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Research Proposal

Cultural Competency Instruction in a 3D Virtual World


Robin Steed

A paper submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Computing Technology in Education

Graduate School of Computer and Information Sciences

Nova Southeastern University


An Abstract of a Dissertation Report Submitted to Nova Southeastern University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

Cultural Competency Instruction in a 3D Virtual World


Robin Steed

September 2009

Approximately one third of the population of Louisiana is African American. According to federal reports, Blacks in Louisiana receive a poorer quality of healthcare compared to the White population. Occupational therapy is a profession of predominately White, middle class females who report in surveys that they are not adequately prepared to provide culturally sensitive care to minorities. Leaders in occupational therapy have suggested instruction in cultural competency as a way to remediate the gap in quality of healthcare services for African Americans. This proposal suggests providing thirteen Louisiana occupational therapists with an immersive cultural experience in the virtual 3D world of Second Life in an effort to bring about increased sensitivity towards the African American culture. The study will employ a pre-test, post-test case study design using the Race Argument Scale and the Race Attitude Implicit Association Test as outcome measures. Qualitative data collected will include answers to reflection questions embedded in the environment and responses to an exit survey. Quantitative measures will include the RAS and the RAIAT given as a pre-tests and post-tests.

Table of Contents

Abstract iii

List of Tables vii

Figure 1 Elements of Immersive Learning in Second Life 73


  1. Introduction 1

Statement of the Problem to Be Investigated and Goal to Be Achieved 1

Relevance and Significance of the Problem 3

Barriers and Issues 7

Research Questions and Hypotheses 8

Limitations and Delimitations 9

Definition of Terms 10

Summary 11

  1. Review of the Literature 12

The Theory and Research Literature Specific to Cultural Competency 12

The Theory and Research Literature Specific to Virtual Worlds 27

Summary 40

  1. Methodology 43

Developmental Phase 43

Intervention Phase 50

Analysis 53

Resources 54

Summary 54


  1. Consent Form for Usability Study 99

  2. Racial Argument Scale 105

  3. Race Attitude Implicit Attitude Survey Data Collection Form 109

  4. Video Discussion Questions: Kim Anderson’s Story 110

  5. Problem-Based Learning Scenario 117

  6. Detailed Protocol for Experimental Study 122

  7. Consent Form for Experimental Study 126

  8. Table of Contents for Participant Notebook 133

Reference List 136

List of Tables

  1. Results of the Race Attitude Implicit Association Test 16

  2. OT Literature Addressing Components of Cultural Competency 27

  3. Multi-media Principles 33

  4. Using the ADDIE Model to Create a Learning Experience in Second Life 37

  5. Instructional Plan 46

  6. Rubric for Expert Review of Instructional Plan 47

Chapter 1


In 2003, the Agency for Healthcare Research and Quality (AHRQ) released two documents that exposed the magnitude of health disparities for minorities and vulnerable populations in the United States: the National Healthcare Quality Report (NHQR) and the National Healthcare Disparity Report (NHDR). The purpose of the NHQR was to focus on safety, effectiveness, patient centeredness, and timeliness in healthcare for all populations; whereas, the NHDR focused on the disparities in quality of healthcare for: women, children, the elderly, and minorities. A review of both documents reveals that disparity in the quality of healthcare exists for individuals in these vulnerable populations. For example, racial minorities and low-income patients are less likely to receive preventive care and require frequent hospitalizations (NHDR, 2006). These same populations are less likely to receive referral to specialists, outpatient rehabilitation services, and patient education. The NHDR also reported that ethnic minorities are more likely to be physically restrained in nursing homes than non-Hispanic whites, raising concerns about safe treatment. Unfortunately, these are but a few of the examples of inequality found in these reports.

Although the exact cause of these disparities is unknown and is most likely multi-factored, the NHDR authors recommend instruction in cultural competency as one possible means of reducing the healthcare gap. This recommendation is supported by the NHDR finding that ethnic and racial minorities and those of a lower socioeconomic status reported more problems in their relationships with healthcare providers (Taylor, 2008; Wells & Black, 2000). A good patient-provider relationship is essential to successful treatment outcomes. Patient-centered care communicates respect to patients by involving the individual in the decision making process, thereby making follow through on treatment recommendations much more likely. An adept healthcare provider must be able to cross cultural barriers in order to build a trusting and effective relationship with patients (Barney, 1991; Kinebanian & Stomph,1992). A culturally competent healthcare provider is one who has developed the attitudes, behaviors, and knowledge that enable her to provide treatment to a patient from a culture different from her own in a way that is perceived by that patient to be personally and culturally appropriate (Lynch & Hanson, 2004; MacDonald, 1998). The NHDR pointed out the importance of cultural competency as a way to reduce healthcare disparity and urged accreditation and licensing bodies to develop standards for their respective healthcare disciplines.

Occupational therapy (OT) is a rehabilitation profession composed of primarily white females who treat a cultural diverse population (AOTA, 2008a). Leaders in the field have called for new initiatives to address healthcare disparities and limited cultural competency in occupational therapists. At the present time, occupational therapists working in Louisiana have limited access to education in cultural competency; which is troublesome since Louisiana has some of the largest healthcare disparities in the country according to a report by the Commonwealth Fund (Cantor, Belloff, Schoen, How, & McCarthy; 2007). Within the United States, Louisiana ranked 46th in health system performance with the following indicator ranks: 33rd in access to services, 41st in quality of healthcare, 51st in avoidable hospital use, 28th in equity of service provision, and 50th in overall population health. With improvement to the best states’ level, Louisiana could save $132,052,000 a year in hospital costs and nearly 3,000 deaths a year would be prevented. Since the largest minority group in Louisiana is African American (U.S. Census Bureau, 2006), cultural competency training for occupational therapists in Louisiana should focus on providing culturally appropriate care for Black clients.

The primary purpose of this study is to provide a readily accessible training intervention in cultural competency for occupational therapists in Louisiana. Therapists who will complete the training will have increased understanding of the importance of culture in a clinical setting, increased knowledge of available culturally sensitive resources, and improved ability to communicate in a culturally diverse environment. The instructional design will take into account current theories regarding the etiology of belief systems and prejudices. Learning content will provide information on how stereotypes are formed and participants would be asked to reflect on ways these theories may apply to them personally. In this way, it is hoped that participants will not just gain knowledge about cultural competency, but will have a measurable change in attitude about clients from a different culture. A secondary purpose of this study is to examine how the design of the instructional intervention supports or hinders learning. The subjective experience of the therapists will be explored to determine what methods were most effective in presenting the learning content. This information can then be used in the design of future instructional interventions.

Relevance and Significance of the Problem

Lack of Cultural Competency in Occupational Therapy

The American Occupational Therapy Association (AOTA) has historically considered culture as an integral component of human experience (Black, 2002; Cena, McGruder, & Tomlin, 2002). The profession’s domain of practice is broad; and encompasses treatment populations of all ages, race, gender and disability. Occupational therapy’s primary purpose is to support “health and participation in life through engagement in occupation” (AOTA, 2008c, p. 628). Occupation has been defined by leaders in the profession in a variety of ways, always with an understanding that cultural beliefs and values infuse activities with meaning. Crepeau, Cohn, and Schell (2003) define occupation as “daily activities that reflect cultural values, provide structure to living, meaning to individuals; these activities meet human needs for self-care, enjoyment, and participation in society” (p. l031). Likewise, Law, Polatajko, Baptiste, and Townsend (1997) describe occupations as activities of daily living, “named, organized, and given value and meaning by individuals and a culture” (p. 32). In essence, the culture itself names and ascribes meaning to “chunks of activities” which are then described as occupations by occupational therapy (Zemke & Clark, 1996, p. vii). The Occupational Therapy Practice Framework: Domain and Process, 2nd Edition (Framework-II) is a document published by the AOTA (2008c), intended to describe the relationships between different constructs within the profession. The Framework-II refers to culture as a context, which includes “customs, beliefs, activity patterns, behavior standards, and expectations accepted by the society of which the client is a member” (AOTA, 2008c, p. 642). Cultural context includes “ethnicity and values as well as political aspects, such as laws that affect access to resources and affirm personal rights” (AOTA, 2008c, p. 645). In contrast, the personal context refers to “demographic features of the individual such as age, gender, socioeconomic status, and educational level that are not part of a health condition” (AOTA, 2008c, p. 642).

The occupational therapy profession recognizes the influence of culture on health and disability, but only recently has formally required that cultural competency be addressed in occupational therapy curriculum. The first accreditation standards focusing on cultural diversity were published in 1991 (AOTA, 1991). The recent 2008 Accreditation Committee of Occupational Therapy Education (ACOTE) standards require that occupational therapy students develop an appreciation for diverse value systems that influence patient performance and behavior. The 2008 standards specify that graduates "demonstrate knowledge and appreciation of the role of sociocultural, socioeconomic, and diversity factors and lifestyle choices in contemporary society" (AOTA, 2007, p.656). Students must also "demonstrate knowledge of global social issues and prevailing health and welfare needs" (AOTA, 2007, p.656). The standards address the need for practicing therapists to carry out occupational therapy services appropriately in a variety of sociocultural contexts.

While diversity has become a widely discussed topic, many leaders in the profession contend that the majority of occupational therapists continue to lack the multicultural skills needed to practice in today's health care environment (Muñoz, 2007; Wittman & Velde, 2002). New graduates have increasingly faced culturally diverse challenges, for which they report their education has not adequately prepared them to meet (Murden, Norman, Ross, Sturdivant, Kedia, & Shah, 2008). Part of the problem may be that the sociocultural makeup of the occupational therapy profession is primarily composed of middle class White females (American Occupational Therapy Association, 2008a; Black, 2002). Another factor may be that cultural sensitivity was not an emphasis in OT curriculum until recent years, and many currently practicing therapists never received cross-cultural training while in school. In response to this apparent gap in the profession's knowledge base, AOTA has encouraged its members to seek out continuing education in cultural diversity.

Unfortunately, occupational therapists seeking education in cultural competency have few options provided by the profession. AOTA has published a manual of culturally competent best practices (Wells & Black, 2000) along with providing a variety of articles, resources, and networking opportunities on the AOTA web site (www.aota.org). AOTA does not offer any continuing education courses in cultural competency, online or face-to-face, although it does approve continuing education credits obtained from an online course on cultural competency for nurses. A number of lectures on cultural issues are offered at the AOTA national conference each year (AOTA, 2008b), but only a limited number of therapists attend the conference.

The type of material that is typically available presents further concerns. Traditionally, therapists are educated on the norms, beliefs, and customs of an ethnic group in order to improve cultural competency (Muñoz, 2007). This training may actually reinforce stereotypes and produce a reverse discrimination that is patronizing and controlling in nature. It does not take into account the individual differences within an ethnic groups that are due to personality, sexual orientation, length of time in the US, geographical location, socioeconomic status, and religious beliefs (Lynch & Hanson, 2004). As the US becomes more racially complex and mixed, traditional training in cultural competence will become even less relevant. Intermarriage and global communication via technology may radically shift the cultural identity of the next generation of clients. New instructional methods are needed to train the next generation of occupational therapists.

Lack of Cultural Competency in Louisiana Occupational Therapists

Louisiana healthcare recipients are culturally diverse; the population is divided among Anglo-Americans, African Americans, French Americans, and Hispanics (U.S. Census Bureau, 2006). The U.S. Census Bureau estimated that the percentage of African Americans in Louisiana in 2006 to be around 32% compared to the national percentage of 13%. Approximately 15% of individuals in Louisiana identify their heritage as Cajun or French compared to 3% in the U.S. Only 3 % of the population in Louisiana is Hispanic. The percentage of people living below the poverty level in Louisiana in 2006 was 19 % compared to 13.3% nationally. In comparison, occupational therapists in Louisiana are less culturally diverse and tend to be primarily White, middle-class females. The importance of cultural competence in Louisiana has become prominent in recent years with the population shift due to hurricane Katrina. More than ever before, Louisiana occupational therapists must be able to interact with a variety of clients with diverse beliefs, attitudes and behaviors.

Barriers and Issues

This study suggested that providing instruction on cultural competency in the virtual world of Second Life would best meet the educational needs of Louisiana occupational therapists. Second Life is an online 3D multi-user program where users are permitted to create the graphic interface. While avatar accounts are free, users must purchase space, called regions, on the program's server in order to build content into the graphic interface. The primary barrier to the achievement of the study's goals was the development of an instructional module in Second Life. The author had some experience with this technology as well as a number of developmental resources with which to consult. The researcher owned approximately 1/8th of a region in Second Life, which was ample space to build an immersive environment.

Recruitment of occupational therapists to participate in the study did not pose a significant problem since the training offered 0.6 free continuing education credits (CEUs) and was relevant to therapists in all varieties of practice. The author obtained approval from the Louisiana State Board of Medical Examiners for the training in order to guarantee its acceptance of the CEUs.

Inherent in any study where attitudinal change is an outcome variable is the limitation imposed by the participants themselves. Since developing cultural competency usually implies a change in belief system, a change that usually requires time, it may be that the intervention was not of sufficient length to effect such a change.

Another barrier that proved to have a significant impact on the study was limited bandwidth allocation to the Louisiana State University Health Science Center School of Allied Health Profession's computer lab, which was the location of the intervention.
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