Influences of Demographics and Life Experiences on Cultural Competency in Student

Physical Therapists.

Authors: Shelby Schneider, Raneen Allos, Erin Brink, Emily Schubbe, Chin-I Cheng
Research Advisor: Emily Schubbe, PT, DPT, EdD

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 13, 2024

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at
Central Michigan University
In partial fulfillment of the requirements of the
Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Emily Schubbe, PT, DPT, EdD

Date of Approval: 4/13/2024

 ABSTRACT

Introduction: Cultural competency in healthcare is a growing topic across all professional

fields. One’s perceived cultural competency levels may be distorted by their personal biases and

may differ from their actual behaviors, attitudes, or knowledge as applied to patient care. This

novel pilot study aimed to develop a method to analyze participants’ “true” versus perceived

cultural competency levels and determine if variables such as demographics and/or life

experiences influence cultural competency.

Methods: A survey containing questions regarding the participant’s demographic information,

life experiences, and both qualitative and quantitative questions to examine participants’

perceived versus supposed “true” cultural competency levels was distributed electronically to

student physical therapists at Central Michigan University. Qualitative questions were

constructed by investigators while the Healthcare Provider Cultural Competence Instrument

(HPCCI) was used to gather quantitative data.1 Responses were reviewed to examine if a

correlation existed between the various demographic or experiential variables and cultural

competency scores.

Results: Demographic variables such as gender, age, and socioeconomic status as well as life

experiences including mission trips, alternative spring break trips, and working within clinical

spaces affected cultural competency scores of the participants. While “true” versus perceived

competency was not fully determined, but there was a positive relationship between several

“perceived” competency quantitative sections and “true” competency qualitative sections of the

survey.

Conclusion: There was a correlation between several demographics and life experience factors

as it pertains to the participants’ perceived and “true” cultural competency scores; despite this,
participants’ “true” versus perceived cultural competency capabilities were not determined due

to a limited number of respondents, making it difficult to reach conclusive results on “true”

versus perceived competency.

Keywords: cultural competency, physical therapy, life experience, demographics

INTRODUCTION

Cultural competency is a topic that has grown over several years in health care.2

Providing culturally competent care means being aware of a patient's social and cultural

influences and considering these factors when delivering health services. 3 Such factors include

age, gender, race/ethnicity, sexual preference, and socioeconomic status. Objective assessments

have been designed to measure individuals’ cultural competency; however, there may be

limitations to identifying the difference between a “true” measurement of an individual's cultural

competency and one’s self-perceived levels of cultural competency. Self-perceptions may be

limited by the individual's ability to self-assess without bias or societal influence.4-13 Individuals

may exhibit social desirability bias if they respond to survey questions in a manner they believe

will increase their scores and allow them to be seen in a more positive light.

Factors such as demographics or life experiences may also affect scores. Unfortunately,

few studies examined demographic factors associated with cultural competency, in any health

profession.4,14 In addition to demographics, life experiences such as clinical rotations or mission

trips may also have an impact on cultural competency levels. There has been conflicting

evidence on whether these experiences positively or negatively impact cultural competency

scores.5-11 The discrepancy lies within the type of experience. For example, service learning

opportunities are often confused with volunteer tourism, or “voluntourism.”5 While voluntourism

is marketed as an opportunity to provide services to underserved communities, the extent of

these trips often becomes a vacation focused more on tourism.5 In contrast, some authors suggest

structured service learning 6-8 or interprofessional clinical experiences are influential in

developing students’ culturally competent health delivery skills 6-9 and improving self-efficacy

1
scores coupled with awareness of diversity.10 Service learning allows students to become more

prepared for future experiences9 and positively benefits the community receiving services.6,7

The development of a student physical therapist’s (SPT) cultural competency may vary

based on several factors. SPTs may have learned about cultural competency through classroom

presentations, field experiences, or through volunteering.11 Physiotherapy students in Australia15

identified their cultural competency curriculum as consisting primarily of education in the

didactic form, as opposed to experiential learning opportunities (i.e., studying abroad,

volunteering, and field trips to indigenous community areas).15 While Te et al.15 provided insight

into strategies for Australian physiotherapy curricula, generalizability to physical therapy (PT)

education in the United States (U.S.) may be limited due to differences in academic rigor and

programmatic requirements.4

There has been limited evidence identifying specific curricular standards for cultural

competency training of SPTs in the U.S. within the last 5 years.16 The Commission on

Accreditation in Physical Therapy Education (CAPTE) sets curricular standards for all

accredited PT programs in the U.S. The newest CAPTE accreditation handbook includes

requirements that the curriculum must include information on justice, equity, diversity, and

inclusion. These new regulations were put into place in 2024, and CAPTE allows programs until

2026 to adopt new curricular changes.17 Comparatively, the Association of American Medical

Colleges (AAMC) has required medical schools to include cultural competency training since

2005.18 Previously, healthcare students have reported feeling unprepared regarding cultural

competency.11,13 This could lead to new graduates being incapable of the same level of patient

care as peers who have had cultural competency training.

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 One way to assess cultural competency was established by Cross et al.19 The Cultural

Competency Continuum Framework ranges from “culturally proficient” to “culturally

destructive” and has 4 descriptors in between. Culturally proficient individuals are those who are

active toward the goal of creating a more inclusive society.19 Culturally destructive individuals

believe in superiority amongst certain groups of people and will oppress those deemed “lesser”

than themselves.19 SPTs can fall anywhere along the continuum, depending on their personal

behaviors and life experiences.20 With formal cultural competency training and a diverse amount

of life experiences, they may find themselves moving towards the proficient side of the

continuum; however, that is also dependent on an individual’s attitudes toward their behaviors.

Molerio et al21 reported how individuals who were asked to rate their level of cultural

competency, rated themselves higher than their capabilities suggested. In a qualitative study of

practicing PTs, many participants recalled receiving little to no cultural competency training,

which contributed to a perceptions of cultural competency inadequacy.11,22 Some had difficulties

identifying examples of how they implemented cultural competency skills when treating

patients.11,22 When individuals self-assess their cultural competency in the context of Cross’

continuum, it is possible they may rate themselves as “culturally proficient” yet are unable to

provide examples to support their claim. This inflated self-perception may result in employers

believing their employees are prepared to work with culturally diverse clients when they do not

have the skillset necessary to be successful.12,23 These individuals may also have a limited drive

towards additional self-improvement due to their perceptions of adequate cultural competency

skills and behaviors, causing a stagnation of their development. Inaccurate self-perceptions may

contribute to poorer patient outcomes if a provider is unable to incorporate culturally competent

care.

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 “True” cultural competency is an objective identification of a therapist’s cultural

competency resulting in competent patient care.24 To bridge the gap between “true” and

perceived cultural competency, this research will attempt to identify specific characteristics SPTs

have that may result in either a match or a discrepancy between these assessments. The attached

figure (See Figure 1) is a visual interpretation of the theoretical framework of this study.

Specifically, it blends the contributions or impact of cultural competency knowledge on

culturally competent behaviors and attitudes in the context of how one may perceive their own

cultural competency as well as how one’s cultural competency may be observed by others. This

interrelationship is based on a framework from which the HPCCI was also created.1 While there

is research on cultural competency within medical professions,4,5, 11-12 the research is unclear if

the cultural competency results are “true” results or merely self-perceived. This question is not

well-studied in current available literature. This study aimed to identify differences in

participants’ perceived versus “true” cultural competency scores and to analyze if demographics

or experiences had any influence on scores.

First, investigators hypothesized a difference when comparing participants’ perceived

versus “true” cultural competency scores. Second, investigators expected an influential

relationship between demographics and cultural competency scores. Third, investigators

hypothesized that SPTs who received formal cultural competency training, completed field

experiences, or participated in service-learning opportunities would have higher “true” cultural

competency scores than those who had none. If individuals who received cultural competency

training demonstrate higher “true” cultural competency scores, programs may consider

implementing curricular strategies for cultural competency education. Incorporating appropriate

4
strategies will instill appropriate behaviors and attitudes in students to provide culturally

competent care to patients.

The investigators will attempt to answer the following questions:

·Will there be observed differences between perceived and “true” ratings of cultural

competency in SPTs?

·Do individuals’ demographics influence cultural competency scores when comparing

perceived and “true” ratings of cultural competency?

·Do life experiences influence cultural competency ratings?

METHODS

This study was a mixed methods design. The survey collected both quantitative data along with

open-ended questions allowing for a qualitative assessment of participants’ cultural competency.

Participants

Participants were eligible to participate in this study if they were over 18 years of age and were

enrolled in Central Michigan University’s (CMU) accredited Doctor of Physical Therapy (DPT)

program.

Experimental Procedure

Participants completed an anonymous survey on Qualtrics XM. Questions were designed

to collect demographic information, life experiences, and self-rated perceived cultural

competency via the HPCCI. The Qualtrics XM subscription is maintained by CMU and all the

collected data was accessible to the investigators only. Access to the survey required a username

and password, as well as a private invitation by the investigators to collaborate. Only the

investigators had access to the survey data. To maintain the anonymity of participants, no

5
participant was required to share their name and the IP tracking option on Qualtrics XM was

disabled. It is possible demographic information in the survey, such as race or ethnicity, could

result in the identification of individuals. Pooling of data across cohorts, as opposed to looking at

data for individual cohorts, assisted in minimizing this risk. If potentially identifiable data was

collected, investigators either limited or eliminated the data from the results to minimize the risk.

A link to the survey was sent to CMU’s DPT program director, who then forwarded the

survey link on to the DPT students for the classes of 2023 through 2026 via university emails.

The survey was also posted on the cohorts’ Facebook pages for further recruitment. The survey

was sent to students on April 3, 2023, and the survey closed on June 19, 2023, at 11:59 pm.

Three reminder emails were sent to increase participation. The researchers hoped to obtain at

least a 15% response rate out of a pool of 190 CMU DPT students.

As participants worked through the survey, they were able to opt out of answering any

question(s) without penalty. The survey’s demographic questions (See Appendix A) included the

participants’ age, gender, race, ethnicity, sexual orientation, what languages they speak, the

highest level of education they’ve obtained, and the socioeconomic status of the participants’

families. The life experiences portion of the survey instructed participants to indicate if they had

participated in one or more of the suggested life experiences (See Appendix B). Each life

experience had examples that defined the category and an “other” option was to provide a free

response if a life experience was not listed in the outlined options.

To score participants’ “true” cultural competency, investigators posed 3 short answer

questions for participants to describe their knowledge of cultural competency, any situations

where they demonstrated culturally competent behaviors, and their attitudes while providing

patient care. (See Appendix C). The open-ended questions were unique to this investigation. The

6
participants’ qualitative responses were scored according to a codebook developed by

investigators (See Figure 2), which was based on the Cultural Competence Continuum

Framework from Cross.19 All investigators contributed to axial coding and constant comparative

analysis. Participants’ responses were scored on a 6-point scale ranging from “culturally

proficient” to “culturally destructive.”19 The primary investigators reviewed each participant’s

responses to reach a consensus on final scores.

For the self-assessment portion of the survey, participants completed the HPCCI1 (See

Appendix D). This validated survey contained 48 questions divided into 5 different subscales

with their own scaling systems. This survey was chosen based on the creator’s desire to measure

aspects of cultural competency as suggested in a framework from Betancourt;1 the subscales are

an attempt to measure respondent’s knowledge, behaviors/skills, and attitudes about cultural

competency, which is consistent with this investigation’s theoretical framework (See Figure 1).

The subscales of the instrument influenced the creation of the study’s qualitative questions in

attempts to compare “perceived” versus “true” competency levels, specifically for SPTs, as it

related to measuring knowledge, behaviors/skills, and attitudes.

Data Collection and Statistical Analysis

The participant's data was anonymized and collected via Qualtrics XM and recorded in

SPSS to be analyzed. The five subscales of the validated instrument were scored separately. Each

answer on the Likert scale was given a point score 1-5 or 1-7 (e.g., strongly disagree=1, strongly

agree=7) depending on the subscale. Questions 1, 2, 5, 8, 33, 34, 35, 36, 38, and 40 were scored

reversely (e.g., strongly disagree= 7, strongly agree= 1). The N/A option, if selected, was

assigned 0 points. If a participant selected N/A or did not respond to a question, it was removed

from the total score of that subcategory. Each subcategory was averaged and converted to a

7
percentage. The percentages correlated to Cross’s Continuum as follows: Cultural

Destructiveness: 0-17%, Cultural Incapacity: 18-35%, Cultural Blindness: 36-53%, Cultural Pre-

Competence: 54-71%, Cultural Competence: 72-89%, Cultural Proficiency: 90-100%. This

scoring strategy was novel to this study and was not a part of the original scoring methodology

by the author of the HPCCI.

Responses to the qualitative questions were then given a quantitative measure via a

numerical score. Investigators created a codebook that linked phrases or inferred behaviors to

categories within the framework from Cross (See Figure 2).19 The investigators coded the

answers to determine a score on Cross’s continuum. If a participant had 3 phrases coded as

“culturally competent” and 1 phrase as “culturally blind,” the answer was scored as “culturally

competent.” Investigators coded responses, gave responses an assigned point value, and

converted the data to a percentage along the Cross Continuum as outlined previously using a

constant comparative method to add context or depth to the codebook. Assignment of scores and

codes were compared between investigators to ensure agreement on how qualitative data was

being analyzed and scored. These practices strengthened the internal validity and credibility of

qualitative data analysis.

Applying Cross’s continuum19 to the scoring of both quantitative and qualitative

responses provided a stronger direct link for statistical analysis between the scores from the

perceived and “true” cultural competency. The use of multiple data collection methods bolstered

the internal validity and credibility of the data overall.

A multiple linear regression was performed by IBM SPSS of the participants’ coded

responses for each subsection of the quantitative survey. This gave investigators a sense of each

participant’s “perceived” cultural competency level. Following this, both linear regression and a

8
multiple linear regression was performed on the quantitative instrument scores and participants’

scores on the 3 qualitative questions to determine a correlation between them. Specifically, each

individual subscale score from the HPCCI was compared against each of the individual

qualitative question scores using Pearson’s correlation and multiple linear regression to examine

for any relationships. Secondly, scores were combined between certain subscales from the

HPCCI and compared against the score for each qualitative answer. For example, subscales were

combined for scoring purposes as subscales 1,4, and 5 all represented cultural competency

attitudes, while scales 2 and 3 measured behaviors. The data was further analyzed utilizing a

multiple linear regression to find if (1) certain demographics could be correlated with specific

“true” or perceived scores and (2) if life experiences had a relationship with competency scores.

RESULTS

Forty participants completed at least one section of the survey. Thirteen participants did

not finish the survey and their data was excluded. The HPCCI1 consisted of 48 questions divided

into 5 scales. Those scales include Scale 1: Awareness and Sensitivity; Scale 2: Behavior; Scale

3: Patient-Centered Communication; Scale 4: Practice Orientation; and Scale 5: Self-

Assessment. A professor in the Department of Statistics at CMU compared the independent

variables (i.e., demographics, life experiences, and qualitative responses) with the dependent

variable (i.e., scores from the validated survey). This comparison was completed utilizing a

multiple linear regression with a 0.05 level of significance. The independent variables were

compared to each scale individually, then were compared against 3 different combined scales

(i.e., scales 1, 4, and 5 combined, scales 2 and 3 combined, and scales 1-5 combined). Scales 1,

4, and 5 were combined to correlate with qualitative question #1, which examined participants’

9
attitudes toward cultural competency. Scales 2 and 3 were combined to correlate with qualitative

question #2, which examined participants’ cultural competency behaviors. Finally, scales 1-5

were combined to correlate with the posed qualitative question #3, which examined participants’

knowledge of cultural competency.

When percentages from the quantitative and qualitative sections of the survey were

calculated and compared, a relationship can only be seen in certain combinations. Most of the

scales showed that participants who scored highly (above the pre-competence level of Cross’s

Continuum) on the qualitative section also scored highly on the quantitative sections. In contrast,

other scales showed further discrepancies such as participants scoring higher on perceived than

“true” sections or those scoring low on the perceived sections and high on the “true.” Ultimately,

due to the very small sample size, results for creating the link between “true” and self-perceived

cultural competency scores were not statistically significant nor linearly correlated.

Regarding the demographics variables, gender was the only variable significant to scale 1

(Awareness and Sensitivity), with females scoring higher on awareness and sensitivity than

males. In contrast, scores for scales 2 (Behavior) and 3 (Patient-Centered Communication) were

only significant with age. Participants between ages 18-22 scored higher for both behavior and

demonstrating patient-centered communication, compared to participants ages 23-27 and 28-32.

Income was found to have the strongest relationship to scale 4 (Practice Orientation); however,

this variable did not meet the <0.05 significance threshold. There was insufficient evidence to

conclude any variables were linearly related to scale 4. The demographic variables significant for

scale 5, (self-assessment), were age (ages 23-27 scored higher than those ages 28-32) and annual

household income (income <$25,000 scored higher than income between $25,000-$50,000 and

$50,000-$100,000). The significant variables for combined scales 1, 4, and 5 were age (ages 23-

10
27 scored higher than those ages 28-32) and income (annual household income <$25,000 scored

higher than those with between $25,000-$50,000, $50,000-$100,000, >$200,000, and

participants who preferred not to report) (See Table). For combined scales 2 and 3, there was

insufficient evidence to conclude any demographic relation to the scales. With scales 1-5

combined, the only variable found to have relevance was income, with annual household income

>$200,000 scoring higher than participants who preferred not to report their income; however,

the results were not statistically significant.

Mission trips, alternative spring break (ASB) trips, and working in clinical settings were

the only life experiences with significant results. Scores on scale 5 (self-assessment) correlated

with mission trips, those who did not attend a trip scored higher than those who had. Participants

who experienced ASB trips and did not work in clinics scored higher on scales 1, 4, and 5

(attitudes) (See Table). When analyzing all combined scales, only mission trips showed

statistical significance, with those who attended a mission trip scoring higher than those who did

not (See Figure 3).

There were limited interactions between the qualitative and quantitative scores.

Participants who scored higher on the second qualitative response (behaviors), had higher scores

on scale 5 (self-assessment). Combined scales 1, 4, and 5 were significant concerning the third

qualitative question (knowledge) (See Table). The second qualitative question had no

significance with combined scales 1,4, and 5 on its own; however, when scores were combined

with mission trips attendance, there was a significant relationship (See Table). Participants who

did not attend mission trips had higher scores in the second qualitative response (behaviors) and

combined scales 1, 4, and 5 (attitudes) (See Table). Similarly, when all scales were combined

11
and averaged, those who did not have mission trip experiences had an increase in their average

score and an increase in scores of the first qualitative question (See Figure 3).

To further explore the relationship between the qualitative responses, the scoring scale

was re-coded. Participants who received less than a 3/6 were coded as “0” and participants who

received >3/6 were coded as “1.” With a readjusted scale, the first qualitative question responses

demonstrated a statistically significant relationship to ASB trips. Participants who did not attend

ASB trips had significantly higher results for the first qualitative question score.

DISCUSSION

This novel pilot study investigated if demographics or life experiences influenced an

individual’s cultural competency scores. The perceived versus true cultural competency scores

were also analyzed to see if there was a discrepancy or alignment between self-perceived and

“true” measures of cultural competency. The alignment of perceived versus “true” cultural

competency was based on the cross-cultural medical educational model provided by Betancourt,

which focused on cultural sensitivity/awareness, multicultural/categorical knowledge, and

implementing cross-cultural behaviors or skills and was the foundational framework for the

HPCCI.3 Open-ended questions included in this survey attempted to establish a basis of

comparison to the HPCCI survey by asking respondents to provide insight into their behaviors,

attitudes, and knowledge of cultural competency in healthcare settings. While the Betancourt

framework was referenced to establish a comparison between the survey responses and responses

to the open-ended questions, the scoring of open-ended questions was based on the Cross

12
continuum for cultural competency due to the measurable and progressive differences between

cultural destructiveness and cultural proficiency.19

This study aimed to determine if perceived versus “true” cultural competency could be

measured. It is unclear if “true” competency was determined from the qualitative questions.

While all measures were taken to increase objectivity when scoring qualitative results, there was

still a risk of bias between the investigators which could have affected scores. This novel survey

attempted to measure true competency by asking participants to recall their personal experiences.

By asking specific situational and knowledge-based questions the investigators hoped to reduce

the risk of participants responding in a socially desirable way. The tone and syntax subtleties of

the 3 questions were poised to root out examples of participant knowledge, attitudes, and

behaviors without explicitly asking about those 3 content areas specifically.

Previous investigators have demonstrated students can perceive the need to respond in a

socially desirable way, often leading to choosing or stating answers which don’t truly reflect

their own personal behaviors or attitudes. At times, this may result in higher cultural competency

scores which are not truly of the individual’s cultural competency.25 The addition of qualitative

questions where participants had to describe their own experiences was the way the researchers

attempted to exclude social desirability. It was a novel approach to compare quantitative scores

to qualitative responses to measure participants’ behaviors, attitudes, and knowledge. There was

insufficient evidence to show a relationship between quantitative and qualitative scores. Three

scales did show significant responses; all were positive relationships, meaning the higher the

score on the HPCCI, the higher the scores for the true qualitative questions. This suggested it

might be possible to measure true cultural competency while limiting the influence of bias by

13
using open-ended questions. This is relevant as Likert-based surveys are commonly used to

measure cultural competency, even while scrutinized for their disability to accurately measure

cultural competency due to the impact of social desirability on scores.26-29 This could be

beneficial in future measures of cultural competency by having respondents complete both open-

ended questions and completing Likert-based surveys.

Upon analysis of the available data, only a few demographic factors (i.e., gender, age,

income) had a significant role in determining participants’ cultural competency for the scales.

Out of the 27 fully completed surveys analyzed, there were only 4 male respondents, following

the general theme of PT being a female-dominated profession.30,31 As of 2021, 65.8-68% of the

physical therapists in the U.S. are female and 32-35% are males. 30,31

Most participants fell within the 23-27 age group and reported annual household income

between $50,000-$100,000. This limited the impact of responses by individuals outside of these

age and income ranges. Despite this, individuals between the ages of 18-22 were found to have

higher cultural behavior and patient-centered communication scores, regardless of having fewer

respondents in that age range. The higher scores earned by participants in the 18–22-year-old age

group may be the result of the recent integration of formal transcultural education and diversity

training within university curriculum.32-34 A recent shift in social constructs surrounding cultural

competency, along with an increase in diverse media content and sociopolitical movements, may

have played a role in the scores for the younger group.35 There was also a significant link

between participants who made less than $25,000 annually and participants’ self-assessments

and attitudes towards cultural competency. Investigators had identified how individuals with

lower household incomes often had lower health literacy rates and experienced more health

14
disparities.36,37 One could note if socioeconomic status or education were to improve, health

literacy and disparities may also improve. While higher education levels may counteract the

impact of lower socioeconomic status on health literacy and disparity for an individual,37

previous experiences from youth, such as growing up in a home with lower family income, may

impact an individual’s self-assessment of cultural competency skills or overall attitudes. These

participants may have experienced health disparities themselves, igniting a desire to further

understand cultural competency’s impact.

Demographics such as sexual orientation and race did not significantly affect

participants’ scores. Out of the study’s participants, only 1 participant reported a sexual

orientation of gay/lesbian. Approximately 12% of physical therapists in the U.S. identify as

LGBTQ+.38 Similarly, only 1 participant reported their race as Black/African American, whereas

the remainder identified as White/Caucasian. In 2021 approximately 75-77.4% of physical

therapists were White/Caucasian, 12.5% were Asian, and 4% were Black/African American.30,31

Currently, Central Michigan University’s DPT student population is approximately >90%

Caucasian/White students, lacking in diversity. Though sexual orientation and racial

demographics were found to be insignificant within this study, these demographics should not be

deemed insignificant when considering knowledge of cultural competency.

Participants who did not attend mission trips and scored highly on the second qualitative

question had higher scores on scales 1, 4, and 5. The same relationship was seen with scales 1-5

and the first qualitative question. This may have occurred because participants who went on

mission trips did not have leaders with proper training or who did not spend their time learning

from the communities they were serving. The participants' level of dogmatism may also affect

15
their responses. As seen in Te et al.,25 participants who are highly dogmatic have lower perceived

cultural competency scores, potentially being closed off from learning about other’s cultural

experiences, so participating in a mission trip would not sway their opinions. STOP

In many of the studies, mission trips were associated with greater cultural awareness. These trips

increased communication skills and allowed for appreciation and engagement of others. 7 Mission

trips had the strongest relationship in comparison to the scales while working in clinics and

alternative breaks showed very little significance. Mission trips negatively impacted scores,

potentially due to mentorship relations, the participant’s age when they attended their trip, and if

the trip was medically focused. There could be discrepancies in scores of mission trips with a

medical aim (i.e. providing vaccines, first aid, etc.) versus community-aimed trips, such as

building houses or schools. In a study focused on short and long-term impacts of a faith-based

trip,39 results showed differences in long-term impacts, including how participants perceived

their cultural competency and felt better prepared to treat those with different backgrounds 1 and

3 years after the trip; however, some participants attended second or third trips in the 3-year

span, which may have impacted their long-term answers.39

Scores may also depend on the participant’s age during their trip or how long it has been

since their trip. Some may have attended a mission trip less than 5 years ago but had personal

experiences after the trip that could sway their beliefs. Others may have attended a trip 10 years

ago that had a long-lasting impact on their attitudes and behaviors. Younger trip participants may

not have fully understood the impact of cultural and socioeconomic differences, versus someone

who went on a mission trip when they were older. There is little research that has been conducted

16
on this possible explanation, but maturity, knowledge, and attitude play a large role in one’s

over-perception.

Mentorship during a mission trip may also influence participants' perceptions of cultural

competency. Some leaders may hold themselves accountable and explain cultural competency to

participants on a mission trip, while others may lack the knowledge to explain it to others. In a

study conducted in Ireland,40 students were sent on a trip that was focused on self-exploration

and medical leadership, however, participant’s attitudes and self-awareness were not explicitly

measured.40 It was noted that the type of mentorship offered and the focus of the trip lend to

growth and self-awareness regarding cultural competency.

Many aspects are contributing to cultural competency within the profession of PT.

Investigators feel that there is room for growth in the PT curriculum. Demographics and life

experiences may or may not affect participants' true or perceived levels of cultural competency in

ways that were initially assumed. DPT programs must train their students on cultural

competency, so that they may demonstrate culturally competent behaviors, attitudes, and

knowledge to patients. DPT programs should ensure their faculty members are trained correctly

to provide learning opportunities for their students, so that new physical therapists are prepared

to treat patients competently, limiting perpetuation of judgment and health care disparities.

LIMITATIONS

The first limitation found in the research was the lack of a scale to measure “true”

cultural competency. A validated instrument was chosen to begin the data collection regarding

participants’ perceived cultural competency. As highlighted in the literature,4-13 cultural

17
competency assessment measures can be influenced by participant dogma and social desirability.

Short answer questions were added to the survey to attempt to measure participants’ “true”

cultural competency levels. The researchers established an objective scale, based on Cross et.al’s

Cultural Competence Continuum Framework,19 to score participants’ free-response answers.

The second limitation of the study pertains to the objective scoring of the “true” cultural

competency free responses. With the scoring being based on the Cultural Competence

Continuum Framework19 and not a pre-existing numerical rubric, investigators had to score

responses based on a scale they composed. This scale was not validated and was ultimately prone

to subjectivity despite investigators’ efforts to make the rubric as objective as possible. Since the

research study is a pilot study, alterations can be made to the scoring criteria during future

testing.

The third limitation is the absence of questions regarding the LGBTQ+ community.

Research regarding the LGBTQ+ community has grown over the past decades and should be

included in this research; however, there are “no known studies that have assessed LGBT

cultural competency of Occupational Therapy, Pharmacy, Physical Therapy, and Physician

Assistant students.”13 To make the research study more inclusive, the researchers added a

question regarding participant’s sexual orientation in the demographics section and a category

for working with the LGBTQ+ community in the life experiences portion.

The final limitation of the study was only having participants from 1 DPT program in

Michigan. External validity and transferability may be limited due to the focus of recruitment

being placed on 1 entry-level DPT program. Of those limited participants, not all fully completed

the survey, thus further decreasing the amount of completed data available to analyze.

18
Although investigators attempted to reach 4 cohorts within a single program, the demographics

of all cohorts are culturally homogenous, limiting diversity of responses regarding both race and

age. Out of the 40 participants, only 3 participants did not choose White/Caucasian as their race

and only 6 were not within the 23-27-year-old age range. The lack of diversity in the program,

along with the incompleteness of survey data, makes the generalizability of the results limited

compared to other DPT programs.

CONCLUSION

Investigators foresaw differences between demographics outlined in the survey and

cultural competency scores. It was expected there would be a discrepancy between the

participants' perceived versus "true" cultural competency scores as well. Researchers believed

there would be higher perceived cultural competency scores compared to the "true" cultural

competency scores, due to a lack of life experiences and formal training. Due to the amount of

literature supporting life experiences' impact on cultural competency, it was believed they would

have a more positive impact on cultural competency scores.

According to the data, there was a lack of sufficient evidence to prove there is a

statistically relevant difference between “true” and perceived cultural competency. Individuals’

demographics did not influence participants’ cultural competency scores when comparing their

self-ratings to their “true” qualitative ratings. There was a relationship between certain

demographics and perceived cultural competency scores; however, demographics did not impact

“true” competency scores. Most of the life experiences did not influence the scores as

anticipated, as those who did not participate in life experiences scored higher on their “true”

cultural competency responses. Even though the data demonstrated a lack of linearity between

19
life experiences and cultural competency levels, investigators still believe in the benefit of

participating in life experiences to gain overall knowledge regarding others.

The researchers hope the data received in this study may be applied to future research,

furthering the importance of cultural competency training in SPTs and other health professional

students. The topic of cultural competency is not a new one, but it is continuously growing and

changing. The definition may encompass more as society changes, and it is hopeful the research

will follow and grow with it.

20
 REFERENCES

1. Schwarz JL, Witte R, Sellers SL, et al. Development and psychometric assessment of the
healthcare provider cultural competence instrument. Inquiry. 2015;52(1):1-8.
https://doi.org/10.1177/0046958015583696.
2. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare
quality. J Natl Med Assoc. 2008;100(11):1275-1285. doi:10.1016/s0027-9684(15)31505-4.
3. Betancourt JR, Green AR, Carrillo JE, et al. Defining cultural competence: A practical
framework for addressing racial/ethnic disparities in health and health care. Public Health
Rep. 2003;118(4):293-302. doi:10.1093/phr/118.4.293.
4. Te M, Blackstock F, Fryer C, et al. Predictors of self-perceived cultural responsiveness in
entry-level physiotherapy students in Australia and Aotearoa New Zealand. BMC Med Educ.
2019;19(1):56. https://doi.org/10.1186/s12909-019-1487-0.
5. de Diego-Lázaro B, Winn K, Restrepo MA. Cultural competence and self-efficacy after
study abroad experiences. Am J Speech Lang Pathol. 2020;29(4):1896-1909.
doi:10.1044/2020_AJSLP-19-00101.
6. James L, Al-Kofahy L. Cultivating cultural competence through academic community
engagement and clinical reflection. J Transcult Nurs. 2021;32(5):623-629.
doi:10.1177/1043659620971699.
7. Haines J, Stiller CH, Thompson KA, Doherty D. Recent graduates’ perceptions of the impact
of a 1-month international service-learning experience in Kenya during their physical
therapist assistant education. J Phys Ther Educ. 2017;31(1):73-79.
https://doi.org/10.1097/00001416-201731010-00010.
8. Elverson CA, Klawiter R. Using guided reflection to link cultural and service learning in a
study abroad course. J Prof Nurs. 2019;35(3):181-186.
https://doi.org/10.1016/j.profnurs.2018.11.004.
9. Fell DW, Kennedy E, Day JM. Mixed methods study: a one-week international service
project enhances healthcare competencies. J Interprof Care. 2019;33(5):437-445.
doi:10.1080/13561820.2018.
10. Long T. Influence of international service-learning on nursing student self-efficacy toward
cultural competence. Int. J. Nurs. Educ. 2014; 53(8): 474–478.
https://doi.org/10.3928/01484834-20140725-02.
11. Schubbe E. Physical therapists’ perceptions of preparedness to engage in culturally
competent practice upon graduation. [Doctoral dissertation]. Mesa, AZ: A.T Still University;
2021.
12. Sherer EL. Physician assistant students' perceptions of cultural competence in providing care
to diverse populations. J Physician Assist Educ. 2019;30(3):135-142.
https://doi.org/10.1097/JPA.0000000000000260.
13. Nowaskie DZ, Patel AU, Fang RC. A multicenter, multidisciplinary evaluation of 1701
healthcare professional students’ LGBT cultural competency: Comparisons between dental,
medical, occupational therapy, pharmacy, physical therapy, physician assistant, and social

21
 work students. PLoS ONE. 2020;15(8):p.e0237670-e0237670
https://doi.org/10.1371/journal.pone.0237670.
14. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care
professionals and its influence on health care outcomes: A systematic review. Am J Public
Health. 2015;105(12). doi:e60-e76. doi:10.2105/AJPH.2015.302903.
15. Te M, Blackstock F, Chipchase L. Fostering cultural responsiveness in physiotherapy:
curricula survey of Australian and Aotearoa New Zealand physiotherapy programs. BMC
Med Educ. 2019;19(1):326. https://doi.org/10.1186/s12909-019-1766-9.
16. Standards and Required Elements for Accreditation of Physical Therapist Education
Programs. Commission on Accreditation in Physical Therapy Education. Published
November 3, 2020. https://www.capteonline.org/globalassets/capte-docs/capte-pt-standards-
required-elements.pdf. Accessed January 17, 2023.
17. Accreditation Handbook 2024 PT Standards and Required Elements. Commission on
Accreditation in Physical Therapy Education.
https://www.capteonline.org/globalassets/capte-docs/2024-capte-pt-standards-required-
elements.pdf Accessed February 18, 2024.
18. Cultural Competence Education. Association of American Medical Colleges. Published
2005. https://www.aamc.org/media/20856/download. Accessed January 17, 2023.
19. Cross T, et al. Towards a Culturally Competent System of Care: A Monograph on Effective
Services for Minority Children Who Are Severely Emotionally Disturbed. 1989. 1-90.
20. Doherty D, Maher SF, Ivanikiw C, Hales M, Lebiecki T, Wren, PA. Perceptions of cultural
competency in doctor of physical therapy students introduction. J Cult Divers. 2017; 24(2),
31-38. https://cmich.idm.oclc.org/login?url=https://www.proquest.com/scholarly-
journals/perceptions-cultural-competency-doctor-physical/docview/1974490707/se-2
21. Moleiro C, Marques S, Pacheco P. Cultural diversity competencies in child and youth care
services in Portugal: Development of two measures and a brief training program. Child Youth
Serv Rev. 2011;33(5):767–773. https://doi.org/10.1016/j.childyouth.2010.11.022.
22. Brueilly KE, Nelson TK, Gravano TN, Kroll PG. The effect of early contextual learning on
student physical therapists' self-perceived level of clinical preparedness. Acute Care
Perspect. 2009;18(3):6-13.
23. Capell J, Dean E, Veenstra G. The relationship between cultural competence and
ethnocentrism of health care professionals. J Transcult Nurs. 2008;19:121-5.
doi:10.1177/1043659607312970.
24. Clingerman E. Social Justice: A Framework for Culturally Competent Care. J Transcult
Nurs. 2011;22(4):334-341. doi:10.1177/1043659611414185.
25. Te M, Blackstock F, Fryer C, et al. Predictors of self-perceived cultural responsiveness in
entry-level physiotherapy students in Australia and Aotearoa New Zealand. BMC Med Educ.
2019;19(1):56. https://doi.org/10.1186/s12909-019-1487-0.

22
26. Gozu A, Beach MC, Price EG, et al. Self-Administered instruments to measure cultural
competence of health professionals: a systematic review. Teach Learn Med. 2007;19(2):180-
190. DOI: 10.1080/10401330701333654
27. Seeleman C, Hermans J, Lamkaddem M, et al. A students’ survey of cultural competence as
a basis for identifying gaps in the medical curriculum. BMC Med Educ. 2014;14(1):216.
https://doi.org/10.1186/1472-6920-14-216
28. Hudelson P, Perneger T, Kolly V, et al. Self-assessed competency at working with a medical
interpreter is not associated with knowledge of good practice. PLOS ONE. 2012;7(6):1-6.
https://doi.org/10.1371/journal.pone.0038973
29. Kumaş-Tan Z, Beagan B, Loppie C, et al. Measures of cultural competence: examining
hidden assumptions. Acad Med. 2007;82(6):548-557. DOI:
10.1097/ACM.0b013e3180555a2d
30. Physical Therapists. Data USA website. https://datausa.io/profile/soc/physical-
therapists#:~:text=The%20workforce%20of%20Physical%20therapists,for%20Physical%20t
herapists%20is%20White. Accessed January 4, 2024.
31. A Physical Therapy Profile: Demographics of the Profession, 2021-2022. American Physical
Therapy Association website. Published July 2023.
https://www.apta.org/contentassets/831610116033426c8f5fd8777dd63c2e/2023_apta_demog
raphics_report.pdf. Accessed January 9, 2024.
32. Jackson CS, Gracia N. Addressing health and health-care disparities: the role of a diverse
workforce and the social determinants of health. Public Health Rep. 2014;129(2):57–61.
33. Mareno N, Hart PL. Cultural competency among nurses with undergraduate and graduate
degrees: implications for nursing education. Nurs Educ Perspect. 2014;35(2):83–8.
34. Reyes H, Hadley L, Davenport D. A comparative analysis of cultural competence in
beginning and graduating nursing students. ISRN Nursing. 2013;5:1–5.
35. The new generations: why and how they embrace inclusivity, equality, and diversity. Opal
Group website. https://blog.opalgroup.net/the-new-generations-why-and-how-they-embrace-
inclusivity-equality-and-
diversity/#:~:text=The%20younger%20generation%20is%20becoming,religious%20beliefs
%20and%20cultural%20practices. Accessed January 28, 2024.
36. Paguio JA, Golbin JM, Yao JS, et al. Self-reported cultural competency measures among
patients with diabetes: A nationwide cross-sectional study in the United States. Lancet Reg
Health Am. 2021;7:100158. Published December 30, 2021. doi:10.1016/j.lana.2021.100158.
37. Stormacq C, Van den Broucke S, Wosinski J. Does health literacy mediate the relationship
between socioeconomic status and health disparities? Integrative review. Health Promot Int.
2019;34(5):e1-e17. doi:10.1093/heapro/day062.
38. Physical therapist demographics and statistics in the US. Zippia website. Published July 21,
2023. https://www.zippia.com/physical-therapist-jobs/demographics/. Accessed January 4,
2024.

23
39. Short N, St. Peters HYZ, Almonroeder R, et al. Long-term impact of international service
learning: cultural competence revisited. Journal of Occupational Therapy Education.
2020;4(1).
40. McMenamin R, McGrath M, D’Eath M. Impacts of service learning on Irish healthcare
students, educators, and Communities. Nursing&Health Sciences. 2010;12(4):499-506.
doi:10.1111/j.1442-2018.2010.00568.x
41. Drake A, Rose C. Researching Historically Marginalized Communities. Heritage Bulletin.
2019, 34.
https://www.oregon.gov/oprd/OH/Documents/HB34_Researching_Historically_Marganized_
Communities.pdf

24
 Table.
Multiple linear regression for averages of combined scales 1, 4, 5a

Standard Error
Parameter Estimate t Value Pr > |t|

Intercept 4.266056057 0.09024650 47.27 <.0001

Qual2_ 0.085563228 0.01156109 7.40 <.0001

Qual3_ 0.048178092 0.01090441 4.42 0.0010

Age 18-22 0.234768301 0.11399421 2.06 0.0639

Age 23-27 0.396640465 0.07934848 5.00 0.0004

Age 28-32 0.000000000 - - -

Income $100,000-$200,000 -0.176626249 0.09147420 -1.93 0.0797

Income $25,000-$50,000 -0.671131640 0.08807393 -7.62 <.0001

Income $50,000-$100,000 -0.473652663 0.07365791 -6.43 <.0001

Income More than $200,000 -1.459993530 0.16163484 -9.03 <.0001

Income Prefer not to say -0.361865781 0.11785486 -3.07 0.0107

Income Less than $25,000 0.000000000 - - -

Mission Trip Yes 0.080568074 0.13509568 0.60 0.5630

Mission Trip No 0.000000000 - - -

Work In Clinic Yes -0.268821272 0.04611880 -5.83 0.0001

Work In Clinic No 0.000000000 - - -

ASB Yes 1.572539922 0.13337856 11.79 <.0001

ASB No 0.000000000 - - -

Qual2_*Mission Trip Yes -0.112398593 0.02787937 -4.03 0.0020

Qual2_*Mission Trip No 0.000000000 - - -

a Table demonstrating relationship between dependent variables (i.e., demographics, life experiences, qualitative
responses) and combined scales 1, 4, 5. This combined scale was meant to represent participants’ attitudes
toward cultural competency.
 Cultural Competency Theoretical Framework Model a

Figure 1.
a Representation of how knowledge, attitudes, and behaviors or skills may influence self-
assessment of cultural competency via surveys, and how it may be demonstrated by a clinician
providing healthcare services. We attempted to differentiate between what an individual
perceives as their own cultural skills or attitudes and how that may be separate from what might
be considered true cultural competency attitudes, behaviors, and knowledge.
 Continuum of Cultural Competency19 Scores
Cultural Destructiveness
1 point {0-17%}
Cultural Incapacity
2 points {18-35%}
Cultural Blindness
3 points {36-53%}
Cultural Pre-Competence
4 points {54-71%}
Cultural Competency
5 points {72-89%}
Cultural Proficiency
6 points {90-100%}
Figure 2.
a “C”= Cross’s definition of the specific continuum score; “I”= Investigators’ definition of the
specific continuum score.
• (C)a Forced assimilation, destructive to a cultural group.
• (I)a Refusing equal access (interpreter services, ending
contracts with insurances due to decreased
reimbursement rates).
• (C) Racism, inability to respond to diverse group's needs.
• (I) Infers stereotypical viewpoints: "You know how they
are."
• (C) Ignoring differences, "Treat everyone the same."
• (I) "I don't see color."
• (C) Explore cultural issues, assess & respond to needs of
culturally and linguistically diverse populations.
• (I) Note pt body language and family dynamics, hire
diverse staff, performs community outreach, "Asked my
patients questions."
• (C) Recognize differences, seek advice from diverse
groups, accept and respect others.
• (I) "Researched on my own,” "Kept their religion/culture
in mind.”
• (C) Implement change to improve services, add to
knowledge base of the field, mentor others.
• (I) Practices based on unique patient needs, promote
equitable healthcare, conduct research to add to patient-
centered care.
Figure 3.
Graph showing positive and negative relationship between income and mission trip attendance in
comparison to all scales combined (knowledge) and qualitative question #1 (attitudes).
Appendix A: Demographic Survey

Q1. What is your age range?

• 18-22
• 23-27
• 28-32
• 33-37
• 38-42
• 42+
Q2. Which gender do you identify with?
• Male
• Female
• Non-binary / third gender
• Prefer not to say
• Transgender Man
• Transgender Woman
• Other
Q3. What is your race?
• White/Caucasian
• Black/African American
• Latino/Hispanic
• MENA (Middle Eastern/North African)
• Asian
• Native American
• Native Hawaiian or Pacific Islander
• Other
Q4. What is your sexual orientation?
• Straight
• Gay/Lesbian
• Bisexual
• Asexual
• Other
Q5. What is your annual family income?
• Less than $25,000
• $25,000-$50,000
• $50,000-$100,000
• $100,000-$200,000
• More than $200,000
• Prefer not to say
Q6. What is the main language you speak at home? If you speak multiple, please list them all.
Appendix B: Life Experience Survey

• Please select yes or no if you have participated in the following life experience: Volunteer
opportunities (Unpaid opportunities, student committees, scouts, church, school, local soup
kitchens, homeless shelters, summer camps, cleaning duties around community, etc.)
o Yes
o No
• Please select yes or no if you have participated in the following life experience: Clinical
experience (Clinicals/internships for academic programs, shadowing hours, research,
scribing, EMT, etc.)
o Yes
o No
• Please select yes or no if you have participated in the following life experience: Study abroad
(School trips with majority educational content.)
o Yes
o No
• Please select yes or no if you have participated in the following life experience: Mission trip
(Service based trips, typically through a church or organization.)
o Yes
o No
• Please select yes or no if you have participated in the following life experience: Working in
clinics (Paid positions which include working as a tech, CNA, front desk staff, etc.)
o Yes
o No
• Please select yes or no if you have participated in the following life experience: Alternative
breaks (Spending any break from school volunteering for a community through an
organization or through the institution.)
o Yes
o No
• Please select yes or no if you have participated in the following life experience: Worked with
historically marginalized groups (Historically marginalized groups are those who have been
misrepresented throughout history and denied rights to/participation in cultural, social,
political, and economic activities. These include, but are not limited to, people of color,
women, LGBTQ+, low-income individuals, prisoners, the disabled, senior citizens, etc.) 41

o Yes
o No
• Provide a free response, in 50 characters or less, if you have participated in a life experience
that is not explicitly listed above.
Appendix C: True Cultural Competency Questions

1) Describe in 250 words or less, how you personally define cultural competence as it relates to
working with patients.
2) Describe in 250 words or less, a time you provided a patient/client with culturally competent
care. Please write in N/A if you have never participated in patient/client care.
3) Describe in 250 words or less, a time where you educated yourself on a patient/client who
had needs different than your own, and thus required culturally competent care. Please write
N/A if you have never participated in any form of patient/client care.
Appendix D: Healthcare Provider Cultural Competence Instrument Questions

1. To what extent do you agree or disagree with the follow statements?

1. Race is the most

important factor in
determining a person’s
culture
2. People with a common
cultural background think
and act alike

3. Many aspects of culture

influence health and health
care
4. Aspects of cultural
diversity need to be
assessed for each
individual, group, and
organization
5. If I know about a
person’s culture, I do not
need to assess their
personal preferences for
health services
6. Spirituality and religious
beliefs are important
aspects of many cultural
groups
7. Individual people may
identify with more than 1
cultural group
8. Language barriers are
the only difficulties for
recent immigrants to the
United States
9. I understand that people
from different cultures may
define the concept of
“health care” in different
ways
 10. I think that knowing
about different cultural
groups helps direct my
work with individuals,
families, groups, and
organizations
11. I enjoy working with
people who are culturally
different from me

2. Please indicate how frequently you engage in each of the following behaviors.
12. I include cultural
assessment when I do client
or family evaluations
13. I seek information on
cultural needs when I
identify new clients and
families in my practice
14. I have resource books
and other materials
available to help me learn
about clients and families
from different cultures
15. I use a variety of sources
to learn about the cultural
heritage of other people
16. I ask clients and families
to tell me about their own
explanations of health and
illness
17. I ask clients and families
to tell me about their
expectations for health
services
18. I avoid using
generalizations to stereotype
groups of people
19. I recognize potential
barriers to service that
might be encountered by
different people
 20. I act to remove obstacles
for people of different
cultures when I identify
such obstacles
21. I remove obstacles for
people of different cultures
when clients and families
identify such obstacles to
me
22. I welcome feedback
from clients and their
families about how I relate
to others with different
cultures
23. I welcome feedback
from coworkers about how I
relate to others with
different cultures
24. I find ways to adapt my
services to my clients and
their families’ preferences

25. I document cultural

assessments

26. I document the

adaptations I make with
clients and their families
27. I learn from my
coworkers about people
with different cultural
heritages

3. Please indicate how frequently you engage in each of the following behaviors.
28. When there are a variety of
treatment options, how often do
you give the client and their
family a choice when making a
decision?
29. When there are a variety of
treatment options, how often do
you make an effort to give the
client and their family control
over their treatment?
 30. When there are a variety of
treatment options, how often you
ask the client and their family to
take responsibility for their
treatment?

4. Please select the answer that best describes your level of agreement with the statement.
31. The health care provider is the
one who should decide what gets
talked about during a visit
32. It is often best for the client
and their family that they do not
have a full explanation of the
client’s medical condition
33. The client and their family
should rely on their health care
providers’ knowledge and not try
to find out about their condition(s)
on their own
34. When health care providers
ask a lot of questions about a
client and their family’s
background, they are prying too
much into personal matters
35. If health care providers are
truly good at diagnosis and
treatment, the way they relate to
client and their family is not that
important
36. The client and their family
should be treated as if they are
partners with the health care
provider, equal in power and
status
37. When the client and their
family disagree with their health
provider, this is a sign that the
health care provider does not have
the client and their family’s
respect and trust
38. A treatment plan cannot
succeed if it is in conflict with a
client and their family’s lifestyle
or values
 39. It is not that important to know
a client and their family’s culture
and background to treat the
client’s illness

5. Please select the answer that best describes your level of agreement with the statement.
40. As a health care provider, I
understand how to lower
communication barriers with
clients and their families
41. I have a positive
communication style with clients
and their families
42. As a health care provider, I am
able to foster a friendly
environment with my clients and
their families
43. I attempt to demonstrate a high
level of respect for clients and
their families
44. As a health care provider, I
consistently assess my skills as I
work with diverse groups of
clients and their families
45. I attempt to establish a genuine
sense of trust with my clients and
their families
46. I make every effort to
understand the unique
circumstances of each client and
her or his family
47. I value the life experience of
each of my clients and their
families
48. The use of effective
interpersonal skills is very
important in working with my
clients and their families