An Opportunity to Integrate Cultural Sensitivity Training Into the Doctor of Pharmacy Curriculum

Social Determinants of Health, Cultural Sensitivity, and Pharmacy Education

Social determinants that result in health disparities among racial minority patient populations are well known: rates of premature death from stroke and coronary heart disease are higher among non-Hispanic African Americans than among whites, infant mortality rates for non-Hispanic African American women are more than double those for non-Hispanic white women, and prevalence of adult diabetes is higher among Hispanics, non-Hispanic Blacks, and those of other or mixed races than among Asians and non-Hispanic whites.^7,8 While race is not the only factor in health equity, the Black Lives Matter movement challenges educators to step away from incremental change and pursue radical and transformational change within our institutions and curricula to address health disparities.

Educational literature discusses various definitions for diversity, inclusion, equity, cultural awareness, and cultural sensitivity.^9-11 The authors of this commentary accept the variations in these definitions and seek to focus on approaches that incorporate simulated practice experience into skills-based education that provides students the opportunity to practice the provision of culturally sensitive care. The literature provides examples of the inclusion of cultural competency into courses or curricula; however, the literature does not contain best practices for cultural competency skill development.^12-14

The Academy has identified significant gaps in teaching diversity and inclusion and cultural competency in our curricula.^16,17 While most pharmacy educators know that they should incorporate cultural sensitivity into their course content, they may perceive many challenges and barriers to creating and accomplishing this. The addition of this content to the curriculum requires faculty members to evaluate their own ability to teach the concepts or improve their confidence in doing so. Some faculty members may not feel competent in their knowledge or confident enough to incorporate cultural sensitivity activities in a thoughtful and meaningful way in a skills-based laboratory. As a result, guidance and resources are necessary for faculty members to provide directions and additional support. Providing faculty development programs, attending certificate training programs, creating diversity and inclusion competencies, and sharing resources to support educators across the continuum might enhance their knowledge of and ability to incorporate concepts into didactic and practical learning.

Self-Efficacy Theory

Self-efficacy theory provides an additional approach that can be used by instructors to promote curriculum design and student development as culturally sensitive practitioners. Self-efficacy theory, as described by Albert Bandura, considers the concepts of efficacy expectation, outcome expectation, and outcome value as factors that influence behavior.^18,19 Bandura describes these three concepts as interrelated and states that each must be considered in promoting enactment of a skill.¹⁹ Authors view the core tenets of self-efficacy theory, as described by Bandura, as a framework that can support the theme integration of cultural sensitivity into skills-based curricula. Furthermore, the authors believe that through intentional integration of self-efficacy theory within skills-based simulations, students will not only better understand aspects of diversity and inclusion but will be more likely to apply the elements of self-efficacy theory to practice as more culturally sensitive practitioners throughout their careers.

Skills-based Education: A Solution for the Integration of Cultural Sensitivity Into Pharmacy Curriculum

The authors view the three components of self-efficacy theory as a roadmap to curriculum design. Efficacy expectation considers personal conviction to successfully complete a certain behavior. From the lens of cultural sensitivity, efficacy expectation may involve students’ confidence in their ability to provide equitable care given the differences and similarities between their personal beliefs and those of patients in the following areas: cultural norms, value-system, religion, or language.²⁰ Bandura describes repeated and supported practice of designated behaviors, with celebration of successes as the key building blocks to promoting self-efficacy.^18,19 The purposeful selection of tasks within skills-based teaching allows students to routinely practice provision of culturally sensitive care in realistic simulated activities.

Outcome expectation requires students to reflect after completing a simulation upon the viability of achieving a desired impact when providing culturally sensitive patient care. Students may consider whether their interventions would likely result in a meaningful outcome, especially when delivered to underserved populations. This process of reflecting on impact can help students to determine how their work may translate into an observable impact on future patients. As the final and perhaps most significant component of self-efficacy theory, Bandura describes outcome value. In order for students to truly incorporate designated behaviors into their practice, students must appreciate the value of the work that they do. In this case, students must have a desire to care for others in an equitable manner. They must have a true sense of compassion to care for the patients that they serve, regardless of their own background. Within skills-based education, opportunities exist for students to build this sense of purpose through engagement in hands-on situational activities and having meaningful opportunities for reflection.

The authors view the incorporation of self-efficacy theory within skills-based, hands-on simulations as a synergistic approach to promoting cultural sensitivity in learners. The hands-on application and safe learning environment within skills-based education serves as an environment ripe for extensive student self-exploration, growth, and increased self-awareness. It is this environment and the opportunity for repetition of skills-based simulations that allow for direct application of diversity, equity, and inclusion within an applied, hands-on setting. Bandura has promoted both repetition and hands-on application as approaches to promote self-efficacy, and in effect, future incorporation of a skill or behavior.

As an example, students can be introduced to the concept of incorporating a patient’s faith and religious practices into their care plan. In a simulated encounter, students can practice collecting information regarding a patient’s preferences of how and to what degree their faith and faith practices should be integrated into their care. This simulation would provide the opportunity to practice cultural sensitivity skills during an encounter rather than simply possessing knowledge of the skills. Aligning with Efficacy Expectation of self-efficacy theory, a skills laboratory provides a safe environment where students can develop confidence in incorporating this skill. In this example, allowing time for student reflection after this activity could provide the opportunity for students to consider how to incorporate this skill into their future practice, thereby aligning with the outcome expectation of self-efficacy theory. Finally, through longitudinal skills-based integration, students can begin to develop a sense of purpose and the essential component of self-efficacy theory: outcome value.

Experiential education also provides opportunities for students to grow as culturally sensitive practitioners. Student pharmacists take part in experiential education throughout their curricula, and this gives them the opportunity to interact with patients. The authors view experiential education as an especially unique opportunity for outcome value to be developed, as students engage with real patients and understand through lived experiences the importance of their work as pharmacists. It also allows them to observe their preceptor in patient interactions, which provides an opportunity to have discussions about the cultural aspects of a patient’s care plan. After observing interactions, students use what they have seen and use those experiences to form how they will respond in similar situations themselves. The service learning experiences students have through their co-curricular activities with organizations also provide opportunities for patient interactions in potentially underserved areas.

While these experiences help shape students’ ability to care for the diverse population around them, there are two assumptions at play. One is that students have had some practice and exposure as part of their classroom training as a means to prepare them to interact with a diverse patient population. Schools and colleges of pharmacy incorporate didactic elements of cultural sensitivity into their curricula; however, students still need to have the opportunity to practice these interactions in a safe environment. The other assumption is that patients that students encounter on introductory pharmacy practice experiences (IPPEs) or advanced pharmacy practice experiences (APPE) are diverse and reflect the population that students will encounter when they are practicing as pharmacists. Didactic and experiential faculty and preceptors cannot necessarily predict this for a student, so exposing them to a diverse set of patient encounters and situations in a skills laboratory would give them confidence to lead interactions when they encounter similar situations in the real world.

Call to Action

The authors fully understand that incorporation of cultural sensitivity within skills-based education is not an easy task. Resources and personnel available to help teach diversity and cultural sensitivity in skills laboratories vary among institutions, and the act of teaching this content requires vulnerability and the ability to step outside of one’s comfort zone as an instructor. The ability to obtain external assistance from experts to create cases and scenarios, as well as being able to have simulated or standardized patient actors that represent diverse, marginalized, and underrepresented groups all serve as approaches that can be taken to enhance our own self-efficacy as instructors.

The authors propose, using the model of self-efficacy theory as a framework, that skills-based pharmacy education is an ideal platform for cultural sensitivity skill development and engagement through its ability to go beyond knowledge attainment and influence student abilities, behaviors, and attitudes. As skills-based instructors, the authors of this commentary call on the Academy to address four areas. First, instructors should self-assess personal and institutional status to determine areas of knowledge or skill deficiency around the provision of culturally sensitive care. Second, if not already being done, Academy members should assess how their school or college is incorporating cultural sensitivity into the curriculum. Third, using self-efficacy theory as a guide, Academy members should integrate best practices for providing culturally sensitive care into skill laboratory activities. Finally, it is essential for Academy members to share practices. It is the authors’ hope that through careful consideration of self-efficacy theory components in the design and delivery of skills-based education, students choose to enact these skills and incorporate best practices taught in skills-based instruction.

As a starting point, the authors call on members of the Academy to use self-efficacy theory personally and collectively. The authors believe self-efficacy can support and promote self-reflection, evaluation of the institution’s resources and curricula, and implementation of radical and transformative change in our institutions. Our patients and the profession are relying on the Academy to graduate practice-ready pharmacists who are not only knowledgeable about patient care skills and attitudes, but are able to take action to address and diminish health disparities.