Ethical multiculturalism, cultural competence, Delphi, international research;


Purpose: The threefold purpose of this research is to identify the essential antecedents of cultural competence as identified by international nurse researchers, to compare the content of the extant cultural competence instruments to these antecedents and to potentially identify gaps in their conceptualization. A secondary aim of this research is to initiate validation of Harper's model of ethical multiculturalism. Conceptual Basis: The model of ethical multiculturalism depicts the attributes of ethical multiculturalism as the fulcrum of a balance between two ethical philosophies of fundamentalism and relativism. The attributes of moral reasoning, beneficence/nonmaleficence, respect for persons and communities, and cultural competence form the pyramidal fulcrum. The antecedents form the base of the pyramid and include cultural awareness, culture knowledge, cultural sensitivity, cultural encounters, cultural skill and understanding of ethical principles. Methodology: An on-line Delphi method was conducted with 35 international nurse researchers identified through published research, university directories, and professional organizations. Consensus was reached after two rounds. Following the Delphi rounds, sixteen members of the expert panel participated in an on-line focus group to validate results of the Delphi and discuss cultural competence in the international arena. Findings: Eighty antecedents of cultural competence were identified. Focus group discussion validated findings of the Delphi. Consensual thematic analysis of the focus group transcripts resulted in six themes: chimerical, contact, contextual, collaboration, connections, and considering impact. The Transcultural Self-Efficacy Tool (TSET) contained the most antecedents identified by the expert panel. Conclusions: Cultural competence is a process, not an outcome, and must be considered from the perspective of the recipient of care or research participant. Nurses must strive to deliver culturally acceptable care. The model of ethical multiculturalism is revised to include cultural desire as an antecedent. Nurses must understand the impact of globalization on individual health and care delivery. Implications for Nursing: Further testing of cultural competence instruments is needed to determine the correlation of self-efficacy with behavior, self-assessment with client assessment, and cultural competence with client outcomes. In education, research is needed to determine the most effective methods of teaching cultural competence. Increased recruitment of minorities into nursing programs is warranted. In practice, nurses must be prepared to provide language assistance as needed, recruitment and hiring of minorities must be increased, and minority thresholds must be used to determine cultural knowledge content for organizations.


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Graduation Date



Byers, Jacqueline


Doctor of Philosophy (Ph.D.)


College of Health and Public Affairs



Degree Program









Release Date

June 2008

Length of Campus-only Access


Access Status

Doctoral Dissertation (Open Access)

Included in

Nursing Commons