Abstract
Objective. Pharmacists must be equipped with the knowledge, skills, and attitudes necessary to provide culturally intelligent and patient-centered care; however, most are not trained to do so. In order to prepare culturally intelligent pharmacists, standards and curricula for cultural intelligence must be defined and implemented within pharmacy education. The objective of this study was to create a cultural intelligence framework (CIF) for pharmacy education and determine its alignment with Doctor of Pharmacy (PharmD) training.
Methods. An extensive literature analysis on current methods of cultural intelligence education was used to construct a CIF, which integrates leading models of cultural intelligence in health care education with Bloom’s Taxonomy. Five student focus groups were conducted to explore and map their cultural experiences to the CIF. All focus groups were recorded, transcribed, deidentified and deductively coded using the CIF.
Results. The four CIF domains (awareness, knowledge, practice, desire) were observed in all five focus groups; however, not every participant expressed each domain when sharing their experiences. Most students expressed cultural awareness, knowledge, and desire, however, only a few students discussed cultural practice. Participant comments regarding their experiences differed by race and year in the curriculum.
Conclusion. This study was a first step toward understanding cultural intelligence education and experiences in pharmacy. The CIF represents an evidence-based approach to cultural intelligence training that can help prepare pharmacy learners to be socially responsible health care practitioners.
INTRODUCTION
Given the increasing racial and cultural diversity of the United States, health care providers must develop cultural intelligence aimed at providing the highest level of care.1,2 Cultural intelligence is defined as the ability to attune to the values, beliefs, attitudes, and body language of people from different cultures and to effectively use this knowledge to interact with empathy and understanding in diverse contexts.3⇓⇓-6 Without education and training, health care providers are more likely to maintain the status quo within a White, ableist, heteronormative dominant culture that fails to address well-documented health care disparities.7,8 In 2019, for example, Whites received better care on 40% of the national health care quality measures compared to Blacks, American Indians, and Alaska Natives.9
As frontline health care professionals, pharmacists are accessible and entrusted to counsel patients regarding medication understanding and adherence,10 making it critical that they are equipped to provide culturally intelligent care.2,3 However, pharmacists are not typically trained in cultural intelligence, including how to examine biases and address social determinants of health.11 Research suggests that providers’ own stereotyping and prejudice can promote racial and ethnic disparities in health care, especially when implicit biases are not examined and challenged.12,13
Related concepts, such as cultural competency, awareness, humility, and sensitivity, also describe the need for health practitioners who can effectively provide care in a multi-cultural setting. Cultural intelligence specifically differs from these concepts in its specific ties to intelligence research.3 It asserts that there is a metacognitive, cognitive, motivational, and behavioral component needed for intercultural settings.4⇓-6 As Richard-Eaglin notes, “cultural intelligence provides a foundation that encourages practices that support diversity, equity, inclusion, and belonging.”14(p90)
Two common culturally-oriented models, cross-cultural competence15 and cultural competence,16 were developed for health care practice. However, discussion focused on health professions students is limited and focused on increasing the diversity of the students enrolled in their programs.15⇓-17 Increased diversity of future practitioners is important;18 however, merely increasing the diversity of the practitioner population does not guarantee culturally competent care.
To prepare culturally intelligent pharmacists, standards and curricula for cultural intelligence must be developed within pharmacy education.19⇓⇓-22 The American Association of Colleges of Pharmacy’s (AACP) 2013 Center for Pharmacy Advancement (CAPE) Educational Outcomes includes a domain on cultural sensitivity, noting that students should “recognize social determinants of health to diminish disparities and inequities in access to quality care.”19 Related, the Accreditation Council for Pharmacy Education (ACPE) 2016 Standards highlight “Cultural Awareness,” defined as “exploration of the potential impact of cultural values, beliefs, and practices on patient care outcomes.”20 Further, the American College of Clinical Pharmacy (ACCP) acknowledged the need for patient-centered culturally sensitive health care and the related role of pharmacy education.21,22 Despite consensus that these concepts are essential for the future of pharmacy practice, there is little guidance available for their implementation within pharmacy education.21⇓-23
To date, most culturally-related pharmacy education efforts have been fragmented, outdated, and lack a strong conceptual framework to create sustainable transformative change.21,23 Most pharmacy curricula focus on health disparities, which has resulted in students linking cultural diversity to negative health outcomes without addressing the root cause of those disparities.13 Further, there is a lack of data on how cultural intelligence training in professional programs aligns with experiences and outcomes in health care.15,24 The objective of this study was to create a cultural intelligence framework (CIF) for pharmacy education and determine its alignment with Doctor of Pharmacy (PharmD) student experiences.
METHODS
A cultural intelligence framework (CIF) for pharmacy education was created through an intensive literary analysis of cultural intelligence education. Search terms included: cultural competen*, cross cultural competen*, cross cultural education, health care cultural education, cultural competenc* framework, cultural competen* education. The phrase “cultural intelligence” is used intentionally for the framework instead of the phrases “cultural competence” and “cross-cultural competence” to highlight the fact that cultural education is a never-ending growth process and that one never reaches full competence. Health care was specified; however, a health care discipline (ie, medicine, nursing, pharmacy) was not specified.
The Association of American Medical Colleges (AAMC) guide for cultural competence education and Van Dyne and colleagues Four Factor Model of Cultural Intelligence were integrated with other primary literature and adapted into a single framework by the researchers.5,6,16,17,25 The resulting CIF proposes four domains of cultural intelligence that represent a continuous, lifelong learning process (Figure 1): cultural awareness as the process of self-examination and in-depth exploration of one’s own cultural background;17,26 cultural knowledge, as the process of seeking and obtaining a knowledge base about culturally diverse groups;5,6,17,26 cultural practice as the process of interacting with patients from culturally diverse backgrounds and possessing the ability to gather relevant cultural data regarding the patient’s presenting problem as well as accurately perform a culturally-based assessment;17,26 and cultural desire as the motivation of a health care practitioner to want to engage in the process of becoming culturally intelligent.5,6,17
The Four Interconnected Domains of the Cultural Intelligence Framework
The Cultural Intelligence Framework consists of four interconnected domains: cultural awareness, cultural knowledge, cultural practice, and cultural desire. Each domain contains objectives scaffolded to build intelligence in that domain, but all four domains are needed to contribute to holistic culturally intelligent learning.
Objectives were developed for each CIF domain according to Bloom’s taxonomy27,28 in an effort to enable translation of the CIF domains for student learning (Table 1). For example, cultural awareness has six objectives: remember, understand, apply, analyze, evaluate, and create. To develop cultural awareness, a student must recognize differences between various cultures and within same cultures (remember), understand how cultural differences can affect patient care and understand health disparities (understand), and so on. For each objective, the project team identified example assessments of how student learning may be evaluated.
After the CIF was developed, qualitative methods were employed to explore and map student experiences to the framework. A combination of purposeful and snowball sampling were used to identify participants from the UNC Eshelman School of Pharmacy. The school’s Associate Dean of Organization Diversity and Inclusion nominated students who had expressed interest in diversity, equity, and inclusion (DEI) through their engagement with DEI initiatives. Those students were then asked to share the names of their peers who had an interest in DEI. Participants were contacted through email and invited to participate in a 60-minute focus group via Zoom (Zoom Video Communications, Inc). First through fourth professional year (P1-P4) pharmacy students (n=15) participated in one of five focus groups during July 2020. The number of participants per focus group ranged from two to four. Students selected a focus group time that was convenient for their schedule. The nature of the work precipitates the need to acknowledge that the focus group facilitator self-identified as a white female, and at the time of the study, was a post-doctoral research fellow with no direct connection to the students other than through the study.
Focus group questions were structured to gain insight into participants’ experiences of cultural intelligence based on the four CIF domains. For example, students were asked, “Think of a time on rotation when an interaction with a patient who was culturally different from you went well. What went well during this encounter?” To gain insight into the domain of Cultural Awareness a follow-up question was posed: “How does your understanding of your own culture help you in these types of situations?” In addition, participants were reminded that cultural differences included attributes such as race, ethnicity, nationality, religion, age, sexual-orientation, and others.
Field notes were created for each focus group, and each focus group session was audio recorded, transcribed, and deidentified. Deductive codes were created through the adaptation of the CIF by two research team members (DL and LM).29 The same two researchers used MAXQDA (VERBI Software, Berlin, Germany) to collaboratively code 60% of the data. The collaborative coding process allowed for the consistent application of the CIF codebook and in-depth discussion of the data. The remaining transcripts were coded individually by both researchers, and intercoder agreement exceeded 80%, reaching threshold for agreement.29 All disagreements were discussed and resolved. Analytic memoing occurred throughout analysis to capture thoughts and themes that emerged within the data.30 Frequency counts were used to highlight which domains and objectives were applied most frequently to the data. This study was deteremined to be exempt by the University of North Carolina at Chapel Hill institutional review board.
RESULTS
The majority of participants (N=15) were female (n=11, 73%); a majority also self-identified as Black, Indigenous, or Person of Color (BIPOC) (n=9, 60%), and had completed at least three years of pharmacy school (n=8, 53%). The four CIF domains were observed in all focus groups, but not every participant expressed each domain or objective when sharing their experience. Participants shared evidence of having cultural awareness (n=98 codes out of 257 total codes, 38%), cultural knowledge (n=78, 30%), cultural desire (n=54, 21%), and cultural practice (n=27, 11%) during the focus groups.
Participant experiences appeared to differ by race and ethnicity. Cultural awareness comments from white students, for example, indicated that they recognized differences between various cultures (remember) and understood how cultural differences could affect patient care (understand). Those students who identified as BIPOC also recognized and understood cultural differences and expressed how their own culture shaped their experience, perspectives, and beliefs (apply), analyzed their personal susceptibility to bias (analyze), and evaluated their own cultural awareness and how it shaped their actions in the practice setting (evaluate). As one BIPOC student shared, “I naturally understand my community because that is my culture. I did not receive that training in school. It’s because of my culture, who I am, what I identify as that I was able to adapt and be knowledgeable in certain situations.”
Experiences also differed by other cultural factors such as religion, sexual orientation, gender identity, and age. For example, a participant shared: “As someone who is gay, I feel like I’ve encountered stigma associated with seeking health care. I’ve talked with providers about something pertaining to my sexual health that made me feel very uncomfortable and I felt judged. But I’ve also had providers that were really great, they were very open and friendly, and it allowed me to be more open and honest with them about the care I thought I needed and facilitated good dialogue. So, I’ve found that, if I translate that into my pharmacy practice, patients are also more likely to open up and have a good dialogue with you.”
This participant demonstrated cultural awareness by expressing their understanding of how cultural differences impacts patient care by acknowledging their own discomfort when engaging with providers (understand), they analyzed their own culture and how that shaped their experiences, perspectives, and beliefs by noting that their comfort with a provider influenced their openness with that provider (analyze), and finally they evaluated their own cultural awareness and how that shaped their actions in their own practice by noting how they have translated their own experiences into practice (evaluate).
Differences by cohort also emerged as P3 and P4 participants shared experiences that mapped to nearly all six objectives of the cultural knowledge domain yet P1 and P2 students mainly focused on describing their understanding of different cultures (understand), how there are challenges in cross-cultural communication (apply) and could articulate how culture affects the quality of patient care. Very few P1 and P2 students could speak to the objectives of evaluate and create.
More detailed results are organized below according to the four CIF domains, with participant quotes provided to illustrate findings. Additional quotes can be found in Appendix 1. Cultural awareness was expressed by all participants, as most recognized differences between various cultures (remember), exhibited the ability to understand how cultural differences can affect patient care (understand), and analyzed how their culture shapes their actions (analyze). For example, a BIPOC student shared, “There’s a lot of stigma in the African American community surrounding mental illness, and so being aware of that … from my own culture, it kind of helped me. I felt like when I extended a hand to this patient who was also of African descent and just trying to be an ally for her and to make sure that she never felt judged by me.”
Here the participant provided an analysis of their own culture by acknowledging the stigma toward mental illness in the African American community. The participant then analyzes their own cultural awareness by identifying how the knowledge of the stigma helped them during the patient encounter. This led the participant to ensure that the patient did not feel judged for seeking support.
Of the six cultural knowledge objectives (ie, understand, apply, analyze, evaluate – culture, evaluate – disparities, and create), participants most readily expressed the strategies they used to minimize cultural barriers for a patient (create), described experiences that required them to analyze how culture affects the quality of patient care (analyze), and described common challenges of cross-cultural communication (apply). For example, a BIPOC participant stated, “…if you are dealing with a diabetic patient and they are Hispanic you need to know the types of foods that they eat to make sure you’re creating a reasonable guide for how to eat healthier and to control their blood sugar. You can’t just tell everyone to go to Whole Foods or Trader Joe’s to get the freshest vegetables if their only option is canned foods.”
The participant shared the importance of having cultural knowledge and exhibited all six objectives. The participant evaluated both the patient’s Hispanic culture and the underlying health and health care disparities that potentially exist when making their recommendation. Further, the participant analyzed how culture could affect the quality of patient care while describing common challenges in cross-cultural communication. Finally, the participant shared a specific strategy of rinsing a canned food item to reduce the sodium as a way to support the hypothetical diabetic patient.
Other times, participants shared experiences that mapped to only one or two cultural knowledge objectives. A white student shared, “I work a lot with the pharmacy assistance program, which has a large Spanish speaking population. We were instructed, no matter what, even if you’re just ringing out the prescription, please call specific interpreters because there are so many things that can be caught.” The strategy of contacting proper interpretive services, even for the most minor transactions in the pharmacy, demonstrates cultural knowledge regarding strategies that reduce barriers for patients.
Cultural desire was expressed by all participants. Participants were able to define cultural desire (remember) and the importance of working to become a culturally intelligent pharmacist (understand). For example, one White participant shared, “I had a great rotation last summer where I was at a federally qualified health center with the majority of patients either uninsured or on Medicaid and it was really great to learn more about the population, how to help them, what specific struggles are unique to them, and how we as pharmacists can … help them and really be a resource to the community.” However, fewer participants were able to effectively describe a plan for becoming more culturally intelligent (create), analyze their current level of cultural intelligence (analyze), and apply cultural intelligence to patient interactions (apply). A BIPOC participant shared, “I wish I knew what resources I could seek out to learn about other cultures. Unfortunately, I don’t know if we’ve been introduced to those resources in the curriculum… I think the best thing, school wise, for me has been [volunteering at a clinic], because I think that’s where I’ve seen the most diverse pool of patients.”
Not captured via the framework were all students’ desire, regardless of race and ethnicity, to have their peers become more culturally intelligent. As one BIPOC participant shared, “the skills that I want are way different from what I want the rest of my classmates who are white and don’t have a minority background to gain. …I’m just more knowledgeable about these things because I’m a person of color…and I want my classmates to gain these basic skills before they’re dealing with patients of color.” Students acknowledged that they sought out and attended the elective/optional programs, but that many of their peers did not. For instance, a white student shared, “I’ve gotten a lot of experiences, but it is because I opted into it and wanted to learn more. I’m super grateful for the experiences I’ve gotten, but I definitely wish that everyone got them, you know.”
Cultural practice was not expressed as readily as the other domains. It was not evident that participants understood the types of cultural differences they may encounter while on pharmacy practice experiences (understand), understood how to obtain relevant cultural information during an encounter (understand), could conduct a cultural assessment of a patient during an encounter (apply), or make recommendations to the pharmacy team for minimizing potential cultural barriers for a patient (create).
When students did express the cultural practice domain, they mainly evaluated the effectiveness of the cultural communication and awareness of the patient encounter (evaluate). For instance, a bilingual BIPOC participant shared “Even when you have interpretive services, a lot of information gets lost…sometimes the interpreter and patient might have a widely huge dialect difference. I’ve sat in on visits before where I’ve heard the patient say something and it gets interpreted by the interpreter way different.” The participant provided a brief evaluation of cultural communication through an interpreter and acknowledged that this strategy is not always effective because of different dialects.
When others provided examples of the understand, apply, evaluate, and create objectives in their description of practice experiences, they also acknowledged their lack of decision-making power as students. For instance, a BIPOC participant shared, “As a student you can only do so much when you’re under the wing of a preceptor. So you can advocate as much as you want to, but at the end of the day the final decision goes to the pharmacist. We were at a pain clinic, and I felt like who I was with at the time was not truly believing the severity of the pain of the black woman… And I was very angry with the interaction and I tried to challenge it and advocate for [the patient] but there was nothing I could do.” Although the participant understood cultural practice in this experience and advocated a recommendation that addressed an apparent cultural barrier, the student’s decision-making power was limited.
DISCUSSION
This is the first study to create a CIF for pharmacy education and evaluate the relevancy of the framework with respect to the experiences of PharmD students. The CIF adapted leading models of cultural intelligence in health care education for PharmD training and included Bloom’s objectives to describe critical, achievable learning outcomes. Student experiences most frequently focused on cultural awareness, knowledge, and desire. Student emphasis on cultural awareness is consistent with other research that suggests becoming culturally intelligent first requires awareness of one’s own cultural background and how it shapes their thoughts and actions.31,32
Unlike other studies using surveys and questionnaires (eg, Clinical Cultural Competency Questionnaire),33 this study utilized focus groups to explore cultural intelligence. Our methodology provided students a space to voice their experiences and concerns, making the connection direct and personal.2,34⇓–36 This allowed for additional detail of participants’ experiences beyond what is captured in a survey.37 For instance, participants shared their ideas for how to integrate cultural intelligence into the curriculum and their desire for their peers to become culturally intelligent.
Most participants expressed objectives in all four domains; however, the frequency and description of their experiences varied by race and ethnicity. These findings are consistent with other studies that examined student cultural awareness, namely that BIPOC students exhibited more evidence of having advanced cultural awareness than their white peers.2,32,34 Differences in experiences based on race suggest that integration of cultural intelligence training into the curriculum should reflect the needs of the student population. Differences by program year could be due to the time P3 and P4 students have spent in experiential practice settings that provided them with more opportunities to engage in cultural pharmacy practice situations.2,38 Training should be varied and provide ample opportunity for students not just to remember and understand, but to apply, analyze, and evaluate their own culture and how it shapes their actions in the practice setting.
Additionally, the cultural practice domain was not readily identified within the data set. This could mean that students lacked experience in the practice setting to make cultural intelligence practice suggestions or they were not fully prepared in this domain. Chen and colleagues found that if students were not provided consistent cultural competency and health literacy training across the curriculum, their scores dropped significantly on the Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals Student Version.38,39 Despite not readily discussing the cultural practice domain, students did identify numerous ways of integrating cultural intelligence training into the curriculum, including having panels of culturally diverse faculty, providers, and patients to share their experiences, holding directed discussions in the IPPE preparation course, and purposefully integrating health disparities and other challenges (eg, no insurance, language barriers) into practice patient cases.
Culture is tremendously dynamic and multifaceted, and evidence shows that cultural competency in a culture or several cultures is not achievable and may lead to overgeneralizing and stereotyping.7,8,11⇓-13 Findings from the focus groups highlighted the need to weave cultural intelligence education throughout the entire professional program (didactic and experiential) and assess it systematically to ensure students are achieving the appropriate knowledge and skills and displaying essential behaviors. The framework along with the UNC Eshelman School of Pharmacy’s DEI Strategic Plan are being used as a guide to incorporate culturally intelligent education, training, and assessment into the PharmD curriculum. The student participants in this study encountered cultural experiences in numerous settings (eg, coursework, early and advanced clinical practice experiences, and co-curricular activities); thus, the school is working to identify ways to incorporate cultural intelligence training in each setting.
Thinking forward, the CIF has the potential to provide consistency in cultural intelligence education, training, and assessment across schools of pharmacy, as well as the potential to be modified to suit the curricular needs of other health care professions. These efforts must be anchored in an organizational strategy to facilitate a shared vision and accountability for recruiting and retaining diverse student talent to produce a culturally informed and prepared pharmacy workforce to improve health equity. The implication of this is the cultivation of culturally intelligent health care practitioners nationwide who are equipped to understand, appreciate, and interact with the growing diverse population of the United States. By addressing gaps in knowledge, skills, and attitudes of pharmacists and training them to be more culturally intelligent, we hope to address health care disparities by providing more understanding and equitable care to historically marginalized groups.
Future studies are needed to further validate the CIF at other schools and colleges of pharmacy, in addition to other health professions institutions. In addition, studies should be conducted to measure differences in cultural intelligence in students prior to and after cultural intelligence training. Because results suggest differences between groups based on various demographic characteristics (eg, race, cohort), more research is needed to understand the experiences and needs of students from diverse backgrounds.18,40 Further, research is needed within pharmacy education to identify and develop effective and inclusive learning strategies that reduce bias and disparities. This work is critical for advancing the small yet growing body of literature exploring diversity, bias, and cultural training within pharmacy education.41
While this study is an important first step toward understanding cultural intelligence in pharmacy education, there are several limitations. First, the focus groups were conducted with a small sample confined to a single school of pharmacy. Second, selection bias may have occurred as students were purposefully recruited. Third, students may have been influenced by social desirability bias, thereby presenting themselves in the best way possible. Finally, the facilitator of the focus groups self-identified as a white female postdoctoral fellow which could have influenced how participants responded to the questions. Despite these limitations, participants were perceived to speak openly, and many expressed appreciation for the opportunity to share their perspective and experiences.
CONCLUSION
The CIF represents an evidence-based approach to the design and implementation of cultural intelligence training that can help prepare pharmacy students to become socially responsible health care practitioners. This study advances the understanding of cultural intelligence education and experiences in pharmacy education. Future analyses will include additional qualitative research regarding efficacy and applicability to other PharmD curricula at additional institutions.
Cultural Intelligence Framework
ACKNOWLEDGMENTS
The authors would like to thank the Research and Scholarship in Pharmacy pathway instructors Dr. Craig R. Lee, Dr. Sachiko Ozawa, and Dr. Robert Hubal for their feedback on early drafts of the CIF.
Dr. Minshew’s current role and affiliation is as an Assistant Professor with the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and School of Pharmacy at the Medical College of Wisconsin in Milwaukee, WI.
- Received February 8, 2021.
- Accepted June 23, 2021.
- © 2021 American Association of Colleges of Pharmacy
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