PhD

dissertationAs the U.S. population diversifies rapidly, the delivery of quality health care to culturally diverse patients has become an absolute necessity. At the same time, the composition of the health care work force has changed with associate degree nurses (ADNs) increasingly being utilized by health services for their technical, cost-effective skills. Researchers have identified variables such as experience, exposure, and education in the delivery of culturally competent care, although questions persist about the ADNs' decision-making skills and application of transcultural theory to clinical practice. This grounded theory study explored and described the decision-making process nurses use to provide culturally competent care. Emergency room and obstetrical units served as research sites because of their frequent use and ease of access by minorities. Twenty-six nurses from three hospitals who had associate, baccalaureate, or advanced practice education were interviewed after reading vignettes describing patient care scenarios involving culturally diverse clients. Demographic data were analyzed using descriptive statistics, and qualitative data analysis was completed using constant comparative analysis. Rigor of study results was obtained by establishing trustworthiness with study participants and by achieving theoretical sensitivity. "Juggling choices" is the basic social process nurses transverse as they decide to care for those who are different. Derived from the core variable of understanding, nurses addressed uncertainty, related by perception, then provided care by accessing resource and environmental variables. Care delivered was basic, adaptive, or both based on the interplay of variables such as peer influence, communication capabilities, time availability, staff expertise, patient acuity, and attitude. Progression through the decision-making process is time sensitive, with personal experience being the main factor nurses used to juggle choices and to navigate through each situation. Nurses did not differ by educational preparation in how they made decisions to care or in how they did not accept the term "cultural competence." Based on interviews, a pictorial definition called the Cultural Continuum of Patient Care was devised to reflect the flexibility and unpredictability associated with cultural care as it actually exists in clinical practice. Implications for nursing practice, education, and future research are provided