) respect, open- 
mindedness, and a non judgmental attitude, and d) social justice (pp. 220-222). 
Results of this study help to answer the questions of what kind of knowledge and 
skills, and which values are necessaryfor culturally competent care forthis 
population.Outcome studies on culturally competent care are limited. I agree with 
Weaver (1 999) when she says that researchers must find a way to measure cultural 
competence in order to better serve clients from a variety of backgrounds (p. 223). 

Research about Client Perceptions of Culturally Competent Providers 

Although it is important to assess the effectiveness of cultural competence 
training and practice as measured by the practitioners, a more important assessment 
of these behaviors, in my mind, is how the recipients of these actions view their 
effectiveness. How do clients recognize culturally competent care? Not enough 
research has been done in this area, but a few investigative studies were found. 
Most of these, however, focus on the racial and ethnic match of the provider and the 

A study by Wade and Bernstein (1991) examined the perceptions and 
satisfaction of Black female clients of their counselor's skills and characteristics, after 
these counselors had engaged in sensitivity training. They also looked at the attrition 
rate of these clients. At the end of the first three counseling sessions, each of the 80 
Black female clients was asked to complete three instruments to assess their 
perceptions of counseling. The researchers used multivariate analyses to examine 
the results which indicated that clients rated those counselors more positively who 


had completed the culture sensitivity training. Results also found that these 

counselors had clients with lower attrition rates. An important finding was that the 
clients' perceptions were more positively affected by the counselor sensitivity 
training than by counselor race. 

Rogers' (1 998) recent study examined the influence of both "race and 
consultant verbal behavior on perceptions of consultants' competence and 
multicultural sensitivity." (p.265). She did this by having 1 54 preservice teachers 
(research participants) view a videotape of an interview in which the race (African 
American or White) and verbal behavior (race-sensitive or race-blind) of a consultant 
and client were completely crossed. The participating preservice teachers rated the 
consultantson measuresof competence and multicultural sensitivity. Rogers 
performed a2x2x2x2x2 multi variate analysis of the four variables in an effort 
to "address the methodological shortcomings of previous research by fully crossing 
all possible racial pairsof the consultant, consultee, and research participant (African 
American, Caucasian) to understand more completely the impact of race on 
consultants' behavior. Results indicated that consultants who engaged in race- 
sensitive verbal behavior were consistently seen by all participants as being more 
culturally competent and sensitive. Consultants who were able to talk openly about 
racial issues were seen as being more credible regardless of racial match, although 
racial match was an influencing factor. 

Another empirical study by Gim, Atkinson, and Kim (1991), which also 
examined the effects of counselor ethnicity and cultural sensitivity on research 
participant perceptions, however, found that Asian American participants rated a 
counselor more credible and competent not only when they exhibited culture 
sensitive behaviors, but when they were also Asian American. 

In summary, there are mixed results in these studies. Although most 
clients/participants rate more highly counselors who exhibit culturally competent skills, 
the counselors 's racial or ethnic match with the client results in varied responses. As 
Sue (1 998) summarizes, " individual differences in the effects of (therapist/client) 
match appear to be very important, so that [racial or ethnic] match is neither a 


necessary nor a sufficient condition for positive treatment outcomes. In other words, 

match may be important for some, but not all clients" (p. 444). 

Analysis and Discussion of Researcli l\Aetliodologies 

What struck me as I began a review of the research on cultural competence, 
was that the majority of studies were analyzed quantitatively using mainly analysis of 
variance with ANOVA and MANOVA designs. (Cui & Awa, 1992; Gim, Atkinson, 
&Kim, 1991; Martin, 1987; Napholz, 1999; Pope-Davis eta!., 1994; Rogers, 
1998; Wade & Bernstein, 1991 ; Wiseman, Hammer & Nushida, 1989). The 
second point I noticed was that almost all of the quantitative studies incorporated 
self-report survey instruments that lent themselves to quantitative analysis. Only a 
few reported studies were structured as a qualitative design (Schilder et al., 2001 ; 
Singleton, 1994; Weaver, 1999), although a few of the quantitative studies also 
sought some qualitative data for analysis (MacPhee, Kreutzer, & Fritz, 1 994; St. Clair 
SMcKenry, 1999). 

Self-Report Scales 

Although the survey instruments varied from researcher-designed to 
standardized, they all measured some attributes of cultural competence. A selected 
few of the more commonly used scales will be discussed below. The Behavioral 
Assessment Scale for Intercultural Communication (BASIC) self-evaluates: Display 
of Respect, Interaction Posture, Orientation to Knowledge, Empathy, Task-Related 
Roles, Relational Roles, Interaction Management, and Tolerance for Ambiguity 
(Koester & Olebe, 1988). A later study by the authors (Olebe & Koester, 1989) 
gave preliminary evidence that the BASIC operates similarly for subjects from 
heterogeneous cultural backgrounds, making it an effective tool to use cross-culturally. 

Another assessment tool used commonly in cultural competence research 
studies is the Multicultural Counseling Awareness Scale (MCAS), form B. 


(Ponterotto et al., 1 994). This is a 45-item self-rating scale developed as a pre-and 

post-test that utilizes a 7-item Likert-type format. Variables consist of: Knowledge 
of multi-cultural issues and skills in relating across cultures and awareness of cultural 
distinctiveness. Knowledge items include the following statements, "I am aware of 
certain counseling skills, techniques, or approaches that are more likely to transcend 
culture and be effective with any client" while an item from the awareness section is 
"I feel that different socioeconomic status backgrounds of counselor and client may 
serve as an initial barrier to effective cross-cultural counseling" (Pope-Davis & Dings, 
1 994). A recent analysis by Boyle et al. (1 999) indicates that the MCAS:B "is an 
efficient instrument with satisfactory internal consistency" (p. 208). 

Pope-Davis and Dings (1 994) performed an empirical comparison of the 
earlier version of the MCAS and the Multicultural Counseling Inventory (MCI) by 
Sodowsky, Taffe, Gutkin, and Wise (1994). The MCI is a 40-item inventory 
developed to measure self-reported cultural competency in the four sub scale areas 
of: multicultural counseling skills, knowledge, awareness, and relationship. An item 
from the skills subtest is "When working with minority clients, I am able to quickly 
recognize and recoverfrom cultural mistakes or misunderstandings." A knowledge 
item includes "When working with minority clients, I apply the sociopolitical history of 
the clients' respective minority groups to understand them better." In the awareness 
sub scale one finds the item "I am involved in advocacy efforts against institutional 
barriers in mental health services for minority clients." And a relationship 
question Is "When working with minority clients, I perceive that my race causes clients 
to mistrust me" (Pope-Davis & Dings, 1994, p. 96). After an extensive 
comparative analysis, Pope-Davis and Dings report that the simplest way to 
explain the difference between the two, is that the MCI focuses on behaviors, 
whereas the MCAS focuses on beliefs, (p. 100). They go on to say that behaviors 
seem to be more appropriate for self-report than do beliefs, and therefore, the MCI 
may in some ways be a more accurate self- assessment. 

Most of the self-report scales used in these studies have multiple questions 
that attempt to identify and assess the attributes of cultural competency. Many 


provide an opportunity to grade the responses througli tlie use of Likert scales. 

Several authors (Cauce, Coronado, & Watson, 1998; Pope-Davis et al., 1994, p. 
33) identified some of the limitations of self-report measures as: participants 
selecting responses that they thought were more socially desirable rather than being 
entirely honest, participants assessing anticipated rather than actual behaviors, and 
participants interpreting items differently than intended. Sue (1996) identified four 
separate limitations as "(a) The instruments may measure "anticipated" ratherthan 
actual behaviors or attitudes correlated with MCT [multicultural counseling and 
therapy] competence, (b) they are prone to social desirability, (c) the conceptual 
foundations of the instrument may not match that of the training program, and (d) we 
cannot be certain as to what the instruments truly measure" (p. 281 ). 

Although these lim itations are important considerations, another concern that I 
have with self-report surveys is that they often do not allow the respondent to 
answer the questions in her own voice and words, maybe because that kind of data 
is too difficult to quantify. Therefore, these so called "self-report" surveys do not 
actually seek a respondent's personal thoughts and ideas about cultural 
competency; rather, they ask a research participant to respond to the thoughts and 
ideas (regarding cultural competent attributes) of the authors of the survey. I believe 
this is a significant missing component in the current research. What might we 
discover if we examine cultural competency in another way, using qualitative analysis 
forfresh comprehension? 

A Look at Qualitative Research and Wtiat it Offers 

What is it that qualitative research might accomplish that differs from 
quantitative? What kinds of questions can be answered with a qualitative approach? 
And how could this apply to research on cultural competence? Before answering 
these questions about what qualitative research does, one has to understand what 
qualitative research is. 

According to Creswell (1998), "Qualitative research is an inquiry process of 


understanding based on distinct metliodological traditions of inquiry that explore a 

social or human problem. The researcher builds a complex, holistic picture, analyzes 
words, reports detailed views of informants, and conducts the study in a natural 
setting" (p. 1 5). The components that make up qualitative inquiry identified in the 
above statement, define what differentiate this approach from quantitative analysis. 
While both attempt to understand social or human problems, quantitative 
methodologies tend to look at the "why" of it, while a qualitative approach looks at 
the "what" or "how." Quantitative questions look for comparison of groups and 
studies the variance of different factors, as the majority of the studies reported in this 
paper do, while the questions in a qualitative study result in rich descriptions of what 
is going on and how it is understood by the actors. Creswell (1998, p. 15) suggests 
that "quantitative researchers work with a few variables and many cases, whereas 
qualitative researchers rely on a few cases and many variables. " 

The advantages of a quantitative approach is that one can "measure the 
reactions of a great many people to a limited set of questions, thus facilitating 
comparison and statistical aggregation of the data" (Patton, 1990, p. 14). This 
approach also allows for greater generalization of the results. My concerns with this, 
however, and with the majority of the studies discussed in this paper, are that (a) the 
reactions of the respondents to the survey questions, are just that - reactions to an 
external stimulus, and (b) the words, ideas, and concepts in those surveys do not 
come from the respondents themselves, and in most cases it disallows them an 
opportunity to express themselves in their own voices. One doesn't learn how the 
respondents understand or personally view the phenomena. The researcher only 
gets a general view of how the participants respond to someone else's questions - 
questions which may not even be the most relevant ones to them, the participants.. 
In contrast, a qualitative study may be more exploratory in nature, giving a more in 
depth perception of the phenomenon (Creswell, 1 998). Silverman (in Coffey & 
Atkinson, 1 996, p.5) states that qualitative analysis is distinct in that it is "centrally 
concerned with avoiding a 'social problem' perspective by asking how principals 
attach meaningsto their activities and 'problems.' " 


This is what is so compelling about qualitative analysis. It explores and finds 

meaning related to a topic, rather than just describing and comparing as is done in 
quantitative studies. Maxwell (1 996) states that meaning is central in interpretive 
approaches to social science research, and the importance of a qualitative study is 
that "you are interested not only in the physical events and behavior that is taking 
place, but also in how the participants in your study make sense of this and how their 
understandings influence their behavior" (p. 1 7). Trying to determine how 
occupational therapy students 'make sense' of the concept of cultural competence is 
a compelling idea for me. 

The 'face-to-face' process through personal interviews, typical of qualitative 
studies "adds depth, detail, and meaning at a very personal level of experience" 
(Patton, 1990, p. 18). At its best it "permit(s) one to understand the world as 
reported by the respondents" and "enable(s) the researcher to understand and 
capture the points of view of other people without predetermining those points of 
view through prior selection of questionnaire categories" (p. 24). This is another 
strength of qualitative analysis and is what has been missing heretofore in the studies 
of cultural competence. Others have compiled lists of attributes and asked people 
to respond to them, but few studies have asked what cultural competence means in 
a way that allows the respondent to discuss her own perspective. 

At its worst, this face-to-face quality of qualitative inquiry sometimes is the 
basis for its most common problems. Glesne and Peshkin (1 992) identify the issues 
that 'entwined lives' can raise. These personal interactions "necessitate the 
discussion of rapport, subjectivity, and certain ethical issues" (p.xi). It changes how 
we approach and refer to the people we want to learn about. It causes the 
researcher to question and reflect on her own beliefs and biases, and how those 
may influence the interaction between the researcher and the researched. In many 
ways, the face-to-face interaction not only personalizes the qualitative study, it also 
complicates it. 

Another unique feature of qualitative inquiry is that it occurs in the participant's 
natural environment. By interviewing and/or observing people within their own 


environmental context one has the opportunity to examine a 'lived life.' Creswell 

(1998) believes that if "participants are removed from their setting, it leads to 
contrived findings that are out of context" (p. 1 7). A questionnaire, or survey, such 
as those used in the quantitative studies reported above, generally does not 
consider the context of the respondent's life. Responses are static, lifeless, and 
easily objectified and enumerated. There is no opportunity to question the 
respondent further in order to clarify a point or embellish an answer. Nor can the 
researcher evaluate the influence of the respondent's environmental context on her 
responses and the respondent cannot respond in her own voice! Although more 
easily statistically analyzed, quantitative data lack the richness and depth of qualitative 

The data one derives from a qualitative study, regardless of the type or 
tradition (Creswell, 1998) of research design, are words, not numbers. "Words, 
especially organized into incidents or stories, have a concrete, vivid, meaningful 
flavor that often proves far more convincing to a reader - another researcher, a policy 
maker, a practitioner - than pages of summarized numbers" (Miles & Huberman, 
1 994, p. 1 ). However, the richness of the data is another source of the complexity 
Inherent in qualitative inquiry. The role of the qualitative researcher Is to make sense 
of the data and the ways they intersect, to "interpret how the various participants in a 
social setting construct the world around them" (Glesne & Peshkin, 1 992, p.6). 
"Qualitative researchers avoid simplifying social phenomena and instead explore the 
range of behavior and expand their understanding of the resulting interactions. 
Throughout the research process, they assume that social interaction is complex and 
that they will uncover some of that complexity" (p.7). Analyzing qualitative data is an 
open, emergent process which allows for discovery of new ideas and perspectives. 
It allows for the negotiation of a shared understanding between the researcher and 
the research subject. Because of this openness and lack of standardization (which is 
more readily seen in a quantitative study), it may also lead to ambiguity (Glesne & 
Peshkin, 1 992). It takes a certain kind of researcher to be able to tolerate the 
'messiness' of qualitative data and analysis. 


"In qualitative inquiry, the researcher is the instrument Validity in qualitative 

methods, therefore, hinges to a great extent on the skills, competence, and rigor of 
the person doing fieldwork" (Patton, 1990, p. 14). A qualitative researcher must see 
her role as an "active learner who can tell the story from the participants' view rather 
than as an "expert" who passes judgment on participants" (Creswell, 1998, p. 18). 
She must be committed to spending time with the participants, and be willing to 
engage in hard and rigorous analysis to effectively make sense of the data. 

Although some researchers believe that the research question determines 
the research design, Glesne and Peshkin (1 992) believe that it is more related to the 
personality of the researcher and that "people tend to adhere to the methodology 
that is most consonant with their socialized worldvlew" (p.9). They cite Schwandt 
who states that, "We conduct inquiry via a particular paradigm because it embodies 
assumptions about the world that we believe and values that we hold, and because 
we hold those assumptions and values we conduct inquiry according to the 
precepts of that paradigm" (Glesne & Peshkin, 1992, p. 9). 

As a researcher, my personality and world view seem more compatible with 
qualitative inquiry. Additionally, the research question that I am examining, how do 
occupational therapy students experience and understand the concepts of cultural 
competence and culturally competent care, is better addressed using a qualitative 


Cultural competence is a concept that is increasingly written about within the 
literature of the various health professions. This literature review has examined the 
meaning and attributes of cultural competence from the professions of nursing, social 
work, counseling psychology and occupational therapy. It has also reviewed 
educational models presented by the professions, and the outcome research that 
examines the effectiveness of those models. Although health professions 
education programs teach about culture and diversity, research that examines 


aspects of cultural competence and culturally competent care is effectively limited. 

What is most commonly reported are quasi-experimental, empirical designs that 
examine research participants' (students or practitioners) views of cultural competent 
attributes through the use of self-report surveys. One premise of this chapter is that 
qualitative analysis would be a more effective approach to examine the meaning of 
cultural competence and culturally competent care to the occupational therapy 
student. As we begin to understand how students think about this concept, 
educators can more effectively teach about it in our classrooms and clinics. In the 
final analysis, those who will benefit from this greater understanding will be the clients 
and the practitioners who work with them . 

Therefore, the purpose of this study is to examine (through 
phenomenological methodology) how occupational therapy students "voice" their 
understanding, definition, and meaning of theconceptsof cultural competence and 
culturally competent care in their last year of occupational therapy study. 



Conceptual Framework of the Model 

This dissertation study will examine how occupational therapy students 
"voice" their understanding, definition, and interpretation of their experiences with 
culturally competent interactions and care. Intheliterature, cultural competence has 
been defined as "an ability by health care providers and health care organizations to 
understand and respond effectively to the cultural and linguistic needs brought by 
patients to the health care encounter" (Cross Cultural Health Care Center, 1 995). 
The intent of this study is to listen carefully to the specific language and words used 
by students in order to understand the essential nature of cultural competence to the 
participants at the end of their academic experiences as occupational therapy 

As the researcher, I am particularly interested in hearing the students' own 
words on the subject - hearing their voices. The term voice is defined as "the power 
of speaking or the right of expression" (Merriam-Webster, 1 995, p.586). Gilligan 
(1993) defines voice as follows: 

... I mean something like what people mean when they speak of the 
core of the self. Voice is natural and also cultural. It is composed of 
breath and sound, words, rhythm, and language, (pxvi). 
Listening carefully to the "breath and sound, words, rhythm, and language" 
participants use as they describe their experiences is an intentional and Important 
aspect of this study. Many other examinations of cultural competence in the literature 
(Cui & Awa, 1992; Martin, 1987; Rogers, 1998) use self-report surveys on which 
participants respond to language (about cultural competence) chosen by someone 
else (the authors of the surveys). Within these surveys, participants rarely have the 
opportunity to talk about cultural competence in their own words. Because voice 


reflects one's cultural position in society (Gilligan, 1 993), and because the focusof 

the study is on cultural competence, this researcher believes that it is important to 
examine the manner in which the respondents give voice to their experiences with, 
and understand the meaning of the phenomenaof cultural competence and culturally 
competent care. 

Phenomenology and Voice 

Phenomenological research is one tradition or approach found within the 
broader category of qualitative inquiry (Creswell, 1 998). Although qualitative and 
quantitative research both are methods of inquiry that are used to explore social or 
human problems, they differ in several important ways. Quantitative research is 
deductive, while qualitative is inductive; quantitative research can be used with large 
numbers of subjects selected randomly, and therefore the results are 
general izeable, whereas qualitative research usually involves a much smaller number 
of participants, gaining insight into their personal responses to an issue or event; 
quantitative analysis involvesthe use of statistics, reporting results in numerical form, 
while qualitative analysis uses words as data, reporting results in long narratives; 
quantitative research is objective and sometimes sterile, with the researcher often not 
having to interact with his or her subjects in any personal way, whereas qualitative 
research is much more subjective, where the researcher usually interacts with the 
research participants in aface-to-f ace manner in the participant's natural environment 
(Bailey, 1997; Creswell 1994, 1998). 

If a researcher has a question or topic that she knows will require personal 
interaction with participants in their own (natural) environment, then she will most often 
choose a qualitative method of inquiry. The question then becomes, which method 
is appropriate for the study? There are many to choose from. Creswell (1 998) 
identifies five separate traditions of qualitative analysis, and thoroughly describes 
their separate and distinct methodologies. There are many similarities between the 
five approaches; biography, grounded theory, phenomenology, ethnography, and 


the case study, but the differences between them determine the choice of inquiry. 

As one reviews Creswell's comparative chart (1 998, p. 65) in his appendix I, one 
sees that, although phenomenology uses interviews as data collection as do the 
majority of the other research traditions, the focus, the discipline origin, the data 
analysis and the narrative form differ from those of the other methodological 

Phenomenology is the only approach in this group that is used to 
"understand the essence of experiences about a phenomenon" (Creswell, 1998, p. 
65) by examining the meaning of that experience for each individual interviewed. 
Cohen, Kahn, and Steeves (2000) state that "the . . . phenomenologist will study 
how people interpret their lives and make meaning of what they experience" (p. 5). 
They and others identify phenomenology as the "study of lived experience" 
(Cohen, et al., 2000, p. 1 ; van Manen,1990). Language is an important aspect of 
"voice" and phenomenologists believe language is significant. "The meaning of 
words is important to think about because language is a primary way we express 
our meanings" (Cohen etal., 2000, p. 10). By carefully listening to a research 
participant's narrative story regarding the phenomenon in question, the researcher 
truly has the opportunity to hear her "voice" as described by Gilligan (1 993). 

Phenomenology is derived from the discipline of philosophy, and the 
philosopher Hegel ( as reported in Moustakas, 1994) referred to it as "knowledge 
as it appears to consciousness, the science of describing what one perceives, 
senses, and knows in one's immediate awareness and experience" (p. 26). This 
definition seems to underscore the same depth of understanding as Gilligan's "core 
ofthe self" (1993, p. xvi). 

Moustakas (1 994) identifies several principles, processes and methods 
identified with phenomenology. These include, but are not limited to the following 


* seeks meanings from appearances of things and arrives at essences 


* is concerned with wlioleness 

* is committed to descriptions of experiences, not explanations or analyses 

* is rooted in questions that give a direction and focus to meaning (58 & 59). 
These statements resonate with what I am seeking in my doctoral research. 

Because I am interested in how occupational therapy students understand and make 
meaning of their experiences with culturally competent interactions and culturally 
competent care, a phenomenological approach seems an excellent methodological 
match for my study. 


Preparation for the Study 

Writing the Prospectus/Proposal 

For the purposes of this paper, the terms proposal and prospectus will be 
used interchangeably. The prospectus for the study, along with a consent form 
(Appendix A) designed to meet the requirements of federal guidelines, was written 
and sent to the University's Institutional Review Board (IRB). After a second 
rewrite to more closely meet institutional guidelines, it was accepted by the review 
board. The frustration of having to rewrite gave me a greater understanding of 
Seidman's (1 991 ) concept of "rite of passage." 

The Pilot Study 

I decided to carry out an initial pilot study in order to familiarize myself with and 
practice doing phenomenological research. I also used the responses and feedback 
from the pilot to revise my protocol and interview questions. Glesne and Peshkin 
(1 992) state, "A pilot study can test many aspects of your proposed research. It 
does so under circumstances that don't count, so that when they do count, you can 


put your best foot forward" (p.30). This was essentially my aim in doing a pilot 


Determining the Sites and Participants 

Phenomenological research is the study of a person's lived experience 
(Creswell, 1998; vanManen, 1990). According to Creswell, its purpose is "to 
determine what an experience means for the persons who have had the experience 
and are able to provide a comprehensive description of it" (p. 53). Each person 
interviewed has to have experienced the phenomenon in order to be part of the 
study. Therefore, the researcher must identify the phenomenon or experience that 
she wants to study, and then select research participants who have had that 
experience. Patton (1 990) describes this as purposeful sampling . He states, " The 
logic and power of purposeful sampling lies in selecting information-rich cases 
[author's italics] for study in depth" (p. 1 69). Because each occupational therapy 
education program must address issues of culture anddiversityintheircurriculum, I 
assumed that each student would know something about cultural competence. I also 
assumed that students from an urban area, where there is usually a greater 
percentage of people from diverse groups, would have had experiences that they 
could identify as being culturally competent or culturally incompetent. Students in 
their final year of occupational therapy study also have had multiple fieldwork 
experiences where they may have observed or been part of culturally competent 

The goal for the pilot study was to test out the methodology rather than the 
inquiry question. 1 had not carried out a phenomenology study in any of my 
academic courses on qualitative research, and I wanted the practice with somewhat 
limited data before attempting to do the dissertation study analysis. Given this 
rationale, coupled with the external time constraints I was working under, I decided 
that I would work with a small sample of convenience selected from the class of 
second-year students from my own program. I was aware of the power issues that 


Seidman (1991) warned about, but I believed that because I was more interested 

in the process than the content, the interviews would not be compromised by my 
relationship with the students. Additionally, I had not taught these students a class in 
the last two semesters, so there was not an ongoing teacher/student relationship. 
Three students signed consent forms and volunteered for the pilot study. After a 
mix-up with a transcriptionist who became ill, one audio tape of one of these 
interviews was never returned, which limited my study to two participants. One 
participant is a 26-year-old man born in India who immigrated to this country when he 
was eight years old. The second participant is a 51 -year-old White woman. 

For the dissertation study, I chose not to interview students from the 
program that I direct. Glesne and Peshkin (1 992) warn that it is "not advisable to 
conduct your study in your own backyard - within your own institution or agency, or 
among friends or colleagues" (p.21 ). They go on to cite the confusion and 
sometimes the political and ethical dilemmas that may arise from trying to assume a 
new role (objective researcher) in a setting within which you already have 
established relationships and multiple familiar roles. Seidman (1 991 ) warns about 
the "perils of easy access" and particularly speaks about the difficulty of a faculty 
member obtaining full responses from students that she teaches. He believes that 
the power differential would cause students to more closely monitor their replies. 


Using a criterion sample (Creswell, 1998), occupational therapy students in 
their last year of academic study in two urban universities in the Northeast section of 
the United States were recruited to participate in the study. The universities were 
selected based on their strong academic reputations, the required multicultural 
contentintheircurricula, and theirgeographical proximity to the researcher. 

A key faculty member from one university and a department chair from the 
other were contacted to seek permission for students' participation in the study. 
Upon receipt of this permission, a cover letter (Appendix B) and consent form 


(Appendix A) were sent to all second year master's level occupational therapy 

students from both programs via the faculty. Twelve students were randomly 
selected from those who responded. The number twelve was chosen because 
Dukes (as cited in Creswell, 1 998) recommends studying three to ten subjects in a 
phenomenological study and Creswell agrees that ten is a reasonable sample size. 
As he points out, "The important point is to describe the meaning of a small number 
of individuals who have experienced the phenomenon" (Creswell, 1998, p. 122). I 
chose twelve in case of attrition. Scheduling the interviews was done via email and 
telephone at which time I also described the study and asked the students to think 
about the concept of cultural competence and their experience with it. 

All participants (1 00%) identified themselves as Caucasian or White, 
although one woman specified that she was Jewish/Caucasian. All are female and 
they range in age from 23 to 39 years, with a mean age of 27.7 and a median age of 
25.5. Eight participants are in their twenties and four are in their thirties. One hundred 
percent of the participants have spent time with people who are culturally different 
from themselves, and four (33%) have lived in a country outside the United States. 
All participants indicated that they have studied multicultural ism /diversity in college in 
the following ways: 





Specific Course 






Guest Spealcers 


Infusion through curriculum 


Field Visits 


* several participants indicated more than one category. 

Data Collection 

After making arrangements to meet the twelve students at their university at a 
time and place convenient to them, an in-depth, semi-structured interview 
(Appendix B) was completed during the last semester of their academic program. 
There are numerous ways to conduct phenomenological research, although every 
author in the literature agrees that the majority of the data collection is through 
interviewing. Creswell (1998) states that the researcher should do "long interviews 
with up to 1 people" (p. 65). Others agree that a "long" interview is the preferred 
methodology (Moustakas 1 994) in order to elicit the personal narratives related to 
the phenomenon in question. The purpose of the interview is that of learning about 
the meaning of the lived experience of each participant, how each person 
understands and perceives the phenomenon they have undergone. 

Given the information from the literature above, I chose to do one long 
interview with each student participant. Interviews were from 60 minutes to 75 
minutes in length. With permission from each participant, the interviews were 
audiotaped to ensure accuracy and later transcribed for analysis. Additionally, 
participants were asked to fill out a short questionnaire that gathered demographic 
data such as age, gender, ethnicity, and experience with diverse groups of people 
(Appendix C). The term culture was defined on the questionnaire so that each 
participant would have the same understanding of the term. The questionnaire also 
asked if and in what ways they had studied multiculturalism/diversity in college. This 
data provided pertinent information that may not be gleaned from the interviews. 

Descriptive and reflective field notes (Glesne & Peshkin, 1 992) were taken 
during and following each interview and included specific observations of the 
participant, the setting and the process. These notes and the data used from the 
questionnaires are included asameansof triangulation to increase the 
"trustworthiness" of the data and analysis (Glesne & Peshkin, p. 24). 


Method of Analysis 

The goal of analysis Is "athick description that accurately captures and 
communicates the meaning of the lived experience for the informants being studied. 
A thick description is one that captures the experience from the perspective of the 
informant in its fullest and richest complexity" (Cohen et al., 2000. p. 72; Geertz, 

In order to accomplish this goal, the researcher must follow several clearly 
defined steps as part of the analysis. According to Creswell (1 998) and Moustakas 
(1 994), most phenomenologists follow the same procedure for analysis.. Using the 
complete transcription of each participant, these steps include the following : 

1 . Listing and preliminary grouping - horizonalization 

2. Reduction and elimination 

3. Clustering and thematizing 

4. Constructing an individual textual description of the experience for each 


5. Constructing an individual structural description of the experience for each 


6. Constructing a composite textual description of the experience 

7. Developing a textual-structural synthesis o1 the meanings and essences 

of the experience, representing the group as a whole 


The first step of phenomenological data analysis occurs by reading the 
transcripts several times, a process sometimes referred to as "immersing oneself in 
the data" (Cohen, et al. 2000, p. 76). This is important in order for the researcher to 
understand and identify the essential characteristics of the data from each 
interviewee. In horizonalization, the researcher makes herself receptive to the 
data in a way that recognizes that each statement holds equal value. Therefore, all 


statements relevant to the question/experience are identified as meaningful. 

Reduction and Elimination 

The reduction and elimination phase is completed to determine the 
invariant constituents. "The invariant horizons point to the unique qualities of an 
experience, those that stand out" (Moustakas 1 994, p. 1 28). He identifies two 
requirements that help to evaluate each horizonalized expression. The researcher 
must ask: 

1 . "Does it contain a moment of the experience that is a necessary and sufficient 

constituent for understanding it?" and 

2. "Is it possible to abstract and label it? If so, it is a horizon of the experience" 
(p. 121). 

If a statement does not meet these two requirements, it is eliminated during 
this phase. Additionally, overlapping, repetitive, and vague expressions are 
dropped at this time. The horizons, or statements that remain, are considered "the 
invariant constituents of the experience" (Moustakas, 1994, p. 121). 

Clustering and Thematizing 

Clustering and thematizing is the next step in reducing and organizing the 
data. The "thematic portrayals of the experience" represent "distinctive processes 
inherent" in aculturallycompetent interaction (Moustakas, 1994, pp. 131-132). 
Seidman (1991) included a three-page section in his book on "Making Thematic 
Connections" (pp. 99-1 01 ). Within this section he talks about organizing excerpts of 
the transcripted data into categories. "The researcher then searches for patterns and 
connections among the excerpts within those categories and for connections 
between the various categories that might be called themes" (p. 99). 


Individual Textural Description 

Although I found myself wanting to move directly to a comparison analysis, in 
an effort to stay true to the process outlined by Moustakas (1 994), I turned to the 
next step of phenomenologlcal process, constructing an individual textural 
description of the experience for each participant from the themes that had been 
Identified. Creswell (1 998) identifies this step as an opportunity to describe what 
was experienced. 

Individual Structural Description 

Following the step above, I completed an individual structural 
description of the experience for each participant. This step describes how the 
phenomenon was experienced by the participant (Creswell, 1 998). It "provides a 
vivid account of the underlying dynamics of the experience, the themes and qualities 
that accountfor "how" feelings and thoughts connected to [cultural competency] are 
aroused, what conditions evoke [culturally competent Interactions]" (Moustakas, 
1 994, p. 1 35). This is the place within the analysis where the researcher uses 
"imaginative variation, reflection, and analysis beyond the appearance and into the 
real meanings or essences of the experience" (Copen as quoted in Moustakas, 
1 994, p. 1 35). It is where the researcher can plumb the depths of the meaning of 
this experience for the participant. 

Composite Textural and Structural Descriptions 

From the total group of individual textural descriptions, I then developed a 
composite textural description. This is where I examined the meanings and 
themes of each participant and combined them to depict the experiences of the 
group as a whole. Likewise, I followed this step by developing a composite 
structural description. This description "is a way of understanding how the co- 


researchers [participants] as a group experience what they experience" 

(Moustakas, 1994, p. 142). 

Textural-Structural Synthesis 

The final stage of analysis outlined by Moustakas (1994) is the 
development of the textual-structural synthesis. I integrated the composite 
descriptions above to develop a synthesis of the meanings and essence of the 
experience, reflecting the voices of the group as a whole. Examples of this process 
and the analysis of the findings are included in the next chapter. 

Critique of the Research Methodology 

Although this critique is not chronologically placed within the sequence of the 
dissertation study, I chose to incorporate it here in chapter three because it speaks 
specifically of the methodology and my experience with it. 

Phenomenology appeared to be the appropriate research approach to use 
for this study given the fact that I wanted to examine students' perceptions and 
experiences of cultural competence by listening closely to their 'voices' or words. I 
initially knew little about phenomenology, but after reading about it in several books 
(Cohen et al. 2000; Creswell, 1998; Moustakas, 1994; Seidman, 1991 ; van 
Manen, 1 990) I chose Moustakas' guidelines because they seemed more clearly 
defined than anything else I had read. Phenomenological methodology arose from 
philosophical thought and I found much of the literature about it quite dense and 

A positive aspect about analyzing the data with this method, was that it 
accomplished the goal of being true to the words of the participants. By going 
through the multiple steps of Moustakas' outline, I was made aware of constantly 
grounding my findings in the data, of not imposing my own interpretations beyond 
what the words of the participants indicated. I found myself often returning to the 


transcripted words from the interviews, assuring that I was representing the ideas and 

perceptions of the participants as accurately as possible. I was also aware of trying 
to maintain the epoche of phenomenology. Moustakas (1 994) describes this as 
"setting aside prejudgments and [maintaining] an unbiased, receptive presence" (p. 
1 80) with the participants and the data. This is done in an effort to "enter the world of 
the unique individual being studied. The aim is to try to see the world from another's 
point of view" (Finlay, 1999, p. 302). 

I found this difficult at times, and wondered how much my own knowledge 
about cultural competence, and my hopes for and expectations of the student 
responses influenced my interviews and my data analysis. Although I believe it is 
impossible to maintain a totally objective and non influential stance during qualitative 
research, this methodology made me aware of the importance of trying to do just 
that. That awareness resulted in a dynamic interaction between the process of data 
analysis, and my self-reflection of trying to maintain an objective and impartial stance. 
It sometimes felt as though I was walking a tightrope. Each time I became aware of 
dipping into my own assumptions, my balance was compromised, and I became 
acutely aware of trying to regain the ability to move fonward without peril. For 
example, as I was examining the concept of awareness, I found myself moving 
some of the phrases from the participants' transcripts into the wrong cluster (of self- 
awareness) during the thematic analysis. When I realized I was manipulating the data 
based on my expectations and what I knew from the literature, I made a concerted 
effort to begin again with a more open awareness that would allow the data to fall into 
more natural clusters rather than those that I was looking for. 

Additionally, I do believe that Moustakas' phenomenology led to a true 
examination of how students perceive and experience cultural competence and 
culturally competent care. Because I was not imposing my own words and ideas 
on the participants, but listening well and helping them develop their ideas by using 
follow up questions, I was able to draw out their perceptions in their own words and 
expressions. The analytic process caused me to continually return to their words in 
an attempt to stay true to their meaning. As a result, I believe I found a deeper 


understanding of their experience througli this process. 

However, I found the methodology quite tedious at times. I was determined 
to follow Moustakas' (1 994) guidelines, and forced myself to perform each step of 
analysis as outlined. It was difficult to differentiate between textural and structural 
descriptions sometimes, and I found that separating the analysis into those 
categories was rather arbitrary and somewhat limiting. Although doing the thematic 
analysis was enjoyable and exciting, reminding me of a grounded theory approach, 
constantly remembering to separate the words and what they said (textural analysis) 
from the meaning of those words (structural analysis) seemed to limit any kind of 
creative thematizing. Perhaps that is the purpose of this approach, and is what 
keeps the analysis so grounded in the words of the participants. This way the 
"essence" of the phenomena is truly derived from them and not from the researcher. 

I also realized that the purpose of this methodology is not to develop theory 
as in grounded theory research, but rather to define what exists from the minds and 
perceptions of the participants. Phenomenology examines and reports the meaning 
of the lived experience (van Manen, 1 990) of a group of people rather than 
attempting to create new ideas based on the analysis of people's thoughts or 
experiences. Because it was important to me to listen to the voices and words of 
the students as they articulated their understanding of cultural competence and 
culturally competent care, this approach better met my goals than another such as 
grounded theory. 

Is this, then, a research methodology that is effective for occupational therapy 
research? In general, I would say yes. Using phenomenology to examine the 
meaning and essence of an aspect of life matches the goal of the occupational 
therapist who is interested in understanding the meaning clients ascribe to life 
activities and roles. The study of occupation is an analysis of the person, his or her 
environment and the activities (occupations) that are meaningful to that person 
(Christiansen & Baum, 1 997; Law et al., 1 996). Phenomenology offers a research 
approach that can help occupational therapists examine the personal meaning 
inherent in the activities that people choose to engage in. 


Finlay (1 999) summarized occupational therapy researcii where the 

investigators used a phenomenological approach. She recognizes it as a viable 
research methodology for the health professions because it helps to "articulate 
important messages about individuals' unique experiences" (p. 300). Finlay also 
discusses the problems with using phenomenology, however. After citing 
prominent occupational therapy researchers who have completed 
phenomenological research studies, Finlay states, 

While the authors cited above show an easy familiarity in terms of applying 
phenomenological methodology, they rarely offer sufficient details of their 
actual method. Then there are other authors who do not demonstrate this 
familiarity in the first place. They assert that they are applying 
phenomenology whereas in reality they are simply using a generalized 
qualitative approach (p. 300). 

I have also recognized this lack of clarity in articles that I have read and 
reviewed for a national journal of occupational therapy. The complexity of the 
process contributes to the difficulty in describing the methodology. I have 
experienced this myself as I carefully attempted to follow Moustakas' guidelines. I 
found myself wanting to skip some steps in his process when they became 
repetitious and somewhat tedious, but forced myself to continue as I wanted to stay 
true to the methodology. As a result of the repetition, the description of the process 
became somewhat redundant as well. It is, therefore, understandable that 
researchers do not carefully describe in detail all of the steps of phenomenological 

Although I believe phenomenology as a method has merit for occupational 
therapy and other health fields' research, the complexity of Moustakas' methods is a 
barrier to the process. Could one simplify the process and still examine the 
essence of life's experiences of study participants? If this were possible, would the 
researcher accurately be using a phenomenological approach, or would the process 
became a more generalized qualitative approach as stated above? I do value the 
process I followed for this study, but I tend to agree with Finlay's (1 999) conclusion. 


"With all its depth, richness and unquantifiable forms, phenomenology can never be 

an easy research option" (p. 305). 



Data analysis was completed as described in chapter three. I carefully read 
each transcript and identified each salient statement (horizonalization). I then went 
through each of the statements and eliminated those that did not apply to the 
research question (reduction). The remaining statements were then chunked into 
similar categories, which were then examined for underlying themes. Individual 
textual descriptions were constructed from the themes identified in each transcript, 
and further analysis was done to construct individual structural descriptionsf or each 
participant's experience. As suggested by Moustakas (1994, p. 184), this chapter 
will provide (two) examples each of individual textural descriptions and individual 
structural descriptions. The majority of the chapter will focus on the them atic analysis 
that I engaged in to develop the composite textural description. This will be 
followed by the composite structural description and the synthesis of the "meanings 
and essences of the experience" (p. 184). 

Individual Textural Descriptions 

An individual textural description of the nature and focus of cultural 
competence and culturally competent care was constructed from the themes and 
horizons of each participant's experience (Moustakas, 1 994). These descriptions 
identify what the person's experience was. The following selections present the 
experiences of LF. and J.M. 

L.F. Participant #1 
Individual Textural Description 

LF describes her perception of the phenomenon of cultural competence and 


what characteristics are essential to it. She views it as a linear, developmental 


/ think cultural sensitivity leads to more knowledge and then leads to 

cultural competence. 
She later added to this formula that cultural competence results in a deeper 
understanding between people and groups who are different from one another than 
does sensitivity. 

For LF, the most important characteristic of cultural competence Is sensitivity, 
which holds a place of primacy in her equation. Cultural knowledge is also an 
important characteristic, but, according to LF, knowledge itself does not make 
someone competent unless that person also possesses sensitivity. In fact, if you 
only hold one of these characteristics, it would be more important for you to be 
sensitive and aware than to just be knowledgeable. 

If you're sensitive without the knowledge, I think that is more important 

than having the knowledge, 'cause you can obtain the knowledge if 

you have to. 

Sensitivity includes both self-awareness, and an empathetic awareness of 
others and what they have experienced, according to LF. She believes that self 
awareness includes recognizing that you don't know something, that you need to do 
something about it, and having a sense of why you should do something. 
Awareness of and sensitivity to others includes knowing that differences occur and 
are important, and having the ability to see the world through another's eyes. It 
makes you realize the need to learn more in order to be more skilled in cross-cultural 
interactions. LF believes that this sensitivity will actually push people to seek out 
and gain more knowledge. 

The kind of knowledge one must seek to be culturally competent ranges from 
knowing (at least a little) the language of another person, understanding the meaning 
of family and their culture as they describe it, and what is important to another 
person. Knowing about differences is important. One way to gain this knowledge is 
by personal interactions with people who differ from yourself and asking genuine 


questions. Another method is to educate yourself by reading or studying about 

others. Gaining l<nowledge is an active process for LF, but knowing doesn't 
necessarily lead to effective behaviors. 

[It's] hard to know what to do. . . I mean if you have an idea it's hard to 

orchestrate it. 

LF identified several behavioral strategies that support cultural competence, 
most of which relate to communication skills. Trying to speak the language of 
someone who is different, talking together to confront differences and getting to know 
people as individuals are high on LF's list of communication skills. Her main 
emphasis was just to try. She stated that being open-minded and just trying to 
communicate was being culturally competent. LF believes that doing something is 
more culturally competentthan doing nothing or ignoring differences. She believes 
that taking responsibility to do something is an important trait. 

There are also important behaviors that one must not engage in if attempting 
to be culturally competent. This includes judging people, avoiding or ignoring 
people who are different, refusing to engage with others, or not making the effort. 
This list emphasizes LF's belief that taking action is a vital aspect of acting culturally 

Finally, as we move towards cultural competence by possessing all the 
above characteristics and actively engaging with people who differ from ourselves, 
LF believes that true understanding will occur. She defines this as a depth of 
awareness that moves toward empathy. In her words, it is really understanding, not 
just a superficial recognition of one another. She also believes that a feeling of 
happiness, and a sense of closeness and appreciation will also accompany true 
understanding and be part of the outcome of effective culturally competent 

In the next example of an Individual Textural Description, J.M. describes the 
meaning of cultural competence in a somewhat different way than did L. F. 

JM: Participant #3 

Individual Texturai Description 

JMs experience in cross-cultural situations have ranged from those she 
describes as culturally incompetent to culturally fluent. She identified a 
developmental process that occurs as people learn to interact with one another that 
incorporates Incremental skills and behaviors. The levels begin with cultural 
sensitivity and then move to cultural competency and then, for some, to cultural 

A person who is culturally sensitive has an awareness of self and others, 
and recognizes and challenges her own assumptions. For JM, a person at this level 
is still pretty ignorant about cultural differences and carries many assumptions or 
stereotypes about people who are different. Cultural sensitivity is the beginning of 
the process. 

. . . Cultural sensitivity, I think, isjust an awareness that there are other 
cultures around. There are differences. And awareness of one's 
ignorance of them and the willingness to seek out what the differences are. 
JM emphasized how ignorant people are initially, and the primacy of 
recognizing this. She described her own process regarding her interaction with an 
African American man who gently confronted her. 

Well, I think first of all, we have to admit that we're ignorant (atx)ut people 
who are different from us and how to interact with them). I think that's 
the first problem. I admit to it freely. I am totally ignorant. .. But in a 
small way he had educated me, at least enlightened me on my ignorance. 
And that is always the first step. 

For JM, self-awareness increases in a manner similar to consciousness raising. 
You realize that you are ignorant, and as a result, you become more aware of the 
differences in people in a way that was not available to you prior to that time. Part 
of that awareness is a recognition of the assumptions that you hold about people 
who are different, and a willingness to let go of those assumptions. JM recognizes 


that this increasing awareness of self and others gives a person more choices about 

how to interact with others. She asserts that we must know more about ourselves 
before we go out to know others. JM also believes that this self-knowledge will 
cause one to seek out more information about other cultures in an effort to try to 
understand them better. This process moves someone into the level of cultural 
competence, according to JM. 

Cultural competence incorporates knowing and understanding about others, 
as well as demonstrating effective skills or behaviors. At this level, people 
understand and can speak one another' s language, and they have a willingness to 
understand others at a basic level. JM refers to this as almost like having a rule 
book. Within that rule book would be information about that person's beliefs and 
value systems, the habits of the people, the norms of the culture, and a knowledge 
of what is accepted and what isn't. It's knowing what people do as part of their daily 
lives, as well as understanding their spiritual and social life. Having this knowledge 
allows people to interact in a competent manner with one another. 

JM emphasizes that interacting is an active process of ongoing exposure. 
She describes it as f/7rusf/ngf yourself out there, and continuing to do so. 

You have to be face to face with the person, and you have to be on 
a daily basis. That's what I mean by exposure. You have to thrust 
yourself in there. 
And if you get rejected 

You try again. You keep going and going because the person who is 
unwilling to learn will not come back. But if you are willing, if you really 
are committed to understanding their culture, you will come back 
So, for JM, the experience of cultural competence is not for the faint hearted. 
It takes commitment to the process and a willingness to put yourself out there, if 
necessary, over and over again. As JM states, it takes time and work. But the 
results are worth it. JM described several culturally competent interactions where 
people worked collaboratively, learned to trust one another, and were welcomed In 
each other's company. There Is a feeling of acceptance and equality as a result of 



During one experience, JIVI was observing at a shelter for homeless women 
in the Boston area, and noticed the way a staff member interacted with a small group 
of Haitian women by speaking French Creole to them. The staff member 
encouraged them to talk as much as they were willing to. . . and was 
really willing to listen (to them). She was welcomed. It seemed like 
she was a trusted person. . . This staff woman went over and sat with 
them as an equal, and they let her join them at the table. I think they 
were maintaining the equality, the feeling of equality, and she was 
accepted as such. 

For JM, being able to work together in a collaborative manner is a major 
reason for becoming culturally competent. In a health care setting this translates into 
timely and effective treatment, and the development of trust between the client and 
the health provider. 

JM identifies another level beyond cultural competence, however, that she 
calls cultural fluency. Not everyone reaches this level of expertise. She sees a 
lot of work between cultural competency and cultural fluency. She bases this on her 
premise that one must have considerable experience in cross-cultural situations in 
order to reach fluency. 

/ think cultural fluency is very much based on experience. I think it 
[helps] to understand the innuendoes, to understand the subtleties, 
and not only that, butlthink the mark of being culturally fluent is to. . . 
when faced with an unexpected situation that crosses cultures, you 're 
able to handle it. 

JM's examples of "unexpected situations" include the arrival of a family from 
an unfamiliar culture who seeks health services, or when an Hispanic family, who 
traditionally takes care of their elderly, chooses not to. Someone who is culturally 
fluent would relate effectively in these situations because she would know how to 
go outside the rule book. She would have an awareness of how to interact with this 
family to gain the needed information for effective communication. 


JM compares this concept to the notion of being fluent in a language. 

Someone can learn a language, but rarely speaks fluently unless spending time with 
a culture that speaks the language. JMs theory of cultural fluency is very similar. 
Someonecan understand another culture and interact in aculturally competent 
manner, but if that person has had a lot of experience within that culture, she could 
become culturally fluent. Some of the characteristics of cultural fluency, according to 
JM are being very comfortable [with] back and forth [interactions], [having] good 
confidence, and the abil[ity] to get through to others. It's knowing how to deal with 
the unexpected in an effective manner because of having a deeper understanding 
of the subtleties of a culture. In some ways, the culturally fluent person as described 
by JM would be almost acculturated into the other culture, having knowledge and 
skills far beyond those found in people who are culturally sensitive, or even culturally 

JM does not see herself at this level yet, nor am I sure that she even 
perceives of herself as culturally competent, but she recognizes people who 
exhibit these characteristics, and aims for that goal for herself. She values the goal of 
cultural competence in health care and believes in its importance for effective 

Individual Structural Descriptions 

Structural descriptions provide "a vivid account of the underlying dynamics of 
the experience" (Moustakas, 1994, p. 135). This part of the analysis describes the 
"how" of the experience, attempting to understand in more depth how the 
participants experience the phenomena the way they do. The following are the 
individual structural descriptions of the experience of cultural competence and 
culturally competent care by LF. and E.B. 

LF: Participant #1 
Individual Structural Description 

LFs experience with and perception of the phenomenon of cultural 


competence is certainly influenced by the fact that she is Jewish. Although she 

states / think I align myself a little more with the majority that I was talking about earlier 
(whom she had described were Caucasians, wealthy males, holding power 
positions), she also recognizes that her cultural and religious differences set her apart 
from that same majority. What makes her part of the majority is her skin color which 
is white. LF recognizes that this characteristic gives her cultural power in this society, 
and she is sensitive to the meaning of that. 

/ want to be aware of when lam. . .in a power situation and I'm the 
one with the power. I don 't want that ever I want to make sure that I can 
make my interactions so that I am on equal footing with the other person. 
She also recognizes that she will carry the power of authority as an occupational 

/ think that a lot of people (when I am gonna be in OT) will view me 
as a professional and see me, you know, in a place of power, and I 

Although LF may be unable to prevent the way others will view her as a 
professional, it is important that she be aware of and sensitive to these issues of 
power and authority. LF is also aware that her difference, her Jewish identity, is not 
visible at first glance, so it is easier for her to "pass" in this society. 

/ do [feel like a part of the majority culture], but I also am Jewish , 
so I can relate a little bit. I am white, which you can 't see the difference 
in me, but I feel it. I feel a little different, a little unique from the majority 
culture sometimes. 
When comparing her experience to that of a Black man she had met, she states. 
But it's just much more visible for him. I mean, people can look 
around and say that is the only black man. No one can do that for me. 
Yet it is her "invisible" difference that increases her awareness of others who are 
different. When talking about her sensitivity to and awareness of a lone Black man 
she met in a public place, she related it to her awareness of herself in a minority 


/ think being Jewish had something to do with that Because I was 

probably the only Jewish person in that bar too. 

LF recognizes her dual status in US society. Sine is Wliite, and therefore 
holds cultural power simply by the color of her skin. Yet, she is also Jewish, which 
places her outside the Christian majority status as well. Because of her cultural self- 
awareness, and her own personal sensitivity around the issues of people treating 
her well, despite her differences, LF has developed an acute sensitivity to other 
people who are different. This may be why she believes in the primacy of the 
characteristics of sensitivity and awareness. 

Because she has been hurt by an insensitive comment from a teacher whom 
she thought was knowledgeable about cultural difference and whom she trusted, LF 
stresses that sensitivity is more important than knowledge in cross-cultural 

If you're sensitive without the knowledge, I think that is more important 

than having the knowledge, 'cause you can obtain the knowledge if 

you want to. 
Yet, knowledge is important to LF. When someone take[s] the time to learn more 
about [her] in an effort to understand her and her culture, she believes that is a move 
towards cultural competence. She doesn't mind being asked questions - even 
ridiculous questions - if the person who is asking is genuinely attempting to learn 
more about her. On the other hand, LF believes that cultural incompetence is the 
lack of knowledge and the lack of effort to learn more about someone else and their 
culture. It is ignorance. 

LF believes that seeking and giving knowledge is a dynamic that should occur 
in cross-cultural interactions. As a person who is Jewish, she believes that it is her 
responsibility to educate others about her culture/religion. In an effort to be more 
accurate about the information she gives others, LF bought a book about about the 
Jewish culture and shares some of that information with others when they ask. She 
also believes that spending time with people who are different from yourself, and 
asking questions about their culture, is an important method of gaining knowledge. 


Sensitivity and knowledge do not necessarily lead to cross-cultural skills, 

however. LF laments the instances when she doesn't know what to do, and it 
leaves her feeling incompetent. Doing something is important to LF. If people at 
least make an effort, if they try to engage with others, then they are moving towards 
cultural competence. She related the story of a young man who was asking her a lot 
of ridiculous questions about being Jewish. His ignorance made him culturally 
incompetent in LF's eyes, but she stated, 

but his asking me was culturally competent. 
The fact that he was trying to learn about her, and was courageous enough to ask 
questions, no matter how ridiculous they might have been, made her perceive the 
interaction in a positive light. 

LF can identify several behaviors demonstrated by culturally competent 
people when interacting with others. Many of these reflect the way she would like 
to be treated as a Jewish woman. She was very specific in her listing of these 
strategies, and I wonder if her own experiences aided in the development of that list. 
For LF, the outcome of cultural competence is true understanding which is coupled 
with happiness and a sense of appreciation for one another. I believe that this is 
what LF seeks for herself. 

JM: Participant #3 
Individual Structural Description 

JM was raised in a town that included very few ethnic people (one black 
family and two or three Jewish families), and she believes that because of this she 
was "ignorant" when it came to interacting with people who were different from 
herself. Not only was she unknowledgeable, she was also fearful. 

Yeah, I just simply know nothing. As a matter of fact, when I . . . 

moved to Boston, I was terrified of black people. I just assumed 

they were going to mug me. . . 
She attributes that fear to her lack of face-to-face exposure, coupled with the images 


and stereotypes she learned from the media. It wasn't until she experienced a 

gentle confrontation with a courageous young Black man that she began to evaluate 
her assumptions and become aware of her ignorance. 

JM's resultant concern with racism and the separateness caused by and 
contributing to racism, influences her perception of culturally competence and cross- 
cultural interactions. ForJM,oneofthe major reasonsfor interacting in aculturally 
competent manner is the importance of collaboration, of working together to solve 
problems, which is the opposite stance from the separateness that is so apparent to 
her with racism. Developing trust between people, welcoming one another, and 
treating one another as equals are also important results of cultural competent 
interactions from JMs perspective. 

JM is quite emphatic about the way someone goes about developing 
culturally competent or culturally fluent skills. She firmly states that you have to put 
yourself out there, that you have to even thrust yourself into cross-cultural situations. 
This is not a passive process. If a person is committed to cultural competence, then 
she must expose herself to others who are different from herself over and over 
again. It is quite clear that this notion of exposure arises from JMs concern that she 
had little exposure to people of different ethnicities during her developmental years. 
Perhaps this idea also results from the African American man who was courageous 
enough to confront JMs fear. She was quite awed by his courage during that 
interaction, and may have used him as a model for effective interactions. 

It was very brave of him too, 'cause he didn 't have to do that But in 

a small way he had educated me. At least enlightened me on my 


JM's emphasis on exposure to others who are culturally different also 
influences her concept of cultural fluency. She sees this level of interaction as a step 
above cultural competency, and likens it to language fluency. Someone can learn 
the rudiments of a language, but rarely speaks fluently unless spending time with a 
culture that speaks the language. Similarly, aculturally competent person can know 
about and understand another culture, and may have developed skills to effectively 


interact in usual circumstances. However, only someone with significant experience 

within the culture can rise to the level of cultural fluency as defined by JM. That 
person can then understand the innuendoes, understand the subtleties, and when 
faced with an unexpected situation that crosses cultures, [be] able to handle it. The 
culturally fluent person can respond beyond the expected; they know how to go 
outside the rule book. JM admits that not everyone reaches this level, but I sensed 
an underlying yearning that she hoped she would one day achieve it. 

Moving from ignorance to cultural fluency takes time and hard work, admits 
JM. In fact, at this point in her own development, this process still feels like work to 
her. She has not yet moved to the place of excitement, joy, or wonder that others 
have identified. JM often spoke of herself as still being quite ignorant, but willing to 
make the effort. She does believe, however, that moving to cultural competence is 
extremely important for health professionals. She stated that it was vital for effective 
and timely treatment of clients. 

It was interesting to me, that even though she didn't see herself as much 
beyond the level of cultural sensitivity, JM was able to clearly articulate a cohesive 
developmental progression of skill and knowledge related to cultural competence. 
This suggests that one may know what to do, and how to achieve it, without actually 
yet developing the skills and necessary behaviors. 

Thematic Analysis 

In order to construct the Composite Textural Description of the phenomena 
of cultural competence, I examined the themes of every participant to depict the 
experience of the group as a whole. The following account describes that analysis. 

The study participants were all quite forthcoming in discussing their 
experiences and ideas of cultural competence and culturally competent care during 
the interviews. Although they each approached the issue differently, all of them 
identified what a culturally competent interaction should and should not look like, and 


more clearly, what a culturally competent person is like, whether the experience is in 

a clinical setting or not. From the examination of the data three themes emerged. 
Theme one identifies the attitudinal levels that lead to cultural competence. The 
second theme, characteristics of a culturally competent person encompassed three 
categories, or sub-themes, while theme three identified the outcomes of a culturally 
competent interaction. 

Theme One: Attitudinal Levels that Lead to Cultural Competence 
Theme Two: Characteristics of a Culturally Competent Person 

1 . maintains an attitude of willingness, 

2. is knowledgeable, and 

3. demonstrates particular behaviors. 

Theme Three: Outcomes of a Culturally Competent Interaction 

Theme One: Attitudinal Levels that Lead to Cultural Competence 

Theme one was discovered only after a thorough reexamination of the data. 
I decided to identify it as the first theme because I believe it frames what follows. 
Some researchers believe that cultural competency occurs as a developmental 
process. Cross et al. (1 989) designed a cultural competence continuum that 
ranges from Cultural Destructivenessto Cultural Prof iciency and which was described 
in detail in an earlier chapter. Although the data from these study participants cannot 
be organized into a true developmental sequence, the attitudes they describe are 
suggestive of some of the levels identified by Cross et al., and can be placed in the 
following hierarchy. 

Attitude Level of Competence 

Ignorance Cultural Incompetence 


Openness to Difference Cultural Sensitivity 

Acceptance Cultural Competence 

Appreciation Cultural Proficiency(Fluency) 


An attitude of ignorance is a state of being unaware or uninformed (IVIerriam - 
Webster, 1 995). One participant described herself tliis way and tiie resultant fear 
sine felt of African Americans because she knew so little about them. 

I admit it freely. I am totally ignorant. Yeah, I just simply know nothing. 

Asa matter of fact, when I moved to Boston, I was terrified of black 

people. I just assumed they were going to mug me. (#3) 
This student spoke about her lack of experience with people who were culturally 
different from herself, and the stereotypical knowledge she had gained from the 
media. This resulted in her erroneous assumptions about an entire group of people 
and her sense of fright when she interacted with Blacks. 

Another student spoke of ignorance and stereotyping as cultural 
incompetence which results in cultural mistakes. To her, ignorance is not just "a state 
of being unaware or uninformed" (Merriam-Webster, 1 995), but is also an attitude 
which disallows a person to learn. 

Ignorance is where a lot of things go wrong. . . and ignorant people 

tend to be culturally incompetent because they lack that openness to 

learning. (#12). 

Therefore, an attitude of ignorance can result in stereotyping, making false 
assumptions, fear, and making cultural mistakes which can be hurtful. This 
description reflects Cross et al.'s (1989) developmental level of Cultural Incapacity. 
Cultural incapacity occurs when people and agencies "do not intentionally seek to be 
culturally destructive, but rather, lack the capacity to help. . . Uhey] remain extremely 
biased. . . discriminate against people of color. . . may act as agents of oppression 
by enforcing racist policies and maintaining stereotypes. [They] are often 
characterized by ignorance and an unrealistic fear of people of color (p. 1 5). 


The next attitude identified by the study participants was that of tolerance. 
One student defined it this way: 

/ guess tolerance would be not being disrespectful. I think you 
can be tolerant without being accepting. Tolerance is a surface [attitude]. 
This student experienced tolerance from her boyfriend's parents and her own 
grandmother. She is Jewish and her former boyfriend is East Indian. His parents 
treated her with respect in [her] face - to - face reactions with them, but then her 
boyfriend 's father had a screaming fit at him for dating outside his race. His parents 
tolerated them dating, but she never felt accepted by them. This student also told 
the story of her grandparents volunteering in the V. A. Hospital in the Bronx, working 
with people who were Hispanic and African American, and apparently enjoying it. 
But when Hispanics and Blacks began to move into their neighborhood, they 
moved. Although her grandparents talked about the respect they held for people 
different from themselves, their actions (moving out of their neighborhood when 
culturally diverse people began to move in) indicated something different. It's 
something like, people who are different are okay in their place, but their 'place' 
cannot be my neighborhood! This participant (#8) recognized this behavior as 
another example of verbal tolerance rather than of acceptance. 
Another study participant described intolerance as 
. . . [not trying] to understand where [people] are coming from, 
what their backgrounds are. [Lacking] a mind set of what people are 
willing to accept and willing to experience and whether or not they 
want to learn about other people. (#4) 

Although this sounds a little like Ignorance, the difference is that there seems 
to be more of a choice in tolerance the way it is described by this participant. This 
seems to indicate, then, that tolerance is also a choice. People decide that they are 
going to be respectful of, and try to interact with people who are different. However, 


there is not true acceptance of these people. An attitude of tolerance falls 

somewhere between Cultural Incompetence and Cultural Sensitivity as identified 
by the study participants, and does not reflect any stage described by Cross et al. 

Openness to Difference 

As might be inferred by some of the statements above, the next attitudinal 
stage in this hierarchy is openness to difference which correlates with Cross et al. 's 
level of Cultural Sensitivity. One student described cultural sensitivity as 
. . . knowing that you need to put out effort. Knowing that you 
need to recognize things, knowing that there are differences, and 
[that] they are important, but not necessarily knowing whattodo 
about that. (#1). 

This student related the story of a faculty member of hers who valued cultural 
sensitivity, often talking about its importance in class, and recognizing the difference In 
this participant's Jewish Identity. However, the teacher made the hurtful mistake of 
wishing participant #1 "Merry Christmas" during the holiday season. She knew 
about difference, recognized the student's unique culture, but then did not act 
appropriately given that information. This participant distinctly separated cultural 
sensitivity from cultural competence, and actually Identified sensitivity as a precursor 
to competence. 

/ think cultural sensitivity leads to more knowledge and then leads 
to cultural competence. (#1). 

Another study participant agrees with this. She describes a hierarchy in which 
cultural sensitivity isthefirst step towards cultural competence. 

Cultural sensitivity is an awareness that there are other cultures 
around [and] there are differences, an awarenessof one's ignorance 
of them and the willingness to seek out what the differences are. (#3) 
Openness to difference encompasses not only an awareness of difference, 


according to these study participants, but also the recognition that difference is 
important, especially to non-majority people, and that culturally sensitive people are 
willing to seek out and learn more about those differences. Some people 
erroneously believe that the correct approach in cross-cultural interactions is to ignore 
difference, to treat everyone the same in an effort to appear unbiased. This is often 
referred to as "color blindness", defined as "the state of not being subject to, or 
cognizant of racial differences" (Herbst, 1 997). Cross et al. (1 989) identify this as 
Cultural Blindness, and state that if you ignore cultural differences, you are also 
ignoring cultural strengths. Thisthen leadsto a lack of recognition and value of the 
individuality of each person. In contrast to that notion, the study participants 
recognize that It is important to recognize and honor difference. 

Cultural sensitivity, as identified by the study participants, and the attitude of 
being open to difference, reflects some of the aspects of Cross et al.'s (1989) 
Cultural Pre-Competence. The authors state, "This term was chosen because it 
implies movement. . .an agency realizes its weaknesses. . . and attempts to 
improve. . . [including] initiating training on cultural sensitivity. Thepre-competent 
agency, however, has begun the process of becoming culturally competent and 
often only lacks Information on what is possible and how to proceed" (p. 17). 


The next step In this process is Cultural Competence which is characterized 
by the attitude of acceptance. One student defined an accepting attitude as 
It's just being open, not making judgments, tailing things for what 
they are, and try[ing] to shelve your own judgments and going with 
the flow. People who are culturally competent tend to be more open- 
minded about things. Everybody's perspective is heard. (#12) 
To another student, being accepting meant 

. . . being respectful of people's differences and their own values. 
It doesn 't necessahly have to interfere with yours. They can have 


their opinions and cultural practices and you can have yours. . . . 

you go beyond tolerance to bridge that gap and make sure that there 
is communication and understanding. Acceptance goes deeper than 
tolerance. (#8) 

This attitude of acceptance as part of cultural competence moves beyond 
merely having a particular attitude. As the above student stated, It is also 
demonstrated by the way we communicate and other skills. This will be explained 
further as part of the analysis in theme two. Another student talked about 
acceptance with the following example. 

The differences would be there, but respected and not expected 
to change. If I was in their country (Arab), I would do what they do. 
I would try to get to know them and the differences so I'm not too 
pushy and more understanding. I don 't pretend to know more about 
the Arab country, but I know women aren 't treated as well as men. 
So I accept that. (#5) 

This participant's response, as does those above, raises the question of 
blind acceptance as an aspect of cultural relativism. This notion will be discussed in 
chapter five. 

Cross etal. (1989) states that "Culturally competent agencies are 
characterized by acceptance and respect for difference, continuing self -assessment 
regarding culture, careful attention to the dynamics of difference, continuous 
expansion of cultural knowledge and resources, and a variety of adaptations (p. 1 7). 
This description closely aligns with the descriptions offered by the students above. 
Interestingly, however, cultural competency is not the ultimate goal for either Cross et 
al. or for at least one of the study participants. 


The highest level on the continuum of cultural competence is called cultural 
fluency by participant #3, and Cultural Proficiency by Cross et al. (1 989) and is 


identified by an attitude of appreciation. Cultural fluency only happens with people 

who have had extensive experience with a cultural group. You not only have 
knowledge about a culture, but also can recognize and respond to the subtle 
meanings within agroup. 

/ think cultural fluency is very much based on experience. [You] 
understand the innuendoes, understand the subtleties. I think the 
mark of being culturally fluent is when faced with an unexpected 
situation that crosses cultures, you 're able to handle it (#3) 
This student went on to say that cultural competency is almost like you have a 
rule book. And with cultural fluency you go outside the rule book. It is a level of 
interaction that comes from a deep appreciation of the culture. Cross et al. (1 989) 
describe it as an advanced level of competence "characterized by holding culture in 
high esteem" (p. 1 7). Not everyone achieves this level of competence in cross- 
cultural interactions, but it may be something to strive for. 

In summary, the study participants as agroup identified several attitudes held 
by people at various stages of cultural competence. These findings correlate with 
the Cultural Competence Continuum identified by Cross et al. (1989) and lead us 
into a closer look of the attributes of cultural competency identified by the 

Theme Two: Characteristics of a Culturally Competent Person 

Although the three areas subsumed under attributes were similar to those 
found in the literature, the study participants emphasized some unique perspectives. 

Attitude of Willingness 

One of the most important attributes of a culturally competent person 
expressed by the study participants is an attitude of willingness. Throughout the 
transcripts of the interviews, the word willing (ness) kept popping up. I saw it so 


often and through so many voices that it couldn't be ignored. I was struck by this 

notion as I began my analysis. 

A few of the ways the study participants talked about willingness were 

willingness to seek out wliat tine differences are (#3) 

willingness to find out what's really going on (#3) 

willing(ness) to accept and experience (#4) 

willing(ness) to listen (#2) (#6) 

willing(ness) to understand ttieir situation (#2) 

willingness to let go of our assumptions (#3) 

willingness to learn (#4) (#6) 

willingness to be open, and listen, and understand (#6) 

willing(ness) to admit you don 't know anything (#6) 

As I thought about this concept of being willing to do something, I 
recognized that the students were talking about making a conscious choice. They 
were talking about a volitional act. Occupational therapists understand the 
importance of volition as part of thetheoretical construct surrounding occupational 
performance. Kielhofner (1997), when discussing the Model of Human Occupation, 
defines volition as "a system of dispositions and self-knowledge that predisposes 
and enables a person to anticipate, choose, experience, and interpret occupational 
behavior" (p. 1 90). We might infer from this definition that a culturally competent 
person maintains an attitude or disposition that allows her to not only be open to 
certain experiences, but also to choose them. The participants stated that a person 
who is culturally competent chooses to have an open mind, chooses to be self- 
reflective, and chooses to attempt things beyond her comfort zone. 

A willingness to look at the world with an open mind was a consistent theme 
of most of the participants. However, they each identified this concept in unique 
ways. One student spoke of it this way: 

Being open means being observant and being willing to if you 

see something that's different, accept that or take that in, incorporate 

it into your session. So open means absorbing what's around the 


culture, aspects of the culture, and using that then to change your 

own behavior (#7) 
She gave the example of a Russian man who spoke little English but his adult 
daughter would translate for him. The daughter worked odd hours and could not 
always be with her father. The therapist rearranged her schedule so that she could 
work with the man when his daughter was available so that he would receive the 
treatment that matched his cultural beliefs and needs. 
Another participant said : 

To me it means never making a judgment without having the 
information to back it up . Even being open minded to the fact 
that down the road if I have an opinion or something formulated 
and something very valid presents itself to change my mind, that 
I'm open to changing my opinion. (#10). 
A third articulated it this way: 

It's being open to hearing what they're saying and maybe where 
they're coming from, and trying to get a real understanding of what's 
making them feel the way they do or see things the way they do. (#4) 
Another participant summarized it this way: 

People who are culturally competent tend to be more open-minded 
about things whereas people who aren 't are more one-track mind[ed]. 
. . . [Being open] is not making judgments , [but] taking things for what 
they are, try[ing] to shelve your own judgments and going with the flow. 
I don 't think you 'II get very far unless you are open minded. (#12). 
Summing these ideas up, being willing to be open minded means being 
accepting of others and not judging them. It means recognizing difference and being 
willing to learn about and from it and incorporating that knowledge into a treatment 
session. It means being aware of and being willing to listen to another's point of 
view. It may also mean choosing to set aside your own beliefs and values for a time 
as you learn about and 'try on' the beliefs and values of others. In an occupational 
therapy setting, it may mean setting goals with the client that are culturally important 


to him, ratherthan choosing treatment activities that are therapeutic, but may have 

little or no meaning for the client. For example, helping a client with a stroke to make 
simple meals for himself before returning home is atypical treatment activity. 
However, if an Arab man has female family members who will do this task for him, it 
does not make sense to encourage him to do this. Instead, the occupational therapy 
practitioner should talk with the client and his family about the daily activities that are 
meaningful for him to accomplish on his own, and together, work on helping him 
achieve that goal. 

With open-mindedness comes awareness of self and others. Although 
over half of the participants spoke of the importance of being aware (particularly of 
others), I was surprised to hear only a few specifically talk about self-awareness. 
This greatly contrasts with the literature that states that self-awareness may be the 
most important of the characteristics of a culturally competent person (Chan, 1 990; 
Harry, 1 992; Weaver, 1 999). The students who did speak about self -awareness, 
however, were quite articulate. One student believes that part of knowing yourself is 
not only being able to identify your strengths and weaknesses, something we often 
talk about as occupational therapists, but being able to recognize what we don't yet 
know (in across-cultural situation) and being willing to admit it. She stated. 

They would be aware that they didn't know much about the person 

[and they would have] the awareness of their lack of knowledge. 

And I think it's important for them to not know. . . They don't know, 

but they do know themselves. . . They know who they are, but they 

also know that they're not the same person and hold the same 

beliefs and values that everybody else does. (#6) 
This student believes that self-awareness is very important. Not only should we 
recognize our own lack of knowledge about others, but we should be aware of 

what our first choice would be, what our initial instinct would be to do. . . 

and then realizing that your initial instinct isn 't everybody else 's. 

According to this participant, we must be aware of our initial thoughts and 
ideas, our "instincts" when we first meet and begin to interact with someone who is 


culturally different, and immediately evaluate those ideas to determine how they will 

fit in this particular situation. By being aware, we can then make choices about our 
behavior. She believes that 

you need to be comfortable with yourself before you can be 
comfortable in a situation, and you know you can't really be 
comfortable with yourself if you don't know yourself (#6) 
The ability to assess your own strengths and weaknesses, to recognize your 
lack of knowledge, puts you in a ready state for learning ; a place of openness. Self- 
awareness allows you to anticipate where the problem areas might be during cross- 
cultural interactions. Asthis student so articulately states, 

. . . you come from a clearer place. You know what you're 
dealing with if you're aware. . . and if you find yourself in a 
situation and something comes up, (such as inadvertently saying 
something that offends the person you're interacting with),yoL/ know 
that's one of those learning moments when you realize, wow, I 
never realized this about myself This is something to keep in mind 
in case it comes up again. (#6) 

This kind of "reflection in action" as described by Schon (1 995) can only 
happen in this way if you are truly self-aware. Another student emphasized the 
importance of being aware of your own opinions or values, warning that being 
unaware of these things might cause you to make unintentional cultural mistakes. 
For example, using the term "sexual preference" is sometimes offensive to people 
who are homosexual, yet many heterosexuals do believe that homosexuality is a 
choice. Using the term above may Indicate your own values and beliefs, or it may 
be a cultural blunder - a lack of recognition of the terminology that people prefer. 
[Spmetimes it comes out and you just realize that you had no idea. (#4) Knowing 
yourself, and being aware of your own beliefs about homosexuality might prevent 
this from happening. 

Self-awareness is a knowledge of one's internal world. Although, as I stated 
earlier, only a few students mentioned this, the majority of the study participants 


spoke about being aware of factors in one's external world. This will be discussed 

further under the section on having knowledge. Awareness of self and others, tied 
with open mindedness, closely aligns with respect, another concept and attitude 
identified by the majority of the participants. One student stated You're supposed 
to respect other people . . . and their differences. (#6). She talked about the 
importance of showing respect by listening to people and trying to learn about and 
from them. It's not pushing your own ideas on others, but rather, recognizing each 
person's uniqueness and valuing him/her as a person. You have to be willing to see 
the other person as an individual, and to do that you must be willing to accept that 
person. Openness to, awareness of, respect for, and acceptance of someone who 
is different from yourself is seen by one of the participants as cultural sensitivity. 
The students who spoke of this felt that it was a vital aspect of cultural competence. 
When comparing awareness or sensitivity to the cultural characteristic of knowledge, 
one student said, 

/ think it's better. If you're sensitive without the knowledge, I think 

that is more important than having the knowledge, 'cause you can 

obtain the knowledge if you have to. (#1) 

Another stated that what makes the difference between a culturally competent 
interaction and one that is not, is the awareness. According to these students, you 
can have knowledge about another group of people, but without awareness (of self 
and others) you will not be culturally competent. On the other hand, someone who 
has cultural awareness but does not' t yet have much knowledge about the culture 
might be considered culturally competent. This is because awareness seems to 
correlate with a willingness to learn. It appears then, that this attitude of willingness is 
a vital attribute that a culturally competent person must possess. 

The term awareness was also used in a unique way by one student who 
spoke of the heightened awareness that she experiences during cross-cultural 
interactions. She was entering the home of a Japanese co-worker and wondered 
whether she should remove her shoes. 

Right at first when I was coming in, and when I was in that awareness, 


and I just wanted to check out how we should be acting. . . it's a 

heightened awareness that you don 't normally have when you're 

acting in your own culture. (#7). 

This sounds like alertness, or the increased arousal that often occurs with people 
during new situations. But this student went on to talk about how it causes her to be 
more observant, and to listen more rather than talk. Actually, this is a positive 
adaptive response to a new situation, and it seems to be especially appropriate 
during cross-cultural situations. 

The final attitude of willingness that was integrated throughout most of the 
transcripts was a willingness to try. One student talked about her attempt to 
speak Spanish to some Hispanic co-workers, even though she doesn't know the 
language well. 

They really, really liked it and it helped to get us a little closer (#1). 
She feels that being willing to try new things, new behaviors, new modes of 
communication, is an important aspect of cultural competence. 

Try to get on the other person 's wavelength a little bit and show that 

you're interested. Try to understand the differences. (#1). 

Being willing to put yourself in this position during across-cultural interaction is 
being willing to make yourself vulnerable. It's putting yourself out there where the 
chance of failure is much greater than when you are with groups of people with 
whom you are familiar and comfortable. Being culturally competent is not for the faint 
hearted. It takes courage and confidence to willingly put yourself in a position of 
vulnerability, but the study participants spoke clearly about the importance of doing 
just that. 

You have to thrust yourself in there. You have to make the effort. 

Really get your foot in the door. You can choose to actively expose 

yourself to varying degrees. (#3) 

When asked what happens if you are rejected when trying out new skills, one 
student responded: 

You try again. You keep going and going because the person 


who was unwilling to learn will not come back. But if you are willing, 

if you really are committed to understanding their culture, you will 

comeback. (#3). 
According to this student, liaving a willingness to try means being committed to the 
process of reaching out to others who are different. It means not only allowing but 
also actively choosing (volition) to be vulnerable, and maybe even being rejected, 
but having the courage and commitment to try again. Although the participants were 
referring here to personal situations, the concept of willingness also holds true for 
clinical situations where practitioners must be willing to put the extra effort into getting 
to know and understand the culturally different client in order to provide the best 
possible care. 

To summarize this attribute of maintaining an attitude of willingness, as 
voiced by the study participants, you make a conscious choice to maintain an open 
mind about others, which involves respecting and accepting them. You also willingly 
increase your self awareness and your awareness of difference and similarities 
regarding others. And lastly, you take the opportunity to thrust yourself into cross 
cultural situations, in order to try to improve your interactions with someone who is 
different from yourself. 

Being Knowledgeable 

The second attribute of a culturally competent person that every one of the 
study participants identified was being knowledgeable. During their interviews, the 
students talked about why it is important to be knowledgeable, what you should 
know, a variety of ways to learn, and the dynamics between knowledge/learning and 
thefirst characteristic, having a willing attitude. 

One of the most identified reasons for learning about other cultures Is to help 
you be prepared to interact more effectively. The following participant spoke about 
the preparation that is needed in a clinical situation. 

In the ideal situation you have some nice amount of time beforehand 


and have an Idea of. . . perhaps what the person 's background is or 

a little bit about them. . . . you can look it up, educate yourself a little 
bit about it. But in the situation where you have five minutes and 
you 've looked at the (medical) chart, . . . then I think it can also 
just be a mind set as to preparedness. Realizing that you 're going 
into a situation where you're going to need to probably ask more 
questions and need to elicit more information. (#4). 
It's interesting that this participant identifies being prepared also as a mind set, 
an awareness that you may have to change your behavior in a particular way. But 
again, she states that ideally, you would learn about the culture of another person 
before interacting with him/her. Other students concurred. One stated, 
/ read a lot and have people tell me about things, and so, I learn 
to face them as heads first (#6). 
This same student went on to talk about how that kind of preparation allows her to 
anticipate what to expect in a cross-cultural interaction. Another spoke of the 
importance of having knowledge when you're in another person's home. She said 
that you fit in by 

. . . learning and having knowledge before you go into a situation 
so that you're prepared for, know what to expect or what to look 
out for. (#7) 

This student also talked about the ideal situation as being one of being 
prepared through knowledge. 

/ think ideally . . . they knew ahead of time that they would try to 
find out about cultures, about the customs. ... The therapist 
would prepare herself beforehand to know the sort of dress and 
the customs about what you do when you're inside the house. {#?). 
In a somewhat different situation, where a student was involved in an 
international experience where she and her team would be providing services to 
children but would be in a minority status herself, preparation was still very important. 
She related how afaculty member prepared them for an academic trip to Rumania 


by teaching her and others about the culture. The participant reported that the 

faculty member told them 

. . . it was going to be a difficult experience and you l<ind of tiave 

to start witii an open mind, nere are going to be things that you 

see that you're not going to lil<e. You're just have to understand 

where everybody's coming from. I thinl< she did a good job 

preparing us. (#9) 
So with that additional knowledge given to her before her trip to Rumania, this 
student felt quite prepared to embark on the experience. 

What kind of knowledge is important to help someone feel more prepared in 
across-cultural Interaction? Generally, the study participants talked about knowing 
the cultural differences and similarities, but they also clearly identified many specific 
areas of knowledge. These included learning about ; 

their dress and customs (#7) 

their interaction patterns and level of formality (#7) (#1) 

their foods and their eating patterns(#7) (#12) 

non- verbal communication patterns such as eye contact and gestures (#7) 
(#8) (#10) 

what they value; what is important to them (#6) (#10) (#5) 

what you may have in common (#6) (#12) (#4) 

their day-to-day experiences, their routines (#9) (#3) (#5) 

their language (#9) (#1) (#3) 

what is culturally relevant to them (#1 1) 

what is going on in their homeland (#12) 

their religion, spiritual life (#12) (#3) 

their perceptions of wellness, illness, death (#12) 

what their family life is like (#1) 

what their culture means to them (#1) 

what our culture means to them (#1) 

what it means to them to be part of a minority culture (#1) 


the subtleties of the culture; those things that are not necessarily expressed 

openly (#3) 
their social life (#3) 

This is a significant and extensive list, and to me indicates that learning about 
another culture or cultures involves a time commitment that might be lifelong in 
practice. It is interesting, however, that this list identifies information that needs to be 
learned about the other person or group, but does not discuss what the participants 
need to know about themselves and their cultural identities, or about the societal role 
each person is given. 

How do you begin to learn about others? The study participants identified 
numerous learning strategies. You can learn through formal education, and many 
stated that they had learned this way. You can also learn by individual reading and 
research, which, along with continuing education offerings, is probably the most likely 
learning strategies for practitioners. Another student suggested reading pertinent 
non-fiction books about other cultures as a way to learn. A good example of this is 
Fadima's (1 997) The Spirit Catches You and You Fall Down which is a compelling 
story of the experiences of a Hmong family with the American medical system. 
Maybe someone could become more culturally competent if they 
read books that . . . showed a different perspective in another culture. 
I would say that they should try to find inspiring novels. (#1 1) 
Although all of the above learning strategies are effective, the method that 
seemed to have the most impact on the majority of the study participants was 
personal experience with cross-cultural interactions. Many of them spoke 
about experiential learning that was transformational to them. One student stated, 
. . . things change me when it directly happens to me. I mean, 
I can read about things and know more, but I think [the experience] 
really impacted me. (#1). 
Another added: 

Traveling and meeting other people and having those experiences 
are. . . the best thing. That's how I grow and have become who 


/ am is by knowing people witii different experiences, and trying to 

experience some of tfiese new things also. Because a lot of tfiis stuff 
I've done in my life, I never would have done if I hadn't met people who 
were different from me. (#4) 
Another student talked about her trip to Rumania, and how it impacted her. 
To actually be there and to have it be part of your experience and to 
see it and to feel it and to share it All of a sudden it really hits home. 
It means something, it's real, it's not just a vague notion of what it would 
be. I think it opens your mind. (#9) 
A fourth participant who talked about her college roommates who were Japanese 
and East Indian, summarized her learning this way. 

/ read a lot and have people tell me about things. . . but until I go out 
and actually see (people and places which are culturally different), 
it's abstract. But once you 're doing it, and once you 've done it, it 
becomes real. . . It's kind of like that "ah hah" moment. So this is 
the way it is! (#6) 

You can almost feel the excitement that radiates from these words. These 
four students, and several other study participants, felt that this was the place of 
greatest learning - where they were able to meet and interact with people who are 
culturally different from themselves. This happened for some (4) of them when 
traveling outside of the country, while others interacted with people from diverse 
cultures during college or even growing up. Several compared personal experience 
with book learning. They all agreed that you could learn significantly through 
studying, but it was the experience of interacting with someone who is culturally 
different from yourself that truly made it real. This closely reflects the interplay 
between the classroom and f ieldwork experiences during occupational therapy 

In the literature, there were several authors who believed that self-awareness 
was the first step in becoming culturally competent (Chan, 1 990; Harry, 1 992; Lynch 
& Hanson, 1998; Weaver, 1999; Wells & Black, 2000). Likewise, in this study, 


some of the participants also stated that an attitude of willingness was the primary 

characteristic. However, there were a few who spoke of the interplay between 
knowledge and willingness. Above, participant #9 spoke of how having cross- 
cultural experiences can open your mind. She went on to say, 

/ think it certainly helps to learn through books and to talk to people, 

. . . [but] I think your mind has to be open already to a certain degree 

before you get there. (#9) 

So, in this dynamic interplay, learning can open your mind to new 
experiences, but having an open mind also allows you to gain the most out of those 
experiences. Perhaps these two characteristics develop in a circular or spiral-like 
fashion. You might be taught to be an open-minded person with an accepting 
attitude and a willingness to try new things. This might lead you to learn about other 
cultures through a variety of methods. Your open mindedness supports your 
learning, allowing you to get the most out of the learning experience, and that 
knowledge then increases your understanding and further enhances your attitude of 

The students in the study experienced this in a variety of ways. Some had 
little knowledge but experienced a cross-cultural interaction that increased their 
awareness and subsequently caused them to seek a greater understanding of the 
culture through research and study. Others had received someformal training in 
diversity and cross-cultural interactions which opened their mind somewhat so that 
they were more prepared for a cross-cultural experience. This experience increased 
their awareness and understanding even further, and led them to more study and 
more experiences. The dynamic interaction between the first two characteristics of 
knowledge and a willing attitude, is unique to each person who is part of the process. 
But as one author said, (McPhatter, 1 997) knowledge and awareness is somewhat 
useless unless you put it into action. That leads us to the third major attribute that 
emerged from the data; culturally competent people practice particular behaviors 
with one another. 


The study participants identified several common behaviors that are 
observable during competent cross-cultural interactions. These include: 

1. active engagement, 

2. appropriate communication skills, 

3. behaviors other than communication which may involve compromise and 

4. client-centered care and the importance of being aware of and responding 
to context. 

Active Engagement 

Being culturally competent is not a passive role you play. The participants 
made it very clear that it involves active engagement. You have to do something. 
One student said that just trying to do (#1 ) something is being culturally competent. 
For example, she tried to speak Spanish to an Hispanic client; she bought a book in 
order to try to educate herself about her own culture; she tried to talk to people who 
were culturally different than herself. In each of these instances, she attempted to do 
something. She didn't just sit back and let things happen to her. Another student 
echoed this notion by using words like 
[You] get out there. . . 

. . really get your foot in the door 

. . you keep going and going 

. . make a point of going over, of approaching them 

..make the effort 

. .you have to thrust yourself in there. (#3) 
It's important to take the initiative during cross-culturalinteractions according to 
the study participants. A culturally competent person must take action. Because all 
of the study participants are White women, I wonder if this might be a response of 


the dominant group when interacting with those who are non-dominant. This concept 

will be further explored in chapter five. 

Communication Sldiis 

Many of the behaviors a culturally competent person engages in involve 
appropriate communication skills . This was a theme that was present in every 
interview, and many participants spoke about the importance of asking Questions as 
a means to engage the other person in discussion, and a method for gaining 
information. This is an interesting point, since many in the United States were 
taught in childhood that it is impolite to ask questions of others, and many other 
cultures also believe asking questions is impolite. Yet the study participants spoke 
of the importance of doing just that. Many of them spoke about the importance of 
asking questionsfor clarity. 

/ think [asking questions] is a very inriportant part. I think that's the 
only way that you can really understand what somebody's saying 
and what they're trying to get across to you. (#4). 
When relating her experience of observing a White occupational therapy 
practitioner interacting with an East Indian family, the student above was impressed 
with thetherapist's ability to communicate. The therapist didn't assume to know why 
the family interacted in a particular way, instead her approach was 
. . . asking questions and trying to understand what their 
cultural normsare, and what their experiences have been. (#4) 
A study participant who is Jewish related the story of a man who was asking 
her ridiculous questions about being Jewish. She didn't mind answering him, 
however, because 

. . . he was trying to know. He was taking time to learn more about 
me. . . he didn't just judge me. He wanted to make sure. (#1) 
This is another important point. You may ask ridiculous questions because 
you know very little about a certain culture. But if you are sincere in the asking, if you 


truly are interested in l<nowing more, most people recognize this and will attempt to 

tell you what you want to know. Again, this suggests that you must be comfortable 
in allowing yourself to be vulnerable. Asking ridiculous questions can be humiliating, 
but according to the study participants, it is important to ask. 

The other aspect of asking Is to listen well. Many students talked about the 
importanceof listening. During cross-cultural interactions, listening is an active, rather 
than a passive process. One student used her listening skills to learn about a Haitian 
client, and then verified what [stie] heard her saying to make sure she was 
understanding her correctly. The client was in a work readiness group, and she was 
trying to let the student know that in her culture it wasn't important for her to get a job. 
The student listened well and then changed her goals with that client. She went on 
to say how their interaction improved because "/ was listening to what she was 
saying and respecting that " (#6). This notion of listening well is strongly supported 
by Delpit (1 995) who writes about "a very special kind of listening, listening that 
requires not only open eyes and ears, but open hearts and minds. Both sides do 
need to be able to listen, and I contend that it is those with the most power, those in 
the majority, who must take the greater responsibility for initiating the process." (pp. 
46-47). The participants in this study seem to agree with Delpit. 

Sometimes communication with another person is hampered if they speak a 
language that you don't know. Although several participants suggested that learning 
and speaking a few words of the other person's language is important to help 
develop rapport and demonstrate respect, many addressed the issue of finding 
translators for people who do not speak English in a clinical setting. This is vital if 
there is to be any true understanding between yourself and your clients. Several 
students talked about experiences where adult family members of the client were 
sought out to help with the translation and understanding for the client. One student 
addressed the proper way to use a translator. 

If I were working with a family who didn 't speak English, and if there 

was an interpreter there, I think the ideal interaction would be forme 

to talk directly to the family, not the interpreter, (#8) 


The emphasis here is to address the client in a respectful way, rather than to talk only 

with the interpreter. She went on to say, 

. . . but I think speaking and making eye contact with the family, 
(helps them) feel that they're included and an active part of 
the discussion, They're the ones that I'm trying to communicate 
with, not the interpreter. (#8) 
Another student added: 

. . . we did have an interpreter. . . but you were very aware of 
your body language because that's how you were talking with 
the people. (#9) 

Both of these students and others addressed the importance of observing 
the person's body language as part of effective communication. An aspect of 
learning about the person's culture is learning the meaning of their gestures and other 
non-verbal patterns such as eye gaze or physical contact. 

Communicating well and effectively is vital in order to reach an accurate 
understanding between yourself and someone who is culturally different from 
yourself. Sometimes non-verbal messages are misunderstood, and questioning for 
clarification is necessary. One participant reported her observations of a clinical 
interaction. While interpreting the head nods by people from Southeast Asian 

. . . the therapist went ahead and really probed more with questions 
to be sure that they understood. They really didn 't and they were 
just trying to be polite and not rock the boat, so I think if it's done in 
a respectful way, that further probing, to make sure that the client . . . 
really understands what the therapist is getting at and making sure 
that it's what they want as well (#8) 

Understanding, or getting through (#4) to people from a variety of cultural 
backgrounds is not only a goal in cross-cultural interactions, it is also an outcome of 
effective communication. Students in this study often spoke of other means of 
communication that they've observed. They spoke of therapists who speak clearly 


and slowly and wait patiently for a response. Some therapists demonstrate what 

they want done, or if trying to more clearly understand their client, will ask the client to 
demonstrate what they mean. Some use humor to break the ice such as 
demonstrating what they want in a silly way, or purposely mispronouncing words in 
the client's language to make them laugh. Another had his client teach him one new 
word of her language each time they met. The purpose of all of these methods is to 
gain a greater understanding and rapport between the client and practitioner in order 
to provide culturally competent care. 

Client-Centered Care 

Within a clinical or practice context, some of the participants spoke about the 
importance of client-centered care (a concept discussed in occupational therapy by 
Law et al. , 1 996) and its relationship to cultural competence. They felt that you 
couldn't truly be client-centered without being culturally competent. 

How could you do one and not the other? It seems kind of inherent 
Justin the nature if you truly invest in and its truly client-centered, you 
would have to be culturally competent because that would be 
something you would be interested in getting to know about the 
individual. (#10). 
When another student spoke about being client centered, I asked her about its 
relevance to cultural competence, and she replied, 

Well, I think it's really a key element. . . If [activities] are not 
something that is important to someone 's culture then. . . they're 
not going to benefit from anything that you do. So, I think 
client-centered has to take into account someone 's culture and 
the experiences that make life meaningful for them, and I think 
culture is a huge part of what makes life meaningful to people. 
You cannot have client centered care without being culturally 
competent. (#1 1). 


This is a very important point for occupational therapists. Although client- 
centered care is a vital principle of occupational therapy intervention, it has rarely 
been as closely associated with cultural competence in the literature, as these 
students make it. 

Compromise and Change 

Related to client-centered care was the concept of change. If you are 
considerate of the client's values and cultural beliefs, you are cautious about what you 
will try to get them to change for therapeutic purposes. One participant talked about 
the cultural custom in Rumania of keeping children in many layers of clothes, even 
when the weather was very warm. The supervising occupational therapist from the 
United States spoke to the Rumanian pediatric caretakers about this, but realized 
this was a custom that was not going to change. The student remarked, 
/ liked the way that she didn 't try to change everything 'cause 
she realized that you can 't really go in and change the whole 
system.. . . You can only change so much, so I liked the idea 
that she was willing to accept some things that they found very 
important to their culture, and yet trying to change as much as she 
can to help the children. (#9). 

Another perspective from another student indicated that you don't try to 
change other people at all. You're the one who needs to change. (#5). 
Others articulated a need to compromise. One participant was working with a 
Haitian woman in a group situation where the goals included developing work 
readiness skills. The Haitian woman did not seem to be interacting well, and upon 
further questioning the student realized that the woman had never worked nor was 
she planning to find a job. 

/ was in a position where it was my job to help her, and coming 
to a compromise was realizing that my helping her doesn 't 
necessarily mean needing what I had in my mind as my goals. 


Kind of reformulating my goals as I went along. . .based on what 

she's telling me. (#6). 
As a result of this awareness and willingness to compromise, the student and client 
developed mutual goals based on what was meaningful for the client, and therapy 
became much more successful for both of them. 

Compromise also means recognizing your own values and beliefs, as well 
as recognizing the other person's, and then trying to find and work where there is 
common ground, according to this student. This sometimes means setting many of 
your own values aside in order to be responsive to the other person. Another 
student talks about it this way. 

You have to find some area of compromise. Obviously it is 
situation-dependent. Like how can you take the situation where 
the client, because of a culture[al belief or custom], can't do this 
or won 't do this, and how can I find some way of making it that 
they can accomplish what I need(ed) them to do and yet still fit in 
with their values and beliefs. (#10). 

One example of this is a therapist who was working with a Somali child to 
develop right hand dominance to improve coordination. The child would not eat 
using the right hand due to the cultural belief related to using the right hand for toileting 
and the left hand for eating. When the therapist learned of this custom, she decided 
not to force the issue, but worked with the child to develop eating skills with the left 
hand, and other fine motor skills with the right. This example demonstrates that 
compromise, as articulated by the study participants is closely integrated with 
culturally competence and client-centered care. 

Many participants in this study talked about how you should behave in a 
cross-cultural interaction. They also talked about behaviors that were inappropriate in 
that kind of setting. These included: 


judge people (#11). (#4) 

avoid talking with someone wtio is different (#1) 

refuse to engage with others (#1) 

close your eyes and not deal with it (#1) 

ignore difference (#1) 

stop making an effort (#1) 

be closed to new ideas or difference (#5) 

assume (#9) 

refuse to try to communicate with someone who doesn't speak English (#9) 
forget to listen (#11) 

fail to respect people (#6) 

patronize (#8) 

be intolerant or stereotype (#8), (#12) 

be afraid to admit your ignorance (#12), (#3) 

be impatient (#7) 

be blind to non-verbal cues (#7) 

stop learning (all) 

give up (#3) 

This lengthy list indicates that the study participants not only recognize 
culturally competent behavior, but are very clear about what you should avoid in a 
cross-cultural situation. Perhaps a close examination of this list is the place to begin 
as it would lead the learner to all skill areas of cultural competence including an 
examination of attitude, knowledge, and behavior. 

Theme Three: Outcomes of Culturally Competent Interactions 

The final theme that emerged from the data identified the various outcomes 
of culturally competent Interactions. For the study participants these included 
an emotional impact, greater understanding of one another , collaboration and 


connection, and ultimately, culturally competent care. 

Collaboration and Connection 

Many of the participants spoke about the sense of collaboration or 
connection that resulted from competent Interactions with people who were 
culturally different. Two participants characterized this concept as ivor/f/ngtogfef/7er. 
/ think that as we become more aware of. . . and learn about 
cultures, and they learn about us, we can work together . . I 
think we really do have to work together in order to get anything 
done.. . .The point is, that if you know them and you can work with 
them, you can understand what's going on, then we can get together 
and solve some issues that we have in common. (#3). 
For this student, the end justifies the means, and working together is the main 
objective of being culturally competent, while, for participant #6, working together is 
an important process rather than the goal. 

[It would] be important because it would have them working 
together on a common kind of goal that forces them to come 
together. It would be the best because they're working together (#6). 
Other students refer to it this way. 

If you can use all that information and come out of it feeling like you 
really connected with the people. . . I think that would be the best. (#7). 

The client collaboration [is what makes it best] because I really think 
that that's so important. . . I think client collaboration means what the 
individual wants. I just think client collaboration and cultural competence 
are the first things that are important to the individual and are crucial to 
healthcare. (#10). 

Greater Understanding of One Another 

A sense of connection or a collaborative working relationship occurs because 
of the greater understanding that is achieved through culturally competent 
interactions. One of the definitions of understend in Webster's dictionary (1995) is 
to know. The participants recognized the importance of getting to know people from 
different cultures. It is interesting that when many of the participants spoke of 
understanding the other person, or understanding one another, they qualified the 
word to give it more emphasis. For example, they would say, 


. . . trying to get a real understanding of what's making them \ 

feel the way they do or see things the way that they do. (#4) 

. . . when the Black man tells a White person stories, the White 
person really understands it. [What's important] is increased 
understanding. (#1). 

better understanding 

If you have a positive cultural experience, maybe then you 
become more accepting and you get a better understanding. (#8) 
Their use of emphatic words indicates to me that their perception of 
understanding someone who is culturally different means getting to know them at a 
deeper rather than at a superficial level. One student defines this as cultural fluency 
which she describes to be a deeper understanding than the basic understanding of 
cultural competency. 

I think cultural competence has more to do with the basic 
understanding of what's going on. I think cultural fluency is 
understanding] the innuendoes, to understand the subtleties. . . (#3) 

Positive Feelings/ Feelings of Comfort 

Beyond the notionsof understanding and connection, anotlier tin read tliat 
wove tlirougliout almost every transcript of tfie interviews described tlie feelings of 
tlie participants during cross-culturallnteractions. Fortlie majority, these were 
positive. One emotion that was identified was that of feeling comfortable . 
There's that sense of comfort that I felt was there. Ithink thatyou 
need to feel comfortable with each other in any setting whether 
it'sjust a cultural or just an interaction. For it to be successful and 
competent, you need to feel comfortable. You have to have that 
comfort. (#6). 

When talking about a group of culturally diverse college friends and her 
experience with them, one participant stated. 

It was very comfortable. It was great. It was a supportive 
environment and I think that's what helped a lot in opening up. (#12) 
Relating a clinical experience that she observed, the same participant told of an 
elderly Egyptian woman who spoke little English. The therapist encouraged the 
family (including the grandchildren) to be part of the therapy session and to help him 
understand his client's needs. As a result: 

The patient was happy. She was always smiling. It was very 
comfortable with her It made it a more comfortable experience for the 
woman. (#12). 

Feeling comfort was identified in the pilot study also. Apparently, this is an 
important result for these participants, and it made me think about the awkwardness 
and discomfort that is sometimes present in cross-cultural interactions. It also made 
me wonder if this is a White/ privileged/ middle-class phenomenon. Would feeling 
comfortable be as important to someone from a non-dominant group? My 
supposition is that many non-dominant people in the United States rarely feel 
comfortable in a society that is viewed by them as hostile and oppressive. 

Many other positive feelings were identified as well. Participants used words 


such as the following to describe their culturally competent experiences. 

It was wonderful. It was good. Very rewarding. Such a feeling 
of accomplishment It was hard but it was also exciting and felt 
good. (#4). 

It felt good because I could explain it to him. So I was glad I could 
do that. (#1) 

Everyone is happy, laughing and having a good time. It's a positive 
thing. (#1) 

It was enlightening, a valuable experience. I felt more satisfied 
that maybe in the future I would be able to use (what I learned). 
Everyone was happy and satisfied. (#8) 

I think it feels wonderful It makes you feel a little bit more worldly. (#1 1) 

I enjoyed it. It would make me feel really good about myself I'd 
feel like I really accomplished something. (#10) 

These students described not only a sense of happiness and goodness, but 
many talked about a sense of success and accomplishment, a sense of 
competence. From the participants' words. It appears that acting in culturally 
competent ways is not only observable, but it can actually be felt by the person 
who has competent cross-cultural interactions. You know when an interaction goes 
well because you feel good about it. You can feel the pride of accomplishment and 
a sense of a job well done. What more can we ask for in our interactions with our 
clients and others who are culturally different from us. This is certainly something to 
strive for. 

In contrast, the study participants also talked about the feelings that arose 


from cross-cultural interactions that could not be characterized asculturallycompetent. 

In one example, a teacher was telling ethnic jokes to aculturally diverse audience. 

In the bad [experience] something offensive was done. Somebody 

was offended. (#6) 
Another participant described an incident where a parent assumed a therapist was a 
gay man and refused to allow her child to be treated by him. This participant was 
quite upset with the injustice of the situation. 

It mal<es me angry. I don 't think anyone deserves to be labeled 

unjustly or inaccurately. . . If I were in that situation (above) myself, 

I would definitely be offended. (#8). 
From a Jewish woman who was told by an acquaintance that all Jewish people 
have money came these words: 

It's like a slap in the face. It wasn 't supportive at all. I wanted to 

get out of there right away. I didn't want to come back and interact 

with that person. (#12) 
From another whose friend was being maligned because he was gay: 

/ would get angry at the general stereotypes. When you hear the 

generalizations it makes me more defensive. (#1 0) 
And from another student who described the results of a client interaction with a 
therapist who had few cross-cultural skills: 

The therapy was not client-centered. It was a waste of time, 

a waste of energy, and was frustrating. (#11) 

Other students used words like resentment, I'd feel bad, feeling anxious, 
disappointing, and sad to describe their feelings regarding negative experiences. 
The contrast in these words from those that described culturally competent 
interactions is clearly apparent. This is not the result we want from our interactions 
with clients, colleagues, acquaintances and friends who are culturally different. 

All of the varied outcomes of culturally competent care that have been 
identified by the study participants emphasize the importance of cultural 
competency in occupational therapy client interactions. As occupational therapy 


practitioners, our goal is to provide tine best possible care for each of our clients. For 

those who are culturally different this can only happen through culturally competent 
care. The participants of this study have clearly identified the important attributes a 
person must possess to be culturally competent and the characteristics necessary 
for culturally competent care. 

The thematic analysis above was necessary in order to construct the 
composite textural description which follows. 


The composite textural description is the synthesis of the individual textural 
descriptions. "The invariant meanings and themes of every co-researcher (study 
participant) are studied in depicting the experiences of the group as a whole" 
(Moustakas, 1994, pp. 137-138). These are then integrated to determine the 
combined themes. 

The experience of cultural competence and culturally competent care occurs 
through an effort of will which takes time, work, and personal investment. As a 
person develops competence in cross-cultural interactions, she holds and responds 
to changing attitudes towards groups different from herself in a pattern that may or 
may not be developmental, but is certainly hierarchical. It is not clear whether one 
must move through these various levels in order to become culturally competent, or 
if she could begin at any level, but these attitudes include ignorance, and then move 
up to tolerance, openness to difference, acceptance and appreciation. Many study 
participants believe that a person must at least be at a level of acceptance when 
interacting with people who differ from themselves in order to achieve cultural 

Participants related that in their experience, people who are culturally 
competent share certain attributes and characteristics. First of all, they choose to 
move in the direction of competence. This is a conscious and volitional decision, 
indicating a willingness to be self-reflective, to be open to others and their 
differences and similarities, and to maintain an attitude of respect towards others. 


Secondly, they must be willing to learn about others and their culture. Some 

of the knowledge that must be sought includes knowing the values, beliefs, and 
customs of the culture, and particularly the specific beliefs of the person from that 
culture with whom they work. Although one can learn much of this information through 
formal and informal study, the participants identified the single most important way to 
gather knowledge about others is through personal experience with people who 
differfrom yourself. Cross-cultural interactions can be, and often are, transformative in 
nature. One participant described it as the "ah hah" experience, where any previous 
knowledge gained from formal and informal study not only gets explored and 
challenged, but where one gets to practice cross-cultural behaviors. This is what 
makes personal experience so valuable. This experience can be gained through 
international study, through field trips across town, or by interacting with family and 
friends who are in some way culturally different from yourself. Students describe the 
opportunity to meet and interact with these folks as invaluable to their learning and 
the development of cultural competence. 

The final characteristic of cultural competence isthe practice of certain 
behaviors. One main point made by the majority of the participants is that being 
culturally competent is an active process. You mustactuallv do something. Most 
learned through their experiences that they had to take the initiative in interactions, 
particularly being from the societally dominant group. You must thrust herself out 
there in an effort to connect with another person, and be willing to make yourself 
vulnerable, and you must do it time and time again. Acting in a culturally competent 
manner isacommitment. 

Some of the particular behaviors noted and experienced include 
communicating effectively, using both verbal and non-verbal skills. If a person 
speaks a language other than English, it is vital to find an interpreter so that 
communication can occur. In addition, culturally competent interactions and care may 
include adapting the way you usually do things In order to accommodate the other 
person's beliefs and customs. Compromise often provides a satisfactory result. 
Changing a treatment goal to one that meets the interests or cultural beliefs of the 


client is one way to compromise. The study participants believe that culturally 

competent care is a necessity if client centered care is the goal. 

The study participants identified important outcomes of culturally competent 
interactions. These include feeling a sense of connection and collaboration with the 
other person, which contributed to further positive interactions and an ability to work 
well together. Additionally, they talked about feeling comfortable in cross-cultural 
situations. For them, this sense of ease and comfort with one another was an 
important result of effective and competent interactions. They also spoke of a sense 
of satisfaction about the process and a feeling of success that provides the internal 
feedback that the experience can be identified as being culturally competent. In 
summary, the study participants believed that although becoming culturally 
competent and providing culturally competent care takes commitment, time, and 
work, it is well worth the effort. 


The composite structural description isconstructed from the individual structural 
descriptions to present "a picture of the conditions that precipitate an experience and 
connect with it" (Moustakas, 1 994, p. 35). This is a way of "understanding how the 
co-researchers (study participants) as a group experience what they experience" 
(p. 142). 

The perception of cultural competence and experience with culturally 
competent interactions and culturally competent care is influenced by the study 
participants' ability to self-reflect, by their personal experience with people who 
differ from themselves and by their own racial or cultural background. Those who 
were self-reflective seemed to be further developed towards cultural competency. 
Reflection of themselves as cultural beings seemed to lead this group of participants 
to be more sensitive to, and willing to learn more about, those who are culturally 
different from themselves. 

Although learning about diversity through formal educational processes is 


useful, it is the opportunity for personal interaction that provides transformational 

learning that has most meaning to the students and changes their perceptions. 
Although all participants state that it takes hard work and commitment to become 
culturally competent, and all could recognize culturally competent care when they saw 
it, many did not feel that they had yet achieved that status. However, those who 
had experienced numerous cross-cultural interactions approached new 
opportunities with openness, excitement, wonder, and a kind of fearlessness that 
allowed them to not only initiate interactions, but to thrust themselves out there over 
and over again, if necessary, to make connections with those who are culturally 
different. About half of the participants (5 out of 11 ) exhibited highly developed 
self-awareness and were confident enough to put themselves in a position of 
vulnerability where they might make cultural mistakes or be rejected. However, for 
these participants, the joy and wonder of learning about others was worth it. 

The other six participants who had had fewer personal experiences were 
open to learning about others but more tentative in their approach. They often 
spoke about growing up in neighborhoods where there was little diversity, which 
they felt was a barrier to learning about others. But by moving to an urban area, or 
taking courses about difference, or meeting culturally diverse people in college or 
while traveling, their knowledge grew and their attitudes changed. Forthese 
participants, moving towards cultural competence is an important goal, particularly as 
health professionals, but the journey seems more arduous for them. There was little 
of the joy and wonder expressed that was seen in the participants with the greatest 

Although all study participants were Caucasian, two self-identified as Jewish. 
For one of the Jewish participants, her culture/ethnicity certainly influenced her 
experience with cultural competence, as she described being oppressed and 
different from the majority of her friends. She related how she could better 
understand and empathize with those who were culturally different. The other Jewish 
participant did not demonstrate any particular sensitivity towards others, however, 
nor did she seem to be more developed in cultural competency given her 



Therefore, given this small sample of participants, no definitive or generalized 
statements can be made regarding one's own minority status and its relationship to 
the development of cultural competence. The main difference between the two 
Jewish women identified above was their ability to be self-reflective. I believe this 
attribute contributed significantly towards their development of cultural competence. 
One concept that may have been more closely related to racial identity and majority 
status however, is their willingness to allow themselves to be vulnerable in cross- 
cultural interactions (mentioned above). Being part of the privileged majority allows 
us to take more risks, because there is a greater sense of safety. The study 
participants may be reflecting their privileged status as they talk about initiating 
action, thrusting themselves out there, and committing to do that time and again even 
if rejected. Only someone who feels quite secure in herself and her world would feel 
free to interact in that way. 

(The Essence of Cultural Competence) 

The final step in Moustakas' (1 994) methodology is to integrate the 
composite structural and composite textural descriptions, "providing a synthesis of 
the meanings and essences of the experience" (p. 1 44). The essence of cultural 
competence, as perceived by the study participants, is stated below. 

Culturally competent interactions are clearly recognizable from those that are 
not. Likewise, people who are culturally competent are readily apparent as well. 
Additionally, there is a range of attitudinal levels which people have as they move 
towardscultural competence. 

The first level, ignorance, often occurs when people have had no personal 
experience with others who are culturally different from themselves. Usually, there 
are few people in their lives who model cultural sensitivity or cultural competent 
behaviors, and the news and other media offerings tend to solidify stereotypes of 


different groups of people that are common in tlie dominant culture. At this level, 

people make erroneous assumptions about others based on these stereotypes, 
have little cultural self-awareness, and little openness to or interest in learning about 
others. This level could be considered Cultural incompetence. 

Tolerance towards culturally different people is an attitude that someone 
adopts because of a beginning awareness of difference. It closely allies with a 
sense of being "politically correct" (in the more negative understanding of the 
term)(Wilson, 1 995), in that a person feels that they should try to be nice to 
someone else. Although a person who is tolerant of differences is aware of not 
being disrespectful, It is a more superficial attitude that does not yet move a person 
to acceptance of people who are culturally different. 

The next attitudinal level is an openness to difference which is a hallmark 
disposition of Cultural Sensitivity. Being culturally sensitive means not only 
being aware and open to difference, but also recognizing that difference is an 
important factor, especially to the person who is culturally different. At this level, 
people can recognize the uniqueness and the strength of that difference, and are 
generally interested in learning more about others. 

Openness to difference is also seen with Cultural Competence, but it is 
the attitude of acceptance that is the hallmark at this level. Although people who 
are culturally competent may or may not pass through the levels identified above, it 
is clear that they share certain attributes. Not only do they respect and accept others, 
they are aware of and accept themselves as cultural beings, and share a 
willingness to reach out to others. Being culturally competent is a volitional act. 
People choose to initiate cross-cultural interactions, and are willing to place 
themselves in a position of vulnerability in order to learn more about, and interact with 
others. Having the confidence to do this may be more of an attribute of privileged 
Whites, who may be more secure in US society than those who are non-dominant. 
Culturally competent people are also knowledgeable about themselves and 
others or actively seek knowledge in order to improve their cross-cultural interactions. 
Although learning may occurthrough more traditional formal (academic classes and 


workshops) and informal (self-study, novels, movies and other media) means, the 

learning activity that is most meaningful and transformational is the actual personal 
experience of interacting with someone who is culturally different from oneself. It 
appears that the more positive cross-cultural interactions one has, the more one is 
motivated to learn about, and interact with others, and the more skilled they become. 
Specific behaviors are also apparent in people who are culturally competent. 

Although it is important to be open to others and willing to interact, as well as 
to be knowledgeable, it is only with the development of specific skills and/or 
behaviors that one is actually culturally competent. People cannot be passive 
participants in this process but must take action. They must do something. 
Active engagement is often demonstrated by using respectful communication which 
includes asking questionsto clarify and to learn, listening well, paying attention to non- 
verbal cues, and sometimes employing an interpreter. Within culturally competent 
care, communicating well may Include all of the above as well as speaking slowly 
and distinctly, waiting patiently for the response, demonstrating what you want the 
client to do, or having the client demonstrate for you. It may also mean using humor 
which is shared or self-deprecating. 

Another behavior observed during culturally competent care may include the 
therapist changing the way she typically practices in order to accommodate the 
values, beliefs and wishes of a culturally different client. For example, the 
occupational therapy practitioner may completely change her goal of teaching an 
elderly Italian man how to dress, when she learns that the women of his family 
believe that it is their duty and privilege to take care of him in that way. Listening well 
to what the client wants and working together towards those goals is effective client 
centered care. True client centered carecannotoccurwithculturallydifferent clients 
without culturally competent care. Compromise is also seen during culturally 
competent care. Oftentimes the client and the practitioner must work together to 
arrive at an intervention goal or solution that Incorporates behaviors that reflect the 
client's beliefs as while providing the most effective therapeutic Interventions. For 
example, an infant with low muscle tone will develop a stronger back and Improved 


erector muscles if lain prone on a firm surface. However, a Navaho custom is to 

always place the child on a pillow when on the floor. Because a goal of both the 
practitioner and the family is a stronger and better-toned baby, the therapist may 
relax her own recommendations about resting positions and help the parents find 
other play activities that will strengthen the infant'sback musculature, and/orthe family 
may agree to lie the child prone without a pillow for a certain time period each day. 

Theresults of culturally competent interactions and care include greater 
understanding between people, which leads to stronger connectioris or rapport and 
increased collaboration or the ability to work together. Emotionally, the participants in 
this study talked about being more comfortable around others, and achieving a 
sense of success and accomplishment with these positive interactions. These 
reactions may be due in part to their privileged status within the society. It is not 
known whether people from other non-dominant groups would identify the same 
feelings and reactions. 

Although cultural competence is often the goal of people who want to 
experience effective cross-cultural interactions, perhaps surprisingly, it is not the 
ultimate level one can achieve. Another level identified as Cultural Fluency is 
characterized by the attitude of appreciation. Becoming culturally fluent is achieved 
by only a few, and happens if one has significant experience, such as an immersion 
experience, with a cultural group. By having intimate knowledge of a group of 
people and their beliefs, values, customs, and language, one can appreciate, 
understand and respond to the subtleties, the unwritten rules of conduct, the 
colloquialisms of the language, the innuendoes, and the unexpected in an effective 

In summary, cultural competence is perceived of by these study participants 
as an objective that occupational therapy practitioners must strive for in order to offer 
client-centered, appropriate care to their clients. However, it takes time, 
commitment, and hard work to achieve. But as the participants in this study who 
have experienced culturally competent interactions have averred, it is well worth the 



Moustakas (1 994), describes the final chapter of a phenomenological 
research report as a summary review of the study where "the researcher returns to 
the literature review and distinguishes herorhisfindingsfrom prior research, outlinesa 
future research project that would advance knowledge on the topic, and discusses 
the outcomes of the investigation in terms of social meanings and implications as well 
as personal and professional values" (p. 1 55). He adds, "Development of a 
summary section of transcendental phenomenological research is an important 
challenge. If offers a kind of abstract of an entire investigation and in a brief span of 
material enables other researchers to determine its relevance to their own research 
pursuits and whether or not to review the entire research report" (p. 1 56). Within 
these guidelines, Moustakas Includes the following in the final chapter: a summary of 
the study, comparison of findings to the literature (the discussion section), limitations 
of the methodology and of the study, implications, future research, and a "brief, 
creative close" (p. 1 84). This chapter will follow the guidelines outlined above in an 
attempt to meet that challenge. 


Initially, I began this study to try to determine whether occupational therapy 
students who had received education that included diversity and multicultural content 
in their curricula saw themselves as developing cultural competence. This question 
arose from my own experience as an occupational therapy educator who was 
attempting to reach that goal. Recognizing the changing demographics and 
increasing diversity in the United States, I knew that occupational therapy 
practitioners needed to be culturally competent in order to offer client centered care to 
the recipients of their services. I had been introducing and integrating the concept of 


culture and its impact on occupational choice within my own courses for years, but my 

increased interest in and study of cultural competence led me to realize that I needed 
to do more. As I revised my own curriculum, I wondered about the impact of these 
alterations. What was the outcome of my teaching and how did it effect student 

As I began the literature search on the concept of cultural competence, I was 
led beyond the field of occupational therapy, which has limited resources, to other 
health-related disciplines, namely nursing, social work, and counseling psychology 
(chapter two). I examined what the literature had to say about the characteristics of 
cultural competence, educating for cultural competence, and the related outcome 
research. During this process, I recognized the need to explore students' 
perceptions and experiences as a way to evaluate how they understood the 
concept of cultural competence. There was a plethora of empirical studies, but a lack 
of student voices or personal responses in the literature, and I decided to begin to fill 
that gap with my own research. I chose to use phenomenology as a methodology, 
and after examining some of the literature on that subject, I decided to use the 
method outlined by Moustakas (1 994) (chapter three). I realized at that point that 
my dissertation study would not be a traditional outcome study of occupational 
therapy curricula as I had first imagined, but I projected that I would gather data that 
would inform educators in important ways. 

I determined that 1 could, yet should not, examine the students that I was 
teaching for my dissertation study. Not only could I not be objective, but as director 
of the occupational therapy program, there was a power differential between myself 
and my students that would likely interfere with the way students responded to me 
during the selection and interview process. I did complete a pilot study on two 
students in my program, in order to practice using the methodology I had chosen. I 
then sought out, selected, and interviewed twelve occupational therapy students 
from two urban universities in the Northeast. Data was analyzed only on eleven of 
these students, however, as the audio tape for the twelfth person was lost by the 
transcriptionist I had hired, and I had not made a back-up tape. 


Data analysis (chapter four) followed Moustakas' guidelines and culminated in 

a composite description of the essence of cultural competence as perceived by the 
study participants. Within the analysis, however, the following three findings 
emerged from the data. 

1 . Students perceived a hierarchical framework of attitudes for cultural 
competence that corresponds with a cultural competence continuum outlined 
by Cross et al. (1 989) (described earlier in this paper). 

2. Students identified the essential attributes of cultural competence that I 
subdivided into three subcategories, 

a) an attitude of willingness that emphasizes the importance of a 
volitional act 

b) knowledge of self, others, and the social-cultural-political world 
within which they live, and 

c) behaviors that are learned through cross-cultural experiences. 

3. Students identified the outcomes of culturally competent interactions. 
As I complete the data analysis, I recognize that the findings do not 

specifically evaluate the occupational therapy curricula from which the study 
participants come. I did not try to correlate curriculum with the responses of the study 
participants but took a broader view that included their education as one aspect of 
their experience and life history. However, as I earlier surmised, the findings are and 
will be important for occupational therapy educators. Teaching for cultural 
competence is vital. By understanding how students currently understand the 
phenomenon, educators can strengthen their teaching in this area to offer students 
what they need to begin to develop competence In cross-cultural interactions. The 
following sections of this final chapter will provide a discussion and implications of the 
findings, acritique of the research methodology, and suggestions for further research 
in the area of cultural competence. 

Discussion of Findings and Implications 

The essence of cultural competence defined by the participants in this study 
did correlate in many respects with concepts found in the literature. They identified 
certain attitudes which seemed to fit within a cultural competency continuum identified 
by Cross et al. (1 989), and also identified essential characteristics they perceived in 
a culturally competent person. These fell into three subgroups and were quite similar 
to those identified by numerous authors as awareness, knowledge and skills 
(Kavanagh & Kennedy, 1992; Lynch & Hanson, 1998; Pedersen, 1988; Pedersen 
& Ivey, 1993; Wells & Black, 2000). The study participants, however, emphasized 
certain characteristics and expressed some major differences from the information 
found in the literature. It will be those that I will discuss in this section. 

Willingness: The Volitional Aspect of Cultural Competence 

One of the most intriguing findings from this study was the notion that being 
culturally competent is a choice. One must be willing to assert herself into a cross- 
cultural situation. Participantstalked about a w/VZ/ngness to; see/fOL/f and to find out 
(#3), to learn, accept and experience (#4), to listen and understand (#2), to be open 
(#6), to let go of our assumptions (#3), and to admit you don 't know anything (#6). 


Having the will to do something connotes having and making a choice. 
Choosing to participate in cross-cultural Interactions is a volitional act. It is important, 
therefore, to examine the concept of volition as part of this discussion. Gary 
Kielhofner is an occupational therapy theorist who has developed the Model of 
Human Occupation, a theoretical practice model and frame of reference for 
occupational therapy practitioners (1 997; 2002). Because he has written quite 
extensively about the concept of volition, and because his work is so widely 


respected within the profession, I will use his ideas to guide my thinking and 


Kielhofner conceptualizes volitional thoughts and feelings as pertaining "to 
what one holds important (values), perceives as personal capacity and 
effectiveness (personal causation), and finds enjoyable (interests)" (p. 44) Volition 
results from the dynamic interplay between these three. 


"Values refer to what one finds important and meaningful to do" (Kielhofner, 
2002, p. 15). Personal values often develop from societal and family values. At 
this point in US history, being sensitive to and having skill in cross-cultural interactions 
Is a developing societal value, particularly for the educated. It is expected that an 
educated person will at least be "politically correct" or culturally sensitive in their 
interactions with one another. Herbst (1 997) defines the term "politically correct" in 
the following way. 

Politically correct describes the efforts of those seeking to deal politically 
with such social and political issues as (1 ) bias related to race, ethnicity, 
religion, sexual orientation, gender, and age; (2) prejudice against the 
physically or mentally impaired or those of a stature outside the perceived 

norms; and (3) neglect of the natural environment A main goal of those 

involved with such issues has been to advance the principle of equality, 
(p. 183). 
I am using "politically correct" in the way Herbst defines it above, even though I am 
aware of the conservative backlash to the term and the societal movement related to 
it (Wilson, 1 998). Because of the increased awareness and sensitivity to difference, 
many people in the United States realize they should not talk about other people in 
a denigrating manner. However, even after adopting that societal value, and with the 
knowledge of what not to say, many people are still at a loss when it comes to the 
appropriate way to interact with those who are culturally different . 


Related to these societal beliefs, the American Occupational Therapy 

Association has developed a Code of Ethics and a statement of core values (Kyler, 
2002) that include the group's beliefs and values related to diversity issues. These 
documents guide occupational therapy practice and education. However, even 
though there may be societal and group expectations for certain behaviors, not 
everyone within a particular group will actually adopt the values or behaviors 
associated with a particular group. Not every occupational therapy student will 
choose to become culturally competent, despite the expectations of the 
professional organization. As a point of interest, not one of the study participants 
mentioned the Code of Ethics of the American Occupational Therapy Association, 
although I am sure that they have all been introduced to it because it is mandated in 
the accreditation standards of the profession. 

However, many of the participants in this study expressed the ways they 
valued cultural competence and culturally competent interactions and care. When 
questioned about a competent clinical interaction that she described, where the 
therapist respectfully questioned an Asian family whose body language was hard to 
understand, one student (#8) stated, / think it'sa valuable experience. When asked 
why, she stated, I felt satisfied that I got something out of it. Forthis participant, what 
was important and meaningful to her was the fact that she was learning from the 

Others talked about particular values they learned as children. Participant #1 

It's how I was raised and the values I was taught [such as] to appreciate 

and be open minded to everyone, and [that] people are individuals. 
She demonstrated this value by taking the time to get to know someone ratherthan 
close herself off to those who were different than she. She went on to apply this 
particular value to a clinical setting, stating that it is important to take the time to pay 
attention to someone. . . and treat them like the person they are, aside from their 

In a similar vein, participant #1 1 spoke about the values she was taught from 


her family. I've been brought up with the understanding that there's a variety of 

ways to live and no one way is the right way For both of these participants, the 
values they learned early in life have contributed to their choice to develop cultural 

Not all participants attributed their values to what they were taught as children, 
yet they did clearly speak about what was important and meaningful to them. 
Many identified how they valued being open minded. The words of participant #10 
are reflective of many of the others. 

/ think it's extremely important to open yourself up to new experiences, and 

have an open mind to find out about something before you judge it or 

ignore it (#12) 

Some talked about the importance of respecting others. Being who I am, I 
tend to respect people... you show your respect in different ways. (#6). Many 
identified how important it is to learn about others. During the interview, study 
participants were asked to describe the best cross-cultural interaction they could think 
of. When asked what made this particular situation the "best", one participant 
replied , Openness to learning and a lack of ignorance (#12). Another student who 
felt that learning was key, expressed it this way. Knowledge is power, essentially. A 
lot of times people aren't at fault [when they make cross-cultural mistakes]. It's just that 
they've never learned any different (#10). 

Many other values were expressed by the participants of this study. 
However, these examples of how they valued being open-minded, respecting the 
uniqueness of individuals, and learning atx)ut others support Kielhof ner's (2002) 
premise that one's values contribute to their volition. These concepts are important 
to the participants listed, and will positively influence them when given a choice 
whether to move towards cultural competence or not. 

Personal Causation 

Personal causation correlates with a sense of personal agency and relates to 


an awareness of how effective one perceives herself to be when interacting in her 

environment. Kielhofner (2002) identifies two dimensions of personal causation. 
The first of these dimensions , sense of personal capacity, is a self- 
assessment of one's physical, intellectual, and social abilities. . . The second 
dimension , self-efficacy, is the thoughts and feelings one has concerning 
perceived effectiveness in using personal abilities to achieve desired 
outcomes in life. . . ; that is, we feel more able to control outcomes in certain 
circumstances than in others. Persons who feel capable and effective will 
seek out opportunities, use feedback to correct performance, and persevere 
to achieve goals (p.46). 

How does this apply to the idea of someone choosing to engage in cross- 
cultural interactions? I interpret Kielhofner's definition to mean that someone must 
have a positive awareness of herself as a sociocultural being who has the confidence 
to approach others and learn from that interaction. If that confidence has not 
developed from childhood, it may result from incidental Interactions. An example 
from the data is the story one participant shared during her interview. She related 
that she had feared African Americans because she had had little contact with them, 
and had learned negative stereotypes from the media. She not only was not 
confident In her interactions with African Americans, she actually was afraid to interact 
with them. While waiting at a bus stop one day, a young Black man came up to her 
and told her he liked her shirt. She became frightened and moved away. He 
courageously followed her and gently told her that he only wanted to compliment her 
on her shirt, and then he walked on. Her response was, 

although I felt silly, it really helped me out. It was very brave of him too. He 
didn't have to do that, but in a small way, he had educated me; at least 
enlightened me on my ignorance. And that is always the first step. (#3). 
This was a defining moment for this participant, moving her to evaluate her personal 
assumptions and causing her to begin to learn about others. Using Kielhofner's 
terminology, she used the feedback provided by this stranger to correct her 
performance, and went on to relate her later success with cross-cultural interactions. 


Although this participant believes she still has a lot more to learn, she does feel that 

her interactive skills are much more effective than those she possessed with that initial 
interaction. Her sense of personal causation has improved. 

Another student described a school trip to Paraguay where the team she 
traveled with had an opportunity to work with children and their parents on dental 
hygiene. She didn't speak the language and knew little about the culture entering the 
project, nevertheless, the experience resulted in very positive outcomes. 

/ think the fact that we were able to communicate and click, and get through 

to people who have come from such a completely different background. . . 

[This made it] a wonderful experience. It is also such a feeling of 


This participant's sense of efficacy was quite high as a result of this positive 
interaction, even though she had initially evaluated her personal capacity (inability to 
speak the language, knowledge of the culture) as low. The positive experience 
resulted in a strong sense of personal causation. 

It seems then, that the more one has the opportunity to interact in cross- 
cultural situations, learn from them , and alter one's behavior, the better is one's sense 
of personal causation in a multicultural world. 

Just having that positive experience . . . set the stage so that I'd be 

comfortable in other situations where I 'm interacting with a person who 's 

different than I am (#6). 
This supports the importance of providing cross-cultural experiences which will be 
discussed later in this chapter. 


The third component of volition is one's interests. "Interests are what one 
finds enjoyable or satisfying to do" (Kielhofner, 2002, p. 53). They can be simple 
pleasures such as making cookies for a grandchild or one's grand passion such as 


composing a symphony. Enjoyment from a task may arise from sensory pleasures, 

from intellectual fulfillment, from aesthetic satisfaction, or a "sense of association and 
fellowship experienced" (p. 55) when interacting and doing things with others. Being 
interested in something means we prefer to do that task over some others. It allows 
us to make a choice based on that preference (Kielhofner, 2002). 

The study participants often spoke of the enjoyment of interacting with 
someone who is different from themselves. When asked what an overseas 
experience was like for one participant, she replied. It felt good. I remember being 
very excited (#4). Another student related her experience working in a Japanese 
company with several Japanese co-workers. / enjoyed it. I had been with these 
people for a long time so I was very comfortable with them (#7). When describing 
her experience with the deaf culture and with friends who are East Indian, a third 
participant expressed her feelings this way. I think it feels wonderful. It makes you 
feel a little bit more worldly (#1 1). For this participant, some of the enjoyment she 
felt from this experience came from her sense of increased sophistication and 
knowledge which broadened her world view. These words clearly demonstrate a 
feeling of enjoyment shared by these participants, which according to Kielhofner 
(2002), contributes to their interest in cross-cultural interactions. 

Kielhofner (2002) believes that it is the dynamic interaction between one's 
values, interests, and sense of personal causation that contributes to a person's 
volition. This notion was evident in the participants from the way in which they 
described their experiences. The data analysis of this study indicated that the 
participants valued effective cross-cultural interactions, although two of them talked 
about it as an emerging, not a realized, value for them. Furthermore, the majority of 
the participants indicated that their sense of personal causation was enhanced by 
their cross-cultural interactions, and that these experiences were enjoyable to them 
and piqued their interest. All of these factors contribute to their motivation to choose 
to interact with people who were culturally different from themselves. 

Levels of Willingness 

Kielhof ner's (2002) concept and discussion of volition contributes to tlie 
realization that being willing to, or choosing to embrace the attitudes, knowledge and 
skills to become culturally competent is a complex task. His theory helps us to 
understand what volition is and how this might occur. It doesn't, however, enlighten 
us as to why the participants in this study often talked about the concept of 
willingness. Did everyone in this study demonstrate the same level of willingness, or 
talk about willingness in the same way? The answer to the question is no. As I 
interviewed and then read and reread the transcripts of the interviews, I found myself 
thinking, "She really gets it" or "She's got a ways to go." I believe that part of my 
personal assessment was based on the way participants talked about their reasons 
for choosing to be part of these activities. 

Non-reflective Willingness 

Sometimes people choose to behave in a particular way because it is what 
is expected of them. With the increase of "political correctness" (PC) in the mid- 
eighties (Wilson, 1998), and an increased sensitivity to difference, many people 
recognize the need to use inclusive and less disparaging language than was used in 
the past when talking about people from non-dominant groups. With an Increased 
sensitivity to diverse groups in this country, people are often taught not to be 
disrespectful of one another. But like other kinds of learning, some people behave 
and respond to the lessons by rote, not really thinking about why they behave in this 
way, or really engaging in the learning in an active way. These people choose to 
interact with others effectively because they're 'supposed to' or they feel like they 
should. They are 'doing the right thing' not because of any internal drive, but because 
of external societal expectations. I call this level of willingness nonref lective 

Only two or three of the participants in this study demonstrated this. One 


participant was telling the story of someone who was telling ethnic jokes. When I 

asked her what was wrong with this she said, 

You're supposed to respect other people. . .and part of being a 
professional is respect for others and their differences, especially 
when you're a teacher (#6). 
This participant recognized that the expected behavior of a professional is to respect 
others which means that you don't tell ethnic jokes. She had learned that lesson well. 
But she did not add anything else that might have indicated that she had an internal 
awareness of the oppression, injustice and hurt inherent in such an act. This 
participant would perhaps choose not to tell this kind of joke, but her decision might 
be grounded only in the expected behavior of someone in a professional role. 
Non-reflective willingness. 

Another participant was talking about how she might react to someone from 
the Middle East. 

/ don 't pretend to know more about the Arab countrfies] but I know women 
aren 't treated as well and are expected to obey the men. So I accept 
that. Over here I would [accept that behavior] too, especially if I was 
working with them [in a clinical setting]. You know, I'm not going to change 
it, [but] I don't have to respect it. (#5). 
This kind of cultural relativism is another way that some show non-reflective 
willingness. This student has learned the concept that each person has his or her 
own culture which should be respected as unique, but she hasn't reflected on the 
moral or eth ical conflicts that m ight arise from some cultural practices or customs. 

Students at this level of willingness are moving in a positive direction, but 
have much more work to do to truly develop a level of cultural competence that 
emerges from their own personal values. At this level, people may have quite a bit 
of cultural knowledge but still need to develop the areas of self-awareness and skills. 

Cautious WUUngness 

Approximately six students demonstrate a willingness to learn and behave in 
more competent interactive patterns, but are still hesitant, either being afraid to make 
mistakes or lacking the confidence in their abilities. This level of willingness I have 
labeled cautious willingness. 

/ think lam not as culturally competent as I would like to be because 
I don 't know more about what it means to confront the difference. . . 
'cause I don 't know enough about the difference, the minority, the 
different cultures. (#1). 
Although the participant above is unsure of her ability and her knowledge, she later 
indicated that she had a clear understanding of power and inequality, and issues of 
difference. She also exhibited some beginning skill in cross-cultural interactions when 
she reported her interaction with an African-American man at a party. 

/ didn't know him very well. Everyone else was White. I asked him "Do 
you feel funny that you are the only Black person ?" I didn 't know If that 
was an appropriate thing to ask him or not And he said, "Yeah." (#1) 
She went on to add that she may be more empathic because she is Jewish, and 
she is often in the minority as well. This woman had a significant amount of 
awareness and sensitivity, as well as knowledge, but was somewhat lacking in skill. 
She needs more practice with cross-cultural interactions to improve her skill and 
confidence, but is making good progress towards becoming culturally competent. 
She chooses to interact with others because of an internal drive to connect, and an 
interest in others. This is a very different level of functioning than that of unref lective 
willingness. The majority of the study participants seemed to be at the level of 

Committed Willingness 

The final level of willingness is what I term committed willingness. These 


are the participants who are not only willing to interact with others, but seek out 

opportunities to do so. They realize that they may make cultural mistakes and that 
they still have a lot to learn, but are eager to work with differing cultures and to learn 
from their mistakes. They have a 'bring it on!' mentality that iscontagious. Listen to 
some of the words of these participants. 

It's like accomplishing [something]. Look what I've come from. Look 
what I've learned. This is what it has been preparing you for. Oh, 
wow! There's a sense of excitement because you realize that there's 
so much more out there than just . . backing away. That's the beginning. 
That's opening a door to a whole new world. (#6). 
Another expressed it this way. 

[Experiences] are exciting, and good, and hard, too. 
For myself, traveling and meeting other people . . . are the best thing. 
I feel like I grow and have become who I am by knowing people with 
different experiences. A lot of stuff I've done in my life I never would 
have done if I hadn 't met people who were different than me. (#4) 
And, yet another. 

You have to be face to face with the person . . .ona daily basis. That's 
what I mean by exposure. You have to thrust yourself in there. You may 
get the door slammed in your face, but then you try again. You keep going 
and going. If you are willing, if you really are committed to understanding 
their culture, you will come back (#3). 
For these students, their willingness to interact with others arises from a strong 
commitment that more clearly embodies Kielhofner's (2002) dynamic interaction 
between their values, interests and sense of personal causation. Although these 
participants still have much to learn, their drive to become more culturally competent 
will increase the likelihood that they will attain this goal, and their excitement over the 
process will enhance that development. 

There are important implications for occupational therapy educators as we 
consider the ideas above. If becoming culturally competent Is a choice, the challenge 


for educators is to determine liow to motivate students to make that clioice. For 

Wliites, and we must remember that all of the participants in this study are 
Caucasian, choosing to engage in cross-cultural interactions may mean putting 
themselves into a vulnerable situation where they might make mistakes, are not In 
control, or may be rejected. For the dominant sociocultural group in the US, it is 
sometimes quite frightening to yield this much power. Why would anyone choose 
to do this? Educators might ask, what is the motivating factor? How can I facilitate 
students to want to choose to become culturally competent? And can I move them 
beyond the level of unreflective willingness? Can motivation and volition be 
fostered in an academic setting? An examination of Kielhofner's (2002) work on 
volition provides us with guidelines for an affirmative response. If volition is a 
dynamic interplay between values, interests, and personal causation, then an 
educator may attempt to develop teaching/learning strategies that will help students 
examine their own values about culture and diversity, spark their interest in learning 
more, and provide experiences that demonstrate that students can perform 
effectively in cross-cultural situations. 

Although this is a challenging task (even daunting to some), there are 
numerous resources available from the disciplines of nursing, social work, and 
counseling psychology to support faculty who wish to develop better 
teaching/learning strategies for developing cultural competence . Only afew 
resources are available within the occupational therapy literature, however. A listing 
and discussion of these resources can be found in chapter two of this paper. I 
believe that these findings issue a challenge to the profession of occupational 
therapy to develop and/or support the development of teaching/learning guidelines 
and resources for the facilitation of cultural competence. 

Self -A wareness 

Another interesting finding from this study is the participants' failure to identify 
self-awareness as an important characteristic of cultural competence, compared to 


many authors from the literature (Kavanagh & Kennedy, 1 992; Pedersen, 1 988; 

Pedersen& Ivey, 1993). Some of these authors even emphasized self-awareness 
as the most vital characteristic of the three which also includes cultural knowledge and 
skills (Chan, 1990; Harry, 1992; Lynch & Hanson, 1998; Weaver, 1999; Wells & 
Black, 2000). Surprisingly, only three of the study participants identified self- 
awareness as an attribute of cultural competence. I have to question why there is 
such a discrepancy between the reports in the literature, and the perceptions of 
these study participants. Was it the lack of cultural Insight by the participants? Have 
they not had any training that emphasized the importance of cultural self-awareness 
as part of the development of cultural competence? Was it related to the maturity or 
development of the participants? Although the data don't provide the answers to 
these questions, an exploration of cognitive development theory and its relationship 
to the development of self awareness might be instructive. 

I found very little information on the development of self-awareness as I 
reviewed the literature on cultural competence. Although Cross et al. (1989) 
identified a continuum of development of cultural competence, they did not address 
how an awareness of self occurs as part of the process. Leonard and Plotnikoff 
(2000) state that "becoming culturally aware is an awakening process in those 
committed to their own development and desire to serve others" (p. 53), but they 
do not delineate how that process occurs. McPhatter (1 997) touches on the process 
when she discusses the development of "enlightened consciousness" which she 
states "requires a radical restructuring of a well-entrenched belief system that 
perceives oneself and one's culture, including values and ways of behavior" (p. 
262). This process includes: 

* a shifting of consciousness and awareness of just how narrow one's 
socialization has been 

* critical review of one's beliefs and values 

* acknowledgement of the shortcomings of one's education and socialization 

* expression of the need to expand our knowledge and understanding of 


* a commitment to do the work necessary to move from the comfort of a 

monocultural existence to a multicultural existence (pp. 263 - 264). 
An examination of the words of the study participants indicate that many are following 
the pattern that McPhatter suggests, but more needs to be understood about the 

In a very recent article, Wittman and Velde (2002) briefly analyze and 
compare the ability to attain cultural competence with the development of critical 
thinking. Using the cultural continuum identified by Cross et ai. (1 989), (and 
described elsewhere in this paper) as their descriptor of the development of cultural 
competence, and comparing it with Perry's (1 970) scheme of intellectual 
development, Wittman and Velde conclude that it is not possible for occupational 
therapy educators to develop the critical thinking skills necessary for the 
development of cultural competence. They base this argument on literature (King, 
Kitchener, & Wood, 1985; Welfel, 1982) that suggests that occupational therapy 
students will not perform beyond Perry's dualistic and multlplistic intellectual levels. 
Perry's theory is based on the way students understand and respond to authority 
and how they view the relationship of authority with knowledge acquisition. Wittman 
and Velde summarize Perry's levels in the following way. "The dualist sees authority 
figures as "all knowing" and looks to authority and the environment for the "right" 
answers. . . In the multiplicity stage, the individual sees knowledge as a matter of 
opinion" (p. 455). Their premise is that this is the way occupational therapy students 

One argument against this theory is that occupational therapy educational 
programs are required to move to an entry level master's degree in 2007. Many of 
these programs will be post-baccalaureate programs catering to and attracting adult 
students. My own experience as the director of a program such is this has been with 
students that range in age from 23 to 55 who have numerous life experiences that 
have moved them to cognitive levels far beyond those identified by Wittman and 
Velde (2002). One can assume that many of these students are functioning at a 
higher cognitive level than Perry's (1 970) dualistic and multlplistic stages, and do 


have the critical thinking skillsto move towardscultural competence. 

Although Wittman and Velde's (2002) correlation of the development of 
cultural competence with the development of critical thinking is an interesting 
premise, I believe it is too simplistic. Cultural competence happens as a result not 
only of intellectual but also affective development. It is not clear how self-awareness 
fits into Perry's (1 970) scheme. 

It is not until I turn to feminist literature that I find a theory of development that 
combines both intellectual and affective components. Belenky, Clinchy, Goldberger 
and Tarule (1 986) in their classic work Women's ways of knowing: The development 
of sell, voice, and mind, identify a hierarchy that includesthe development of self 
awareness as part of subjective knowing. An aspect of subjective knowledge is 
moving from a place where others' voices determine how you think and sometimes 
who you are, to a place where you begin to examine yourself as a viable knower 
and thinker. It is here that women "begin to assert their own authority and autonomy" 
(p. 77) and demonstrate an "increased experience of strength, optimism, and self- 
value" (p. 83). Debold, Tolman, and Brown (1996) describe this as "self-as- 
knower" which "describes an ongoing process in which "I" creates self from moment 
to moment within the context of internalized and situational power relations" (p. 92). 
They cite Mead (1 934/1 967) when he concluded that "there are all sorts of different 
selves answering to all sorts of different social reactions" (p. 1 42). According to these 
authors, the sense of self and self-awareness shifts as one experiences multiple 
social interactions which confirms one's recognition as self-as-knower. Recognizing 
that one is able to think for oneself is a heady feeling, leading to increased self- 

I observed some of the behaviors identified above in the study participants 
who came from backgrounds with little diversity, where they may have heard or 
been taught racist or monocultural views as children. These women developed their 
own, more enlightened perspectives on culture and diversity when they moved 
away from home and into a more diverse environment. As a result of that shift, and 
the experiences that they have had within that more diverse environment, many 


were able to voice their own ideas about culture and diversity, reflecting personal 

and subjective thinking and knowing, as opposed to presenting only ideas given to 
them by others (Belenky et al. 1986). 

The theories above provide a beginning understanding of the development 
of self-awareness as a cognitive process, and touch upon how this development 
may impact one's ability to become culturally competent. Although the discussion 
above may provide some insight as to why only three of the study participants 
identified self-awarenessasan important characteristic of cultural competence, more 
research is necessary to clearly identify the connection between self-awareness, 
cognition, critical thinking and cultural competence. 

I believe these study findings also have important implications for 
occupational therapy education. It is clear from the literature on cultural com petence 
that self-awareness is an important and vital attribute. Therefore, it is imperative for 
educators to help students develop their cultural self-awareness through learning 
exercises and strategies that help a student understand her standing and position 
within her sociocultural context, and how that sociocultural position impacts people 
from other contexts and cultures. For Caucasian students (and faculty), this will mean 
an examination of White privilege and the impact that may have on clinical practice. I 
have found that White students are often resistant to this work at first, but as they 
begin to become more aware of their privileged status in our society, their entire 
world view begins to change in a way that makes them more open to learning about 

Although those who write about White privilege note that this is difficult work 
(Frankenberg, 1993; Howard, 1999; Kivel, 1996; Mcintosh, 1988; Paley, 1996), I 
would argue that without this kind of work and this kind of education, without the 
development of one's cultural self-awareness, students will not attain the goal of 
cultural competence. 

Learning Through Experience 

Having cultural knowledge is one of the attributes of cultural competence 
identified both by the study participants and the literature. However, the students' 
concept of essential knowledge was quite limited in comparison to that found in the 
literature. Although the participants identified several items in a long list (chapter four) 
that they perceive are important to know, most of those items identified fell within the 
category of learning about others and their culture, and some fell within the category 
of self-knowledge. When discussing knowledge necessary for cultural competence, 
the literature recognizes the categories mentioned above by the students, but also 
considers a broader knowledge of societal roles, expectations, and issues of power 
and privilege (McPhatter, 1 997). Perhaps the students in this study did not identify a 
broader range of relevant information because they have not had an opportunity to 
learn this information, and have not studied the concept of cultural competence in the 
way the authors have, either formally or informally, or had the opportunity to apply it 
in cross-cultural situations. 

There are multiple methods through which students can gain knowledge 
about themselves and others, many of which are identified by both the study 
participants and the literature. But the most effective and perhaps transformative 
learning strategies identified by the study participants are those that actually involve 
cross-cultural experiences. 

To actually be there and to have it be part of your experience and to see it 

and to feel it and to share it. All of a sudden it really hits home. It means 

something. It's real, not just a vague notion of what it would be. I think it 

opens your mind (#9). 

Experiential learning theory has proven over and over again the old adage, 
'experience is the best teacher.' Drawing on the works of the Russian cognitive 
theorist, Vygotsky, and Dewey, Lewin, Piaget and other educational theorists, Kolb 
(1 984) makes the case that "learning from experience is the process whereby 
human development occurs" (p. xi). Kolb later states that learning is "a process 


whereby concepts are derived from and continuously modified by experience" (p. 

26). I recognize the accuracy of that statement when I listen to the words of the 
study participants as they talk about how their understanding of people and a culture 
changes when they have an opportunity to actually interact with those particular 
people or that culture. 

/ read a lot and have people tell me about things. . . but until I go out and 
actually see it, it's abstract. But once you 're doing it, and once you 've done it, 
it becomes real. . . It's kind of like that "ah hah " moment. (#6). 
Within the cultural competence literature, several authors mention, but don't 
emphasize, that experience with people who are different from yourself is important 
in the development of cultural competence (Jones, Bond, & Mancini, 1 998; Kiselica, 
1991 ; Kramers Bateman, 1999; Leonard & Plotnikoff, 2000; McPhatter, 1997; 
Pope-Davis, Prieto, Whitaker, & Pope-Davis, 1993; Sowers-Hoag & Sandau- 
Beckler, 1996). Pope-Davis, Breaux, and Liu (1997), however, are some of only a 
few authors who suggest that cross-cultural experiences might be fundamental, 
"because such in vivo experiences may provide the basis for reducing prejudice 
and racism" (p. 228). The authors cite the work of Stephan (1 987) who reported that 
research indicates that "contact situations among members of different groups are 
expected to improve intergroup relations" (p.232), a concept known as the contact 
hypothesis. Contact among multiethnic groups have shown to improve 
relationships, especially if certain conditions such as equal status and an accepting 
social atmosphere are present (Rothbart & Lewis, 1994; Stephan, 1987). Pope- 
Davis et al. go on to say that contact between groups is more effective if significant 
time is spent together. Research studies suggest that short cross-cultural or 
simulated activities may actually increase students' ethnocentrism and biases 
(Bruschke, Gartner, & Seiter, 1 993; Rothbart & Lewis, 1 994). Bruschke et al. 
attribute this finding to a lack of adjustment time following a period of culture shock. 
Based on their examination of the literature, Pope-Davis et al. (1 997) concluded that 
"the most valuable experiential exercise would be one of longer duration involving in 
vivo contact" (p. 232). 


A cross-cultural immersion and exchange program described by Jones, 

Bond, and Mancini (1998) builds on the ideas expressed by Pope-Davis et al. 
(1 997). In an effort to increase cultural competence in nurses in Dallas who work with 
an increasing number of Hispanic clients, a training model was developed that 
included a week of language and cultural learning experiences in Cuernavaca, 
Mexico for a group of Dallas nurses. The model also included an exchange 
program between nurses in Dallas and a hospital in Cuernavaca that would last 
between two and eight weeks. Upon evaluation of the project, Jones et al. found 
anecdotal evidence that suggested that participants greatly valued the experiences, 
but their major suggestion was to increase the length of the program. Jones et al. 
concluded that, although this model is a very positive step in the development of 
cultural competence, "the short duration of intense exposure may create a desire to 
learn more about the complexities within a specific culture, but it may also only 
highlight the need for additional intense, targeted experiences to continue the 
language and culture learning process" (1998, p. 287). 

In an effort to evaluate the effectiveness of cross-cultural practice on cultural 
competence, Kim (1 996) compared responses of occupational therapists who had 
only practiced in the United States to those who had practiced in another country for 
at least three weeks. Using the Multicultural Counseling Inventory (MCI) 
(Sodowsky, Taffe, & Gutkin, 1 991 ) and adapting the questions to address 
occupational therapists rather than counselors, Kim examined the four areas of 
awareness, knowledge, skills, and relationship of 94 participants. Using statistical 
analysis, Kim found overall significant findings for the group of therapists who had 
practiced out of the country, indicating that international experiences increase the level 
of cultural competence. Interestingly, she also found that the length of stay in another 
country positively correlated to the level of awareness, supporting the findings and 
beliefs of Pope-Davis et al. (1 997) and the other authors mentioned above. Kim's 
findings indicated that as the number of months of overseas practice increased, no 
matter which country the therapist practiced in, her self-awareness increased as well, 
as measured by the MCI. 


Research in cultural competence and in experiential learning theory supports 

the importance of cross-cultural experience in the development of cultural 
competence, and also indicates the Increased effectiveness of more lengthy 
experiences. Additionally, the current study participants identified their cross-cultural 
experiences as highly meaningful and transformational in nature. 

. . . things change me when it directly happens to me. I mean, I can read 
alDout things and l<now more, but [the experience] really impacts me (#1) 
Not only do those experiences alter the participants' understanding, it shifts their own 
sense of self - who they are in a multicultural world. As Kolb (1 984) might state, their 
own human development has progressed as a result of these cross-cultural 
interactions. There has been a transformation, not only in their knowledge, butin their 
very selves. Mezirow and his associates (2000) clearly explain this in the following. 
Transformative learning refers to the process by which we transform our 
taken-for-granted frames of reference (meaning perspectives, habits of mind, 
mind-sets) to make them more inclusive, discriminating, open, emotionally 
capable of change, and reflective so that they may generate beliefs and 
opinions that will prove more true or justified to guide action. . . Transformative 
learning has both individual and social dimensions and implications. It 
demands that we be aware of how we come to our knowledge and as aware 
as we can be about the values that lead us to our perspectives, (pp. 7-8). 
Mezirow's words resound with the literature on the development of cultural 
competence, where people learn about their own values and cultural perspectives in 
order to have a greater understanding of people from diverse cultures. The 
participants in this studyclearly articulated how personal encounters with culturally 
diverse people transformed their learning experiences 

The voices of the students in this study must be heard. Their perspective is, 
that although they can learn from a variety of means, it is the experiences they have 
had with people who are culturally different than they are that have the greatest 
meaning for them. Cross-cultural experiences transform the knowledge they have 
gained in the classroom into a conceptual understanding that is bigger and better than 


all the book knowledge they have gained. These experiences not only change what 

they know, It changes who they are. 

Although the participants Identified several other means of gaining 
knowledge, the experiences that they had with people who differed from 
themselves were the most meaningful for them. From this evidence. It became 
clear that cross-cultural experiences must be part of occupational therapy education If 
the goal is to facilitate the development of cultural competence for students. 

The Implications for occupational therapy educators are many. A 
determination must be made regarding the type and duration of these experiences 
and how these may be added to the curriculum. As stated above, the longer the 
experience, the more effective It is. This may mean changing curricula and course 
structure, increasing facultydevelopment offerings and training, and finding additional 
funding for faculty who can provide supervision during these experiences. 

Choosing the type of cross-cultural experience will differ with the educational 
facility. It might Involve working with an HIV-hospice center across town, or teaching 
a group of immigrant women how to use public transportation or public facilities such 
as laundromats, or providing leisure activities in an inner city boys and girls club. It 
might also Involve International study. Service learning projects are another effective 
way to engage students with community groups. 

Cross-cultural experiences can require no additional cost to the educational 
program or they could be complex and costly. There are many approaches that can 
be used to reach this goal and each occupational therapy education program can 
determine which approach fits their mission and abilities. The importance of 
providing these experiences, however, is clearly heard in the voices of the 
participants of this study. I believe it is important to listen carefully and to learn from 

Developing a Sense of Comfort 

Another intriguing finding was the participants' Interest In feeling comfortable in 


cross-cultural Interactions. Almost every participant spoke of it. Although they 

generally spoke of their own comfort, they also talked about the importance of 
comfortfortheother person orclient in across-cultural interaction. Iwascurious 
whether this was an attitude unique to this group of White students and went back to 
the literature to determine what had been written about this notion. I discovered that 
the Multicultural Counseling Inventory (MCI), an assessment tool designed by 
Sodowsky, Taffe, and Gutkin (1991), measures not only multicultural awareness, 
knowledge, and skills, but also a subsection called relationship. Within this area there 
are "eight items [which] measure the interaction process with the minority patient 
(e.g., comfort level, world view, and trustworthiness)" (Pope-Davis et al.. 1993, p. 
840). I scoured the literature for research studies that used this tool as an 
assessment measure for cultural competence with the following limited results. 

In the three research studies that were found using the MCI, the relationship 
sub scale was not mentioned in one (Pope-Davis & Ottavi, 1 994), and was not 
found to significantly correlate to any other variables in the other two (Kim, 1 999; 
Pope-Davis et al., 1 993). There was nothing specific to "comfort level" discussed in 
any of the articles and none of these studies contributed to my understanding of this 
concept. The lack of information did make me wonder why that subsection was 
included in the assessment by Sodowsky et al. (1991). 

However, other authors have included the issue of being comfortable in 
cross-cultural interactions. Kavenaugh and Kennedy (1992) address the importance 
of making the setting comfortable for the client In a list of goals they recommend "to 
facilitate communication among members of diverse groups" (p. 46). One study 
participant recognized this point as well. 

. . . by allowing family members [to be] there [in the clinic during a 

treatment session], it [was] a more comfortable experience for the 

woman (#12) 

Betances (1 999) talks about his use of humor to increase the comfort level 
while promoting multicultural understanding while other authors have a negative 
perspective of the importance of a sense of comfort in cross-cultural interactions. 


DeMott (1 999), in a provocative article entitled "Put on a happy face: Masking the 

difference between Blacks and Whites," comments on the need for White 
Americans to feel good about multiracial interactions. He talks about current films 
such as Pulp Fiction, White Men Can't Jump, Die Hard With a Vengeance, and the 
Lethai Weapon series which lull the American publlcinto thinking that racism is no 
longer a problem. The biracial friendships portrayed in these movies between the 
White and Black characters is "the stuff of romance" (p. 359) and dreams, but this 
kind of portrayal does help to make people of the majority feel more comfortable 
with others. DeMott concludes with : 

The vision of friendship and sympathy placing blacks and whites "all in the 

same boat," rendering them equally able to do each other favors, ... is 

a smiling but monstrous lie" (p. 365). 
Although DeMott's words might be considered by some to be harsh, I wonder if this 
is what is going on with the participants in this study. Do they search for that sense of 
comfort in multicultural interactions because it makes them feel better and "takes them 
off the hook" of looking more closely at the realities of the lives of people from 
sociocultural non-dominant groups? 

The participants spoke not only of their own comfort, but often of the 
importance of both parties feeling comfortable, 

/ think you need to feel comfortable with each other for it to be successful 

and competent (#6) 

The patient was happy and very comfortable (#12) 

[It was culturally competent] because the man was comfortable with it. (#1) 
I wonder if this is a concern mostly for Whites. Does a goal of being comfortable 
indicate a superficial level of interaction which does not permit the exploration of 
some of the "hard work" that is often necessary for good cross-cultural interactions? Is 
it a way for Whites to pacify themselves into thinking that everything is all right? 
Is this notion gender-related? Perhaps feeling comfortable in cross-cultural 
interactions Is more of a trait of women. Gilligan (1 993) and her colleagues have 
clearly identified the importance of maintaining relationships as a gender-related trait. 


Perhaps male participants would respond in a different way. 

Although I tend to think that the emphasis on being comfortable may be 
indicative of a more superficial or early stage of cultural competence, the data do not 
provide answers to these questions. Perhaps a better approach to developing 
cultural competence is to gently push people into a place of discomfort in order to 
elicit more profound interactions with one another. I think this is one aspect of the data 
that deserves more research. 

It is apparent from the data that being comfortable in cross-cultural interactions 
is important to the study participants and perhaps to students in general. What might 
be interesting is to explore with students what this sense of comfort means to them 
and how it contributes to their interaction patterns. This could be facilitated with self- 
awareness exercises, with journaling about their experiences, and with class or small 
group discussions about what makes them comfortable and uncomfortable in certain 
settings. It would be extremely interesting to include a group of ethnically and 
culturally diverse students to compare their reactions to those of the study 
participants who were all White women. 

Although much of the data from this study correlated with the literature on 
cultural competence, the findings discussed above provide some unique information 
that has important implications for occupational therapy education and research. I 
believe that these findings may provide a basis for future examination of the 
phenomena of cultural competence and culturally competent care. 

Summary of the implications for Educators 

I believe that the findings from this study have important implications for 
occupational therapy educators. First of all, educators must be cognizant of the 
characteristics of cultural competence, and knowledgeable about how these might 
be developed in students. They must also be aware of themselves as cultural 
beings, and know their own strengths and biases when working with those who are 
culturally different from themselves. This may mean additional faculty development 




for many, which translates into a need for administrative support. This requires 

faculty to educate their administrators regarding the importance of this work. 

Pedagogically, these study findings indicate that faculty need to provide 
learning experiences that develop cultural self-awareness in students, increase 
knowledge about the sociopolitical realities of our society, including issues of power, 
prejudice, and privilege, and provide opportunities to increase students' skill in cross- 
cultural experiences. These findings indicate that people choose to be culturally 
competent; that one must be motivated to do so; that one's volitional system must 
be engaged in the process. The challenge to faculty is to provide appropriate 
learning strategies that will increase interest and motivation in students, so that they 
are not only willing to engage in cross-cultural interactions, but also choose to do so. 

Additionally, the participants in this study clearly articulated the need for cross- 
cultural experiences which transformed their learning. The mandate to educators and 
educational programs are clear. In order to increase knowledge and develop cross- 
cultural skills occupational therapy students must have the opportunity to interact with 
people who are culturally different from themselves. The literature indicates that the 
most effective learning happens with experiences that occur over a longer period of 
time, rather than a short-term encounter. This may mean semester-long experiences 
that could be as complex as international study, or it may mean working with local 
immigrants, or people with HIV within a community hospice setting. It might also 
mean working with another group of students in a program in another state who are 
culturally different from the students in your own program (Black & Bowen, 2002). 
The main goal of any of these activities would be to provide students with an 
opportunity to communicate with people who are culturally diverse in order to 
develop cross-cultural skills as part of the process of developing cultural 

Other challengesfor occupational therapy educators includeincreasing their 
scholarship in the areas of culture, diversity, and cultural competence. The literature in 
these areas is extremely limited in our field. More research must be done that 
addresses the outcomes of pedagogical approaches mentioned above, and 




research articles and theoretical and concept papers must be written to increase the 

knowledge about cultural competence in the field of occupational therapy. 

There is a dearth of research in the United States on cultural competence. As 
educators begin to intentionally attempt to facilitate its development in the classroom 
and field, outcome studies that indicate the effectiveness of these efforts will be 
necessary. Findingsfromthisstudyindicatethe importance of cross-cultural 
experiences. Research that indicates which kinds of experiences are most 
beneficial would also add to the literature and knowledge. This study examined the 
perceptions of only White female students. An interesting extension of this study 
might include the perceptions of culturally diverse and male students as well. 

Additional research on the relationship of volition to the development of 
cultural competence, and the meaning of the concept of comfort in cross-cultural 
interactions would build on the findings of this study as well. The American 
Occupational Therapy Association, in conjunction with the American Occupational 
Therapy Foundation has identified a research agenda wherein the impact of culture 
on a person's occupational (activity) choice and performance has been included as a 
priority. Any research which contributes to the knowledge and understanding of 
cultural competence will meet not only the needs of society but also the expressed 
needs and interests of the field. 

Additionally, there Is a desperate need for information and guidelines about 
howto teach for cultural competence. I challenge and encourage occupational 
therapy educators and practitioners who are addressing these areas in their work, to 
add to the developing body of literature on diversity and cultural competence. The 
benefit of such scholarship to educators, practitioners, students, the profession, and 
society in general is untold. 

Limitations and Value of the Study 

Perhaps the biggest limitation of this study was the researcher's unf amiliarity 
with the research methodology. In an effort to lessen this barrier, I did complete a 


pilot study which I analyzed using Moustakas' (1 994) method. I believed that this 

helped to familiarize me with the methodology, and I also believe that 
phenomenology is a viable research approach for occupational therapy research, 
but a person more skilled in this type of analysis might have drawn more from the 
data than I did. 

Additionally, I made the mistake of not making copies of the interview tapes, 
and one transcriptionist I used early on became seriously ill and two tapes (one pilot 
and one research study) were lost. The results from the tape that was lost may have 
influenced the data analysis in some way. The loss of this tape was an important 
lesson to a novice researcher. 

Typical of all types of qualitative research, the results from this study cannot 
be generalized, nor can the study be used as an outcomes study for occupational 
therapy education because it did not specifically correlate the findings with the 
students' educational experiences. However, the findings from this study certainly 
inform and have implications for the way educators teach for cultural competence. 

The value of this study lies In the opportunity It provides to hear from 
students' voices how they perceive of and understand cultural competence and 
culturally competent care. Their voices are often missing from other studies in cultural 
competence. By listening carefully to what these students say, educators can know 
what and how they experience culturally competent care, what is important for them 
to know and learn, and what (in comparison with the literature findings) is missing in 
their education. The words of these students provide occupational therapy educators 
with a depth of understanding that is not found elsewhere. Their voices need to be 
heard, and their perceptions must Inform the practice of occupational therapy 
education, particularly around the issues of diversity and cultural competence. 


Since the events of 9/ 11 / 01 , our world has changed in ways that are hard to 
imagine. Suspicion of Middle Easterners, Muslims, and other non-dominant groups 





is at an all-time high. Because of the volatility of the world away from our shores, 

there has been an increase in the numbers of refugees and immigrants who come to 
the United States. Many of these people will seek out health care in settings that are 
mandated to provide competent care (Cross Cultural Health Care Center, 1 995), 
but may find increased hostility because of world events. Their children will enter the 
US educational system needing support from related services such as occupational 
therapy in order to succeed. Because of these factors, and because of the general 
increase in diversity in the United States, more than ever before, there is a 
desperate need for culturally competent practice and care. Occupational therapy 
practitioners and other health care providers must be educated to effectively and 
competently provide the very best services to our nation's changing population. 
We must learn to work and play together with our culturally diverse neighbors, friends 
and colleagues. In order to do this well we must be culturally competent. 

There is a great need to understand what being culturally competent means, 
particularly to the field of occupational therapy. We must recognize the attributes of 
cultural competence and culturally competent care so that educators might facilitate 
these in their students. This phenomenological research study begins to do that by 
examining how occupational therapy students perceive the essential features of 
cultural competence. 

Although the theory of cultural competence is important, the practice of cultural 
competence is necessary. The findings from this study made me realize the 
necessity of providing cross cultural experiences for students. My future plans 
include finding ways for the occupational therapy students in my program to work 
with and provide services to the burgeoning Somali community in Lewiston, Maine. 
This experience will support the community as well as help occupational therapy 
students develop cross-cultural skills necessary for cultural competence. In 
conjunction with this plan, I would liketo research the effects of these interactions on 
both the students and the community members, and report the results to the larger 
occupational therapy community through a published article. It is my hope that 
many other studies will follow, and I encourage my colleagues to join me in this effort. 


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and independence reconsidered. Canadian Journal of Occupational 
Therapy, (pp.324- 336). 

Wilson, J.K. {1998).The myth of political correctness. Durham and London: Duke 
University Press. 

Wiseman, R.L, Hammer, M.R., & Nishida, H. (1989). Predictors of intercultural 

communication competence. InternationalJournalof Intercultural Relations, 13, 

Wittman, P. & Velde, B.P. (2002). The Issue Is. Attaining cultural competence, 
critical thinking, and intellectual development: A challenge for occupational 
therapists. American Journal of Occupational Therapy, 56(4), 454-456. 

Zeller, C. (1 995). Cultural vignettes: A multicultural educational teaching strategy. 
Nurse Educator, 20{2), 8-9. 


Dissertation Prospectus 


Consent Form 



Investigator: Roxie M. Black 

The Research Question: 

The purpose of this study is to examine how occupational therapy students 

"voice" their understanding, definition, and interpretation of the concepts of cultural 
competence and culturally competent care during the last semester of the academic 
portion of their education. The intent is to listen carefully to the specific language 
and words used by these students in an effort to understand the essential nature of 
cultural competency as understood by the participants during their educational 

Definition of Terms: 

Occupational therapy students will include matriculated students enrolled full 
time in an entry level accredited occupational therapy education program. Because 
the majority of occupational therapists are white and female , I would expect that the 
majority of participants will be white female students. It is possible, however, that 
there will be white men as well as men and women of color in the study. 

The term voice is defined as "the power of speaking or the right of 
expression" (Merriam-Webster 1995, p.586). It means speaking and being heard. 
Gilligan (1993) defines vo/ce as follows: 

... I mean something like what people mean when they speak of the core of the 
self. Voice is natural and also cultural. It is composed of breath and sound, 
works, rhythm, and language. And voice is a powerful psychological instrument and 
channel, connecting inner and outer worlds. Speaking and listening are a form of 
psychic breathing. This ongoing relational exchange among people is mediated 
through language and culture, diversity and plurality. For these reasons, voice is a 
new key for understanding the psychological, social, and cultural order - a litmustest 
of relationships and a measure of psychological health, (p. xvi). 

Listening carefully to the words and language participants use as they 
describe their experiences is an intentional and important aspect of this study. 
Many other examinations of cultural competence in the literature use self-report 
surveys in which participants respond to language (about cultural competence) 
chosen by someone else (the authors of the surveys). Because voice reflects 
one's cultural position in society (Gilligan 1 993), and because the focus of the study 
is on cultural competence, this researcher believes that it is important to examine the 


manner in which the respondents voice their experiences with and understanding of 

the phenomenon of cultural competence. 

Culture is defined as the sum total of a way of living, including values, 
beliefs, standards, linguistic expression, patterns of thinking, behavioral norms, and 
styles of communication that influence the behavlor(s) of a group of people that is 
transmitted from generation to generation (Wells & Black, 2000). This definition 
refers to a broad range of cultural groups including subgroups related to race, 
ethnicity, age, gender, sexual orientation, class, and ability. 

In the occupational therapy literature, cultural competence has been defined 
as people "moved from being culturally unaware to being sensitive to their cultural 
issues and how their values and biases affect racially different patients/clients" 
(Pope-Davies, Prieto, Whitaker, & Pope-Davies 1993, p. 839). Within counseling 
psychology Sue (1 998, p. 440) states that cultural competency "is the belief that 
people should not only appreciate and recognize other cultural groups but also be 
able to effectively work with them." This definition is supported by that of the Cross 
Cultural Health Care Center(1 995) which reports that "cultural and linguistic 
competence suggests an ability by health care providers and health care 
organizations to understand and respond effectively to the cultural and linguistic 
needs brought by patients to the health care encounter." 

The definition most often quoted in the literature, however, comes from 
Cross, Bazron, Dennis and Issacs in a monograph entitled. Towards a Culturally 
Competent System of Care, Vol 1 (1989). Cross etal define cultural competence 
as a "set of congruent behaviors, attitudes, and policies that come together in a 
system, agency, or among professionals and enables that system, agency, or 
those professionals to work effectively in cross-cultural situations." This definition 
may be quoted more often because it moves the concept of cultural competency 
beyond individuals and into organizations and communities. It supports the 
examination of the climate of an organization and the policies that enhance or 
diminish a climate of competency. This definition takes a much broader view of the 
concept, which in turn suggests that research related to cultural competency can also 
be directed to broader fields rather than to just individuals. 

Culturally competent care is the process of actively developing and 
practicing appropriate, relevant, and sensitive strategies and skills in interacting with 
culturally different persons (AOTA Multicultural Task Force, 1 995). It incorporates 
three major characteristics from the care provider. These include self-awareness. 


knowledge (not only of other groups but also of the issues of power, privilege and 
oppression), and the skillsto work effectively within cross-cultural interactions 
(Kavanagh & Kennedy 1992; Lynch & Hanson 1998; Pedersen & Ivey 1993; 
Wells & Black 2000). 


Research Design: 

Because of the nature of the research questions and the intent to examine the 
meaning of student's understanding and experience of cultural competence, a 
phenomenological qualitative inquiry approach will be employed. " A 
phenomenological study describes the meaning of the lived experiences for 
several individuals about a concept o\ the phenomenon " (Creswell, 1998, p. 
51 ). Moustakas (1 994) states that the research question must have both social 
meaning and personal significance. The topic of this study meets both of these 
criteria. Asan educator who has devoted significant study to the concept of cultural 
competence, it is important to me to understand how students perceive of this 
concept. Additionally, as the occupational therapy profession continues to examine 
cultural competence, a study of students' perceptions and meaning of the concept 
will be significant. 



Up to twelve occupational therapy students who are in their last year of 
academic study in an urban University in the Northeast will be recruited to participate 
in the study. The university will be selected based on required multicultural content 
in itscurriculum and its proximity to an urban area. The multicultural content must 
include minimally the aspects of culturally competent care identified in the literature as 
"self-awareness" and "knowledge" (Pedersen & Ivey, 1993; Wells & Black, 
2000). The participants will be selected as a "Criterion Sample" (Creswell, 1998) 
as necessary to match the research design. In phenomenological inquiry participants 
must have experience with the phenomena being studied. (Moustakas, 1994) In 
this case, the students must have had classroom content which helps develop 
cultural competence. Participants will be apprised in a cover letter that the study will 
include a minimum of one in-depth interviews. 

Data Collection 

One in-depth interview will be done with each student during the last 
semester of her academic program. The purpose of these interviews is to evaluate 


each student's experience and understanding of cultural competence and culturally 

competent care. 

Additionally, participants will be asked to fill out a short questionnaire t hat will 
gather demographic data such as age, gender, ethnicity, and experience with 
diverse groups of people. This data will provide pertinent personal information that 
may not be gleaned from the interviews. Reflective field notes will betaken 
following each interview. These notes will describe the process of the interview and 
any additional data observed. 

Method of Analysis 

Phenomenological research design follows a clear sequence of analytical 
steps. The first step of the process is the epoch where "the everyday 
understandings, judgments and knowings [of the researcher] are set aside, and 
phenomena are revisited, freshly, naively in a wide open sense" (Moustakas 1 994, 
p.33). It is under these conditions that the interview is conducted. Synthesizing the 
information from Moustakas (1994) and Creswell (1998), the steps of analysis 

1 . Honzonalization - examination of the interview transcripts and listing of the 
significant non repetitive and non overlapping statements of how each participant 
experiences the phenomena. 

2. Relate and cluster these statements into "meaning units" or "theme^'. Then 
synthesize these "meaning units" into a "textural description" of the experience - 
what happened - including verbatim examples. 

3. The researcher then constructs a structural descriptionoi each transcript that 
describes how the participant experienced what she did. 

4. Composite textual and structural descriptions are then developed from the data. 

5. The final step of phenomenological analysis is the presentation of a narration of 
the "essence" of the experience, which is a synthesis of the information found in 
step #4. 


In the health professions, and in occupational therapy in particular, it is vitally 
important to be client centered in approach, to understand the values, beliefs and 
interests of the client in order, not only to develop rapport, but also to fully engage 
that person in therapeutic interventions that are meaningful to them and, therefore, 
beneficial and effective. A person's values, beliefs and interests are determined by 
one'ssociocultural background, as are the occupations or activities that are 
meaningful and in which one engages. One's cultural beliefs also determine how a 


person defines health and wellness, how she responds to the sick role, and how 

she interacts with health care personnel. 

Although the changing demography of the United States has resulted in an 
increasingly diverse patient population, the occupational therapy work force 
continues to be comprised of predominantly white women. For therapists to work 
effectively with the changing population, they must increase their cultural 
competence in order to deliver culturally competent care. 

Cultural competence is a fairly new concept in occupational therapy although 
other professions, especially counseling psychology, nursing, and social work, have 
addressed these issues for years. It has been only since 1 991 that the educational 
standards for occupational therapy have included statements about diversity 
(Educational Standards, 1 991 ). Since that time there have been only a few 
publications on the topic of cultural competence (Khamisha, 1997; MacDonald, 
1998; Pope-Davis, Prieto, Whitaker & Pope-Davis, 1993; Wells & Black, 2000), 
and very little research. Although there are educational standards that require 
inclusion of diversity issues in occupational therapy curricula, there have been no 
guidelines suggesting ways to teach for cultural competence and no assessments 
have been developed to evaluate the effectiveness of curricular offerings. 

Research on the effectiveness of cultural competence has abounded in other 
professions, however. There have been studies that examine various models for, 
teaching cultural competence (Manoleas, 1994; Ronnau, 1994; Nakanishi & Rittner 
1992; Lenburg, 1995; Pope-Davis, Eliason, &Ottavi, 1994; Napholz, 1999; 
St.Clair & McKenry, 1 999). Several studies examined the various characteristics of 
cultural competency (Cui & Awa, 1992; DingesS Baldwin, 1996; Martin, 1987; 
Wiseman, Hammer, & Nishida, 1999). Additionally, there were also studies 
reported in the literature that examined client perceptions of culturally competent 
providers (Gim, Atkinson, & Kim, 1991 ; Rogers, 1998; Wade & Bernstein, 1991). 

What became apparent to me as I reviewed this research was that the 
majority of the studies were empirically based, incorporating self-report survey 
instruments to collect data on cultural competence. These tools were used because 
they lent themselves to quantitative analysis. Most of the self-report scales used in 
these studies have multiple questions that attempt to identify and assess the 
attributes of cultural competence. 

My biggest concern with self-report surveys is that they do not allow the 
respondent to answer the questions in their own voice and words, because that 
type of response is too difficult to quantify. Therefore, these so called "self-report" 
surveys do not actually seek a respondent's personal thoughts, ideas and 
experiences about cultural competency. Rather, they ask a participant to respond to 
the thoughts and ideas of the author(s) of the survey. I believe this is a significant 


deficit in tine literature and research on cultural competence. 

Therefore, I believe that the research study outlined in this prospectus will 
make a significant contribution to the developing literature in the field of occupational 
therapy. Examining the perceptions and experiences of the phenomena of cultural 
competence and culturally competent care by students, and reporting the essence 
of that experience will provide occupational therapy educators and practitioners with 
important information to guide curriculum and practice. Additionally, examining the 
voices and perceptions of students as they discuss their experience with cultural 
competency will provide an alternative way to examine this phenomena that has not 
yet been reported in the literature of any discipline. 

Consent Form 

To: Potential Research Participants: 

This is an invitation for you to participate in my dissertation research study," 
The Meaning of Cultural Competence and Culturally Competent Care in 
Occupational Therapy Students". This has been an interest of mine for years, and 
will provide important information to the growing body of literature related to 
multiculturalism and occupational therapy. 

The purpose of my study is to examine how occupational therapy students 
talk about and understand the phenomena of cultural competence and culturally 
competent care. Data collection for the pilot will entail two interviews of 
approximately 1 to 1 1 /2 hours each. The first will occur this spring while you are still 
taking courses, and the second one during the latter part of your last level II fieldwork 
experience in the fall. The interviews will take place in a setting convenient for you. 
They will be recorded and then transcribed in order to precisely understand your 
words and meanings. You will also be asked to fill out a brief and simple 
questionnaire that will provide me with demographic information about you and your 
academic experiences. 

Confidentiality will be maintained at all times. Your name will not be 
associated with the findings in any way, and your identity as a participant will be 
known only to me. All data (audio tapes and questionnaires) will be stored in a 
secure file in the office of my residence, and will be destroyed following the 
completion of my dissertation paper. There are no known risks and/or discomforts 
associated with this research. If you choose to participate, you would be free to 
withdraw from the study at anytime without penalty. 


Your participation in tliis study will be of great benefit to the occupational 

therapy academic community as we explore and report on the meaning of cultural 
competence for OT students. Further, it will give you first-hand experience as a 
participant in the research process. I am excited to work with you on this project, 
and appreciate your willingness to help me with my study. Please sign your 
consent with full knowledge of the nature and purpose of the procedures. A copy of 
this consent form will be given to you to keep. 

Signature of Participant Date 

Telephone Number Email Address 

If you have any comments or questions about this research study, please contact: 

Roxie M. Black, MS, OTR/L Director, MOT Program 

Tel. (w) (207)753-6515; (h) (207)829-3542; email (w) (h) 



Cover Letter 


Interview Protocol 

Interview Protocol 
Project: The Meaning of Cultural Competence 

Time of 

I nterview 

Date Place_ 




1 . Describe an experience that you have had that exemplifies/demonstrates cultural 

2. What was it like to have this experience? Explore: what did it feel like? 

3. Describe an experience you've had that demonstrates the opposite of cultural 

4. How does this experience differ from the first you described? 

5. In a practice setting, describe a time when you've either been part of, or have 
observed culturally competent care. 

6. What was it about that experience that made you realize it was ccc? 

7. Describe a fantasy about the best culturally competent interaction there could be. 
What would it look like and what would it feel like? 

8. What about this interaction makes it the best? 


Post Interview Observations 

About the Interviewee: 

About the Setting: 

About the Process: 


Phenomenological Interviewing 
Exploratory Comments 

How did it happen? 

How did you talk about It? 

Who said what? 

How did you feel about that? 

In what way? 

Can you give me an example? 

What was it like? 

What did it feel like? 

Tell me a story about it. 

Tips for Interviewing 


Don't be too directive 

Don't overstructure 

Avoid why. Aske how or what questions 

Don't ask opinions or ideas - but details of the expehence 


Cover Letter 

Roxie M. Black, MS, OTR/L 
Director, MOT Program 

University of Southern Maine 

Lewiston/Auburn College 

51 Westminster Street 

Lewiston, Maine 04240 

March 2, 2001 

Dear Occupational Therapy Student: 

You may recognize from my name that I have recently coauthored a book 
with Shirley Wells entitled Cultural Competency for Health Professionals. Despite 
the information in our book, however, there is still much more to discover about this 

I am a doctoral student at Lesley University, Cambridge, Massachusetts. I 
am planning a qualitative study for my dissertation research that focuses on the 
meaning of cultural competency for occupational therapy students. I am currently 
developing my study sample by inviting students from Tufts University, Boston 
University, and the University of New England to participate in my research. 

I need students who are in their last year of study prior to completing their two 
level two fieldwork experiences, and who are willing to participate in two interviews 
that I would conduct. One interview would take place in March or April of this spring, 
and the second would occur in the latter half of your second fieldwork experience in 
the fall. The research participant must be willing to engage in both interviews. 

It would be of great help to me, and would be extremely beneficial to the 
Occupational Therapy profession, if you are willing to participate in the study. Please 


fill out and sign the enclosed consent form and return to me at the above address. 
Or you may email me with your information, and I will contact you to make 
arrangements for the first interview. If I receive significantly more offers of 
participation than I need for the study, participants will be chosen on a random basis. 

Thank you again for your interest. I look forward to hearing from you. 


Roxie M. Black, MS, OTR/L 

PS. Please respond by March 16, 2001. 


Participant Questionnaire 


Research Study 

"The Meaning of Cultural Competence 

and Culturally Competent Care for Occupational Therapy Students" 

Primary Investigator: Roxle M. Black 


Name (Optional) Participant Code #_ 


Age Gender Race/Ethnicity_ 


(daytime) (night) 


Level II Fieldwork 

Address Dates 

2nd Level II 

Address Dates 


Culture: The sum total of a way of living, including values, beliefs, standards, 
linguistic expression, patterns of thinking, behavioral norms, and styles of 
communication that influence the behavior(s) of a group of people. This definition 
refers to a broad range of cultural groups and subgroups related to race, ethnicity, 
age, gender, sexual orientation, class, and ability 

1 . Have you spent time with people who are culturally different from yourself? 
Y N 

2. In what capacity have you been with diverse people? 

Socially In School Family 

at Work 

Please Explain: 


3. At what level have you known diverse people? 
I don't really know anyone who is different from me._ 

As acquaintance(s) As friend(s) 

As family member(s) Partner/Spouse_ 

4. Have your experiences with diverse people been 
Generally positive Sometimes positive 

Neutral Sometimes negative. 

Generally negative 

Please Explain; 

5. Have you lived in a foreign country? Yes No_ 

Where For How Long. 

6. Have you studied about multiculturalism/diversity in college? Yes No_ 

7. In what ways have you studied? (Check all that apply.) 

Specific courses Modules within a course 

Individual lecture(s) Guest speakers 

Infusion throughout many courses Field Visits, 

Other (please describe): 

Sf37 '3^ 

D 113T os3fl7^^ ^ 


For Reference 

Not to be taken from this room 



LUDCKE Library 
Lesley Uriversity 
30 Mellep Street 
Cambridar MA 02138-2790