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Research Questions and Hypotheses

Research Questions

  1. Can an immersive virtual world experience improve cultural competency attitudes, behaviors, and reasoning in Louisiana occupational therapists? If so, what instructional methods are effective in educating Louisiana occupational therapists in cultural competence using a virtual world environment?

  2. What type of support for learners is necessary in an online virtual environment designed to teach Louisiana occupational therapists cultural competency?

  3. What is the phenomenological experience of occupational therapists participating in cultural competency training in Second Life?

Research Hypotheses

    1. Louisiana occupational therapists participating in cultural competency training in Second Life will have statistically significant lower post test compared to pre-test scores on the Racial Argument Scale.

    2. Louisiana occupational therapists participating in cultural competency training in Second Life will have statistically significant higher post test compared to pre-test scores on the Racial Attitude Implicit Association Test.

Definition of Terms

Cultural competency. For the purposes of this study, cultural competency is loosely defined as the ability to interact with a member of another culture in a way that is relevant and appropriate to the member of that culture (NHDR, 2003).

Culture. The NHDR definition of culture is used for the purposes of this paper, which is as follows:

an integrated pattern of learned beliefs and behaviors that can be shared among groups. It includes thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices, and customs. Culture is shaped by multiple influences, including race, ethnicity, nationality, language, and gender, but it also extends to socioeconomic status, physical and mental ability, sexual orientation, and occupation, among other factors. These influences can collectively be described as “sociocultural factors,” which shape our values, form our belief systems, and motivate our behaviors. (NHDR, 2003, p. 1 )

Virtual World is defined by Bell (2008) as “a synchronous, persistent network of people, represented as avatars, facilitated by networked computers” (p. 2).

Avatar is defined as “any digital representation (graphical or textual), beyond a simple label or name, that has agency (an ability to perform actions) and is controlled by a human agent in real time” (Bell, 2008, p. 3).

Instructional methods are "the elements included in instruction for the purpose of supporting the achievement of the learning objective" (Reiser & Dempsey, 2007, p. 314). Instructional methods in this study will include multi-media presentations, visuals, role play, group discussion, and journaling.

Scaffolding involves the removal of distracting and confusing elements in a complex learning environment in order to support novice learners. As learners become more skilled in the environment, complexity may be added gradually. (Young, 1993).


Disparities in the quality of healthcare services for minorities in Louisiana are some of the largest in the nation. Education in cultural competency is suggested as a way to remediate this gap in healthcare services. The current economic crisis and lack of appropriate continuing education opportunities make obtaining continuing education a challenge for many occupational therapists in Louisiana. Online learning may provide a solution that is economical and convenient for even rural therapists, but little research has focused on what would constitute an effective instructional environment in this content domain. This study will examine the efficacy of providing Louisiana occupational therapists 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.

Chapter 2

Review of Literature

This chapter will first explore current understanding of cultural competency in the general healthcare literature and in occupational therapy specifically. This is followed by a discussion of current educational applications, affordances, and instructional design of virtual world environments. The review concludes with a summary of what is known and unknown about education in virtual worlds as it relates to cultural competency instruction for occupational therapists.

The Theory and Research Literature Specific to Cultural Competency

This portion of the review will focus on general theories of cultural competency, how researchers have measured competency, and how occupational therapy has approached research and instruction in competency.

Cultural Competency in Healthcare

Based on an analysis of relevant literature in psychology, social work, medicine, and education, Suh (2004) has described a model of cultural competence for health care clinicians. This model identifies prerequisite conditions in four domains that must be experienced and explored in order to achieve culturally competent practice: cognitive, affective, behavioral, and environmental. This model suggests that changes in attitudes, behaviors, and context must occur in addition to acquisition of basic knowledge of cultural norms and beliefs. Because cultural diversity may heighten anxiety in clinicians, the first step in training is best taken in the affective domain with the development of cultural sensitivity. Rather than focusing exclusively on gaining a knowledge base about a culture, which may or may not be accurate, the cognitive prerequisite domain should focus on developing interactive reasoning, or appropriate social judgment, as well. Using informed interactive reasoning from the cognitive domain, the clinician can develop skills in the behavioral domain that enable culturally competent health care delivery. The final prerequisite condition is an encounter with another culture. In particular, immersive experiences have been shown to be effective in the development of cultural sensitivity. Immersion experiences are those in which students can explore the variety and complexity of a culture in a natural context. In addition to the development of a cognitive understanding there is an affective appreciation for the ways of being and doing in the culture.

Another approach to understanding the development of cultural competency is the examination of the psychological and cognitive processes that support the persistence of negative attitudes towards different cultures (Feinberg, 2000). Two powerful perceptual processes, illusory correlation and out-group bias, support the tendency to stereotype people from another culture. Illusory correlation is the inclination of the brain to perceive elements in the environment that are rare as being related to each other (Jones, 1997). This may explain why negative characteristics, such a physical or mental illness, are incorrectly thought to occur more frequently in minority populations. Out-group bias is the tendency to believe that cultures different from one’s own are more homogenous (Pettigrew, 1997). This can lead to a healthcare provider treating patients from a certain race or culture according to a stereotype rather than as an individual with specific needs. Since both of these processes are unconscious, explicit instruction on how to recognize their influence is warranted.

Assessment of cultural competency has been approached in several ways. Most often cited in the literature are self-report surveys measuring attributes of cultural competency (Beach et al, 2005; Campinha-Bacote, 2003; Jeffreys, 2006; Stanhope, Solomon, Pernell-Arnold, Sands, & Bourjolly, 2005). The most popular method of measuring cross-cultural attitudes and commitment to change in health care providers are self-efficacy assessments (Jeffreys & Smodlaka, 1999). Self-efficacy, a construct found in social learning psychology, is an individual’s perception of his or her ability to engage in a behavior (Bandura, 1977). Other less common outcome measures of cultural competency training include written examinations on cross-cultural knowledge, observation of interview skills, and completion of written assignments such as treatment plans and behavior analyses.

Although self-report measures are more commonly used, this method is not without limitations. Since lack of self-awareness may lead to cross-cultural incompetence, test takers who lack insight may be prone to reporting higher competency. Austin et al (1999) found that nurses who scored unusually high on a self-report measure of cultural competency also believed that culture does not play a part in providing effective care. The effect of the social-desirability of cultural competency is another threat to the validity of self-report measures of this construct (Brown & Naumann, 2001).

Occupational therapists have been taught that discrimination based on race violates the AOTA Code of Ethics. This knowledge may predispose a therapist to report a more open attitude toward a culture than what is actually practiced in a clinic. This does not necessarily indicate deception since numerous studies have shown that such undesirable attitudes are held unconsciously (Baron & Banaji, 2006; Dovidio, Kawakami, Johnson, Johnson, & Howard, 1997; Greenwald & Banaji, 1995). One way to measure implicit thought processes is through a latent response test such as the Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998). In a Race Attitude IAT (The Implicit Association Test, Inc; 2008), subjects are asked to pair pictures of people of color and pictures of Caucasians with positive and negative words. The assumption is that a task that requires more mental processing will take longer. If a person takes longer to pair positive words with pictures of people of African descent than with pictures of Caucasians, then it is suggested that a negative association with African Americans mediates the lag in response time (Lane, Banaji, Nosek, & Greenwald, 2007). The Race Attitude Implicit Association Test (RAIAT) is available free online (implicit.harvard.edu/implicit/Study?tid=-1) along with 16 other implicit association tests designed to measure other constructs. Prior to taking the Race Attitude IAT, test takers have the option of first answering questions aimed at extracting explicit race preferences. For the actual RAIAT, participants are presented with two target categories, white and black, and are asked to assign negative and positive words and images to either category. The result of the RAIAT is reported as a designation to one of seven categories (See Table 1).

Table 1. Results of the Race Attitude Implicit Association Test


Percent of online test takers designated to each category

Strong automatic preference for White people compared to Black people


Moderate automatic preference for White people compared to Black people


Slight automatic preference for White people compared to Black people


Little to no automatic preference between Black and White people


Slight automatic preference for Black people compared to White people


Moderate automatic preference for Black people compared to White people


Strong automatic preference for Black people compared to White people


Between 7/2000 and 5/2006, the test was taken 732,881 times, yielding a large data set from which to extrapolate correlations between implicit and explicit associations and the strength of implicit and explicit preferences. The difference between no preference and preference for White race is expressed in Cohen’s d effect size. The mean difference between these two preference strengths on the IAT has an effect size 0.86. The effect size for the mean difference on the explicit measure is 0.36. The correlation between the means of the implicit and explicit measures is 0.31. One interpretation of these findings would be that people, in general, have a preference for the White race and, in general, are unaware of the strength of that preference (Nosek, Smyth, Hansen, Devos, Lindner, Ranganath, et al., 2007). The authors of the test report that laboratory findings substantiate the online data.

Another method of assessing racial attitude indirectly is based on the concept of biased assimilation, the process by which people interpret information so that it supports their current belief system. The Racial Argument Scale (RAS) consists of thirteen arguments and corresponding conclusions relating to African Americans (Saucier & Miller, 2003). Individuals are asked to rate how well they think the argument supports the related conclusion, but not how much they agree with the argument itself. Munro and Ditto (1997) have shown that study subjects will interpret ambiguous information according to how that information fits beliefs and attitudes regarding another group (Saucier & Miller, 2003). Like implicit association tests, an advantage of the RAS is its poor correlation with measures of social desirability, but unlike the RAIAT which reports results in terms of ordinal data, the RAS returns interval data. The results of the RAS are therefore more sensitive to change in an individual’s attitude. The RAS has adequate internal consistency, test-retest reliability, and concurrent validity; and has been shown to be an accurate predictor of positive and negative behaviors towards African Americans.

Cultural Competency in Occupational Therapy

Cultural competence has been defined in a variety of ways in the occupational therapy profession. One of the earliest definitions of culture found in the OT literature is offered by Litterst (1985): " a system of shared meanings, the collection of folkways, beliefs and objects associated with a given people, the interconnected system of institutions characterizing human social life, and the medium of environmental adaptation that is uniquely human" (p. 603). Litterst criticizes the inexact and subjective research methods used by OT scholars to study culture and advocates further study of the topic in order to understand the role of culture in a therapeutic context. Seven years later, Dillard, Andonian, Flores, MacRae, and Shakir (1992) provide a response to Litterst's recommendation in their description of the San Francisco General Hospital's multicultural model in which patients are placed in special focus treatment programs; including "Asian/Pacific Islander, Latino, African Peoples, Women, and HIV (human immunodeficiency virus)" (p. 722). Dillard et al. define cultural competence as "an awareness of, sensitivity to, and knowledge of the meaning of culture. It includes one's openness and willingness to learn about cultural issues, including one's own cultural biases" (p. 722). Culture is seen as more than ethnicity and includes sexual orientation, family background, life experience, age, gender, and socioeconomic status. Fitzgerald, Mullavey-O’Byrne and Clemson (1997) describe culture as "an abstract concept that refers to learned and shared patterns of perceiving and adapting to the world, reflected in the learned, shared beliefs, values, attitudes, and behaviors characteristic of a society or population" (p. 3). More recently, Wells and Black (2007) suggest culture is the "sum total of ways of living developed by a group of human beings and transmitted from one generation to another" (p. 32). Cultural competence is seen as the ability to respond non-judgmentally to the needs of individuals who are not of the mainstream or dominant culture. This ability encompasses four domains: a) cognitive-cultural awareness and knowledge; b) behavioral- cultural skills; c) affective- cultural sensitivity; and d) environment- cultural encounter.

Unlike theorists previously discussed, McGruder (2009) defines culture as learned social values that are chosen by a group of people. In her perspective, ethnicity, sexual orientation, gender, language, and social class influence culture but are not considered to be precisely culture because they cannot be chosen. Individuals of a cultural group decide, whether consciously or unconsciously, to adhere to an agreed upon way of living which includes ideas of right and wrong, aesthetic beauty, appropriate gender roles, and proper dress code. McGruder believes, as does Dickie (2004) that occupational therapists have neglected to develop cultural self-awareness in an attempt to understand the social rules and patterns of behavior of non-dominant cultures. Both authors recommend learning the general rules of a culture, but only as a basic starting point and as a way to learn the rules of one's own culture.

Bonder, Martin, and Miracle (2004), propose a broad model of culture emergent that describes culture as growing out of ordinary interactions between people. This model takes into account collective and individual experiences of diversity as well as the many dynamic influences in a multi-cultural environment mentioned by McGruder (2009) and Dickie (2004), such as the individual biological and psychological factors in each person. Culture is seen as uniquely expressed and experienced by each individual in the culture and thus is varied from person to person. Change in the collective culture occurs slowly over time, which is beneficial in a system that maintains societal values and beliefs. Not all individuals in a culture will adapt to new information and technology at the same rate, and so, subcultures within the main culture may develop.

Citing Sue (2000), Bonder, Martin, and Miracle (2004), suggest that cultural competency in occupational therapy has three characteristics. The therapist must have scientific-mindedness in order to form a hypothesis based on culture-specific knowledge. This hypothesis must be tested in every new encounter with a client from that culture, which will lead to a set of assumptions about that culture. The assumptions will then be tested and continually adapted through dynamic sizing skills. These skills allow the therapist to recognize when cultural generalities apply to a specific individual in a particular context and when they do not. "Therapeutic encounters become something of a dance between the individual and the cultural. The therapist must recognize the limitations of cultural generalities, but, at the same time, possess a fund of knowledge from which to begin" (Bonder, et al, 2004; p.166). In order to interact with clients from a culture different from one's own, the therapist must attend carefully to each interaction with that client. Clues to culturally-based factors that might influence therapy may be revealed in a persons' choice of words, emotional expression, gestures, and body posture. Competent therapists will ask clients about the meaning of these clues in order to gain a better understanding of the individual. Bonder et al also emphasize the importance of therapists' examination of their own culture and how it may influence their interactions with others.

Wells and Black (2007) specify the approach to integrating culture into the clinical reasoning process in four phases. Phase one consists of identification of problems which may be a source of cultural misunderstandings prior to actually meeting the client. The therapist must have a general fund of knowledge of the client's culture, and based on basic referral information prepare to respond to the client's needs appropriately. Phase two, framing and delineating the problem, takes place during the initial occupational therapy interview. The therapist asks the client about the meaning of his or her disability, beliefs about possible recovery, and family involvement. Based on this information, the client and the therapist enter phase three, to develop an intervention plan. The therapist has formed a hypothesis at this point about the influence the client's culture might have on treatment. During phase four, implementation of the intervention plan, the therapist continues to gather information about the client's culture and modifies the plan as needed.

Wells and Black (2007) address the need for a model of to guide the instruction of cultural competency in occupational therapy curriculum and continuing education. They define multicultural education as "an interdisciplinary process that fosters understanding, acceptance, empathy, and constructive and harmonious relations among people of diverse cultures" (p.273). Goals of multicultural education in occupational therapy include: a) helping students develop the knowledge, skills, and attitudes necessary to practice competently in the profession; b) helping students to develop an empathetic phenomenological view of all clients; c) dispelling stereotypes; d) promoting the value of cultural competency and equal access to healthcare; and e) helping students develop awareness of their own culture and how their biases can shape interactions with others. Pedagogical considerations to teaching cultural competency include active student participation, honest and open dialogue between student and teacher, and affective learning.

A transformative curriculum that supports the development of cultural competence cannot be constructed merely by adding content about ethnic groups and women to the existing Eurocentric curriculum or by integrating or infusing ethnic content or content about women and other groups into the mainstream curriculum. Such an additive approach does not challenge or substantively change the basic assumptions, perspectives, and values of the dominant culture or curricula. (Wells and Black, 2007, p.277)

Rather, students should participate in role plays, discussion groups, fieldwork experiences, simulations, case studies, and problem-based learning applications. Students should have an emotionally safe environment in which to discuss often sensitive subjects with peers and instructors. Educators should encourage authentic sharing of experiences and unconditional acceptance in student discussion settings. Learning should be made meaningful through the engagement of emotions in the construction of knowledge. Transformative learning occurs best when students are affectively engaged in learning content.

Several studies in the occupational therapy literature have explored the efficacy of specific strategies used to teach various components of cultural competency (Ekelman, Bello-Haas, Bazyk, & Bazyk, 2003; Velde & Wittman, 2001; Yuen & Yau, 1999). Ekelman, Bello-Haas, Bazyk, and Bazyk (2003) demonstrated that an immersive experience in an unfamiliar culture can be effective in the development of cultural sensitivity and cross-cultural reasoning that avoids an emphasis on stereotyping. Although providing occupational and physical therapy students a week-long immersion in a Mayan village in Southern Belize greatly improved the students' sense of cultural self-efficacy, this method is too time consuming and costly to be practical for most therapists.

Velde and Wittman (2001) in contrast, describe a cross-cultural experience that was integrated into the academic curriculum locally. Four occupational therapy students were asked to keep journals while participating in occupational therapy treatment for African American clients over the age of 65 in a rural community in North Carolina. Students were to respond in their journals to weekly reflection prompts provided by the instructors. After spending 8 - 10 hours with the clients, students identified as being in the stage of cultural blindness/cultural pre-competence on a cultural competency continuum (Cross, Bazron, & Dennis, 1989) which included (in order of increased competency): cultural destructiveness, cultural incapacity, cultural blindness, cultural precompetence, cultural competence, and cultural proficiency. The researchers concluded that the experience was effective in helping students develop cultural awareness. Yuen and Yau (1999) reported on a practice common to most occupational therapy academic programs; requiring students to interview individuals from a culture different from their own. Interview questions focus on gender roles within the culture, views on healthcare, religious practices, communication patterns, and beliefs about illness, death, and life in general. Students were then asked to respond to a survey and their answers were analyzed for content themes. Of the forty two students that participated, thirty (70%) indicated that the assignment increased their awareness of another culture, nineteen (45%) stated increased cultural sensitivity, and eighteen (43%) agreed that it had an affect on their attitude toward another culture. In addition, the students also expressed some ethnocentric ideas, such as not perceiving the culture to be much different from their own. These results indicate that the cultural interview assignment was a positive experience overall, but had limited value in achieving cultural competence.

In an effort to determine what types of experiences were most effective in developing cultural competence in occupational therapy students, Forwell, Whiteford, and Dyck (2001) conducted a joint qualitative study between the University of British Columbia in Canada and the Auckland Institute of Technology in New Zealand OT programs. A total of 38 students were interviewed by research assistants not associated with the OT programs. Relevant teaching strategies used to teach cultural diversity content were identified by the students as "the instructor using oneself, use of storytelling, assignments given, and audio-visual presentations" (p. 96). The New Zealand students were required to take a course on Maori culture taught by an instructor from that culture. The success of this course in providing meaningful content was attributed for the most part to the dynamic and positive teaching style of the instructor. Students stated that he provided a safe environment in which to discuss personal beliefs and values. Another technique that prompted student recall of culturally oriented content was that of the instructor telling personal stories of encounters with another culture in clinical practice. The Canadian students most frequently identified culturally oriented case studies as the most meaningful strategy use to teach about diversity. The researchers suggest this may have been due to the independent learning required in this type of assignment. The least relevant teaching method was that of a 24 minute film presented to the Canadian students. Students stated that overall the content presented in coursework had a positive effect on their development of cultural competency. Some students indicated a need for more prescriptive details regarding interaction with specific cultures, while others stated that it was more important to learn to keep an open mind at all times.

Surveys of OT students' perceptions of the importance of cultural influences in occupational therapy and of their own readiness to treat clients from a non-dominant culture have been conducted in Great Britain (Cheung, Shah, & Muncer, 2002), Australia (Rasmussen, Loyd, & Wieland, 2005), and the United States (Murden, Norman, Ross, Sturdivant, Kedia, & Shah, 2008). All three studies used the Cultural Awareness and Sensitivity Questionnaire (CASQ) developed by Cheung et al (2002). The results of all three studies indicate that while students appreciate the importance of cultural influences in a treatment setting, the majority of students in the British and American programs felt a need for more knowledge about different cultures as well as ways to remove barriers to providing culturally competent care. Specifically, 88% of the students in the British program, and 55% in the American program were unaware or had limited awareness of sources of information about cultures, as compared to 45% of students in the Australian study. The majority of British (88%) and American (75%) students were unaware or had limited awareness of methods to reduce barriers to providing culturally competent care in contrast to 39% of the Australian students. Rasmussen et al suggests that the differences between English and Australian student responses may be due to the extended focus on cultural issues in the Australian curriculum. Respondents in all three studies indicated that practical experiences in fieldwork provided the best opportunity to develop cultural awareness. Murden et al explored differences in perceptions of students according to level of progression through the university program. Entry-level students believed that exposure to diversity in the classroom would increase their cultural self-efficacy. Participants who had completed their coursework but not their fieldwork indicated a need for more specific emphasis on cultural influences on occupational therapy; whereas, participants who were a year post-graduation stated that training should focus on the effect of socio-economic status on healthcare beliefs and values. None of the studies indicated what types of teaching strategies had been employed to expose students to cultural diversity.

In a qualitative study of occupational therapists' perceptions of a concept closely related to cultural competency, New Zealander researches explored differences in attitudes towards cultural safety (Gray & McPherson, 2005). Cultural safety is a term unique to New Zealand and has developed in response to the dominant New Zealander-European culture's historic socioeconomic advantage over the indigenous Maori culture. Cultural safety, like cultural competence, refers to providing health care in a way that is sensitive to the cultural needs of the client; however, cultural safety specifically recognizes the differences in political power and socioeconomic status in a bicultural society. Gray & McPherson interviewed 13 occupational therapists from the dominant culture and identified four themes in their transcript content analysis; generational differences, personal experiences having more relevance than formal education, attitudinal ambivalence, and confusion regarding cultural competency concepts. Older participants indicated that contact with other cultures, traveling, and personal experience of discrimination had helped them develop increased cultural awareness and the formation of beliefs that were radically different from those of their upbringing. In contrast, younger therapists appeared to have less awareness of the effect that a disadvantaged socioeconomic status might have on their clients and treatment interventions. Participants agreed that personal immersion in another culture had more influence on their attitudes and knowledge than did workshops and academic programs. Although most therapists agreed that cultural safety is a worthwhile goal, many indicated a lack of willingness to learn more about the Maori culture. In addition, statements made in the interviews indicated that therapists were unclear about ways to integrate knowledge about the Maori culture into clinical practice. Gray and McPherson point out that although cultural safety has its roots in New Zealand, the concept has applicability to any bicultural society where resources have not been allocated equally.

There is a general consensus in the occupational therapy literature that obtaining cultural competency requires awareness of professional and personal cultural identity, acquisition of knowledge about different cultures, and proficiency in skills needed to interact with clients from different cultures ( Abreu & Peloquin, 2004; Awaad, 2003; Iwama, 2003, 2007; Odawara, 2005; Rudman & Dennhardt, 2008). Various authors have addressed these elements in detail in the occupational therapy literature (Table 2).

Table 2
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