Assessing Performance in the Area of Cultural Competence: An Analysis of Reflective Writing

Abstract

Background and Purpose. Cultural competence in clinicians and students has typically been assessed with self-assessments. The purpose of this study was to determine the interrater reliability of using the Cultural Competence Continuum (CCC) as an ordinal scale to assess behavior in cultural interactions revealed in reflective student writing. Subjects. Reflective writing in the clinical journals of Doctor of Physical Therapy (DPT) students on their first clinical affiliation were reviewed retrospectively. Methods. Two raters identified key concepts within the CCC to create a coding system used to (1) determine whose behavior was rated in the written passages and (2) determine the level of the CCC demonstrated in the behavior described in the reflective writing. The reflective writing was coded by the 2 raters independently and was analyzed for agreement. Results. One hundred and ninety-one total entries were coded by at least one rater (Rater 1 rated 169; Rater 2 rated 174), describing actions of the student (41.4%), the clinical instructor (42.4%), the institution (14.7%), or a patient (1.6%). Of the 6 codes in the CCC, the most frequent CCC level rated was precultural competence (PC) (Rater 1 = 35.1%, Rater 2 = 44.0%) followed by cultural competence (CC) (Rater 1 = 34.0%, Rater 2 = 27.7%). Of the 152 entries coded by both investigators, the incremental weighted kappa was 0.77 with standard error = .053 and 95% confidence intervals bound by 0.67 and 0.87. Discussion and Conclusion. There was substantial agreement between raters, demonstrating that analyzing student writing can be used reliably to assess performance in the area of cultural competence. This study provides a moderately reliable method to assess behaviors in cultural interactions. Key Words: Assessment, Cultural competence, Reflective writing. INTRODUCTION The United States population is growing more diverse every year.1 As the population changes, the need for cultural competence has been recognized as an important goal in many disciplines, including health care,2,3 education,4,5 administration,6 business,7,8 and government.' For health care practitioners, the ability of the clinician to navigate culturerelated issues may determine the effectiveness of patient care.9 Knowledge of culture-related risk factors for different pathologies, variations in responses to medications, or outcomes to treatment options10 can have a direct impact on effective clinical decision making.9 Without cultural self-awareness and knowledge of the sociocultural context of patients, physical therapists can exhibit veiled discriminatory attitudes towards minorities, which can create a barrier to patient management.11 Increasing cultural knowledge through cultural sensitivity training has been shown to improve the cultural awareness of counselors and their patients' social functioning, in one of the few evidenced-based outcome studies available.12 A language barrier between patient and practitioner is a significant risk to competent care because the practitioner can misunderstand the patient's medical history, current status, treatment, or responses, leading to ineffective or even dangerous decisions. While language barriers are perhaps the most commonly considered cultural barrier, a disconnect between the practitioner and the patient with regards to acceptable touch between men and women, the meaning of physical proximity to another person, or the standard level of social formality may lead to discomfort that may hinder communication or trust and potentially increase malpractice claims.9 Thus, cultural competence can be considered an integral component of quality care. The concept of cultural competence is based on 3 criteria that can be considered sequential steps towards cultural competence: acceptance, assessment, and adaptation.13 1. The first step requires acceptance and respect of different cultures and their influences on people and self. …