Teaching & Training Cultural Competence
Structural Competency Handouts: Developed by the Berkeley Rad Med Critical Social Medicine Collective Structural Competency Working Group., theses handouts include key concepts, a structural violence checklist, interventions, case studies and exercises. (Link)
APA Task Force on Race and Ethnicity Guidelines in Psychology: These guidelines provide aspirational guidance for the development of racial and ethnocultural responsiveness for psychological practice. Racial and ethno-cultural responsiveness means the continual development of knowledge, awareness, reflective practice, and skills needed to promote health, well-being, and equity for racially and ethnically diverse individuals and communities. Although the guidelines aim to be comprehensive, it is beyond the scope of any single document to provide an exhaustive review of all areas related to race and ethnicity. Instead, these guidelines are a starting point reflecting the current knowledge base and context. Citation: APA Task Force on Race and Ethnicity Guidelines in Psychology. (2019). APA guidelines on race and ethnicity in Psychology. (Link)
Brown University Training Materials: Cultural Competence and Community Studies: Concepts and Practices for Cultural Competence. The Northeast Education Partnership provides online access to PowerPoint training slides on topics in research ethics and cultural competence in environmental research. These have been created for professionals/students in environmental sciences, health, and policy; and community-based research. (Link). If you are interested in receiving an electronic copy of one the presentations, just download their Materials Request Form (found on the main Training Presentations page under "related files"), complete the form, and email it to NEEPethics@yahoo.com.
Standards of Practice for Culturally Competent Nursing Care Executive Summary: A task force of the Expert Panel for Global Nursing and Health of the American Academy of Nursing, along with members of the Transcultural Nursing Society, has developed a set of standards for cultural competence in nursing practice. The aim of this project was to define standards that can be universally applied by nurses around the world in the areas of clinical practice, research, education, and administration, especially by nurses involved in direct patient care. The document includes a Preface and 12 Standards:
Standard 1. Social Justice
Standard 2. Critical Reflection
Standard 3. Knowledge of Cultures
Standard 4. Culturally Competent Practice
Standard 5. Cultural Competence in HealthCare Systems and Organizations
Standard 6. Patient Advocacy and Empowerment
Standard 7. Multicultural Workforce
Standard 8. Education and Training in Culturally Competent Care
Standard 9. Cross Cultural Communication
Standard 10. Cross Cultural Leadership
Standard 11. Policy Development
Standard 12. Evidence-Based Practice and Research
For each standard, a definition, supporting rationale, and numerous suggestions for implementation are provided. A glossary of terms is appended. All standards are based on the concepts of social justice and human rights, as defined by the United Nations and the International Council of Nurses. These concepts are manifested at a systems or governmental level by political, economic, and social policies that exhibit impartiality and objectivity. All task force members have experience working with peoples from a variety of cultures throughout the world. In developing this document, the task force reviewed more than 50 documents on cultural competence published by nursing and health care organizations worldwide. In addition, an on-line survey solicited comments from nurses in many countries. Responses from nurses representing a variety of settings and educational backgrounds were incorporated into the final document. Every attempt was made to develop standards that can be used globally. (Link)
Cultural Competence Education for Students in Medicine and Public Health (2012): The Association of American Medical Colleges (AAMC) and ASPH sponsored a Joint Expert Panel on Cultural Competence Education to develop a set of core cultural competencies appropriate for, though not limited to, medical and public health students. These competencies aim to help ensure the development and delivery of appropriate health care and population health services and policies and for a growing diverse population that includes those currently medically underserved. The competencies are designed to enable faculty in medical schools and graduate schools/programs of public health to standardize curricula, benchmark student performance, and prepare graduates for culturally competent practice. The panel additionally provided recommendations for embedding cultural competence education within and across curricula of medicine and public health, highlights of exemplary case studies, and a road map for the future. (Link)
Curriculum for Culturally Responsive Health Care: The Step-By-Step Guide for Cultural Competence Training: Authors Ring , Nyquist, Mitchell (2008) have published this manual comprising a curriculum for residencies and medical schools looking to implement new, or enhance existing, curricula in culturally responsive care. It describes teaching strategies that to learners and faculty alike, challenging them to grow in their attitudes, awareness, desire, knowledge and skills to effectively practice culturally responsive medicine. It demonstrates commitment to teaching culturally responsive medicine towards the elimination of health disparities, be they related to gender, race/ethnicity, income, sexual orientation, religious background or world view. The manual includes a step-by-step guide for each year of the curriculum, with detailed session descriptions, and sections on teaching techniques, evaluation tools, cultural competence exercises, together with information on further resources. (Link)
A Train The Trainer Guide: Health Disparities Education: Produced by the Society of General Internal Medicine Disparities Task Force in 2008 to provide teaching approaches to disparities education. (Link)
Eastern Virginia Medical School (EVMC): Live Humble: Practicing with Cultural Humility. The primary goal of this project is to improve students’ knowledge, skills, and values in cultural humility and structural inequity. This, in turn, will improve quality of care, particularly for those who have been stigmatized. This project's objectives are as follows: 1) Define cultural humility and structural inequity and describe the dynamics of each; 2) Describe the skills associated with cultural humility and structural inequity in interpersonal and clinical settings; 3) Choose to execute this three-part process in clinical encounters: a) self-assess their own thoughts and behavior, b) be sensitive to the other’s values, beliefs, and priorities, and c) identify and execute effective strategies to diminish potential power differentials; and 4) Value cultural humility. (Link)
Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education: The Role of the HRSA Centers of Excellence: This curriculum guide, “Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education: The Role of the HRSA Centers of Excellence,” is one result of the efforts of HRSA and the COEs. While directed to Centers of Excellence funded by the HRSA, the guide is applicable to any health care program or institution. The aim on this document is to provide the health professions with strategies, tools, and resources for implementing and integrating cultural and linguistic competency content and methods into existing academic programs under the leadership of the HRSA Centers of Excellence. (Link)
Cultural Competency in Medical Education: A Guidebook for Schools: The Guidebook provides an explanation of why culturally competent medical education is important and includes: it includes, strategies for preparing medical school faculty to teach cultural competency through integration; a suggested curriculum outline for cultural competency that can be tailored to any school; a look at ways to evaluated the efficacy of a culturally competent medical education and student/faculty performance within it; detailed methods for student instruction in cultural competency, based on existing curriculum type; a blueprint for making cultural competency an integrated part of an institution. (Link)
Cultural Competence Education for Medical Students: Produced by the Association of American Medical Colleges in 2005, these guidelines assist medical schools in their efforts to integrate cultural competence content into their curricula. This document discusses what cultural competence is, criteria for a culturally competence curriculum, and how to assess and evaluate students in cross-cultural by using the Tool for Assessing Cultural Competence Training (TACCT). (Link)
Tool for Assessing Cultural Competence Training (TACCT): The TACCT is a self-administered assessment tool that can be used by medical schools to examine all components of the entire medical school curriculum. TACCT enables schools to identify gaps and redundancies in their curricula, which will enable schools to make the best use of opportunities and resources. The TACCT can be used for both traditional and problem-based curricula. An AAMC project—called "Medical Education and Cultural Competence: A Strategy to Eliminate Racial and Ethnic Disparities in Health Care" and made possible by The Commonwealth Fund—developed TACCT to assess cultural-competence training in medical schools. (Link)
Quality Interactions: A Patient-Based Approach to Cross-Cultural Care: Developed in 2004 by three physicians who are leaders in the field of cross-cultural health care (Betancourt, Green, & Carrillo), this educational resource is an interactive e-learning course designed to improve your ability to deliver quality care to culturally diverse patient populations. It is based on the nationally recognized curriculum developed for and used by the country’s leading medical schools and academic health centers. It is a certified Continuing Medical Education (CME) program for physicians and a Continuing Education Unit (CEU) program for nurses and other health care providers. (Link)
A Physician's Guide to Culturally Competent Care Project: Sponsored by by the American Institutes of Research and the U.S. Department of Health and Human Services Office of Minority Health. The project consists of the development and testing of a set of modules to train family physicians to be culturally competent according to the principles of the National Standards on Culturally and Linguistically Appropriate Services. (Link)
The Culturally Competent Nursing Modules (CCNM) Project: Sponsored by the American Institutes of Research and the U.S. Department of Health and Human Services Office of Minority Health is designed to help nurses better meet the cultural and linguistic needs of an increasingly diverse patient population, by offering them a case-based curriculum to improve skills in providing culturally competent nursing care. (Link)
HealthBegins: Health begins upstream provides upstream education and training for healthcare professionals. Their practical, skills-oriented educational content and training materials, along with an Upstream Quality Improvement approach, is used across the country as part of curricula in universities, medical schools, and other graduate schools and continuing medical education (CME) courses. (Link)
Cultural Competency-MUSC: The College of Medicine Medical University of South Carolina (MUSC) has developed a website focusing on cultural competency in health professions’ education. Topics of discussion include tips for providing culturally competence care, culturally sensitive medical interviewing tools, working with interpreters, traditional beliefs, alternative medicine, transcultural healthcare resources, and religious and spiritual issues. (link)
Race, Ethnicity, and Culture in Health (REACH) Action Committee: The Race, Ethnicity, and Culture in Health (REACH) committee aims to reduce health disparities between different racial, ethnic and cultural groups through advocacy, education and service. Their goals include: strengthening cultural competency in medical education, promoting diversity of the physician workforce, and empowering future physicians to actively engage in the political and social movement towards health equity. (Link)
Multicultural Pavilion: Includes resources, such as experiential exercises on becoming culturally competent, for educators and trainers. (Link)
JAMARDA Resources Inc. : This website provides resources in clinical diversity training and education products for healthcare educators. (Link)
Structural Competency: New Medicine for Inequalities That Are Making Us Sick: This site provides access to training materials (e.g., articles, webinars, curriculum) on structural competence from a global structural competency network. (Link)
Structural Competency Working Group: The Structural Competency Working Group is comprised of healthcare workers, scholars, public health professionals, students, educators, and other community members. They help promote the training of health professionals in structural competency and have developed and disseminate open-use structural competency curricula. (Link)
Center for Advanced Research on Language Acquisition (CARLA): Culture Learning: Simulations & Exercises webpage- Games are a fun and effective way to introduce issues of cultural awareness and intercultural communications to students. The information on this webpage, compiled by the Intercultural Studies Project, is a good place to start looking for specific cultural simulations and exercises and for ways to incorporate them into the curriculum.(Link)
Journal Issues Dedicated to Cultural Competence Training:
- Journal of Nursing Education. (2006). Volume 45, Issue 7. This July issue is devoted to cultural competence in nursing education.
- Journal of Nursing Education. (2003). Volume 42, Issue 8. This June issue is devoted to cultural competence in nursing education.
- Journal of Transcultural Nursing. (2002). Volume 13, Issue 3, presents several theoretical and conceptual models as well as frameworks to organize knowledge about transcultural nursing and health care.
- Journal of Nursing Education. (2007). Volume 48, Issue 6. This June issue is devoted to diversity in nursing education.
- The Journal of General Internal Medicine (2010). The Journal of General Internal Medicine dedicated its May 2010 supplement to health disparities education. This supplement focuses on approaches to teaching health disparities and health disparities curriculums for students.
Quality InteractionsSM. A Patient-Based Approach to Cross-Cultural Care is a one hour, continuing medical education (CME) course designed for physicians. The course provides physicians and clinicians with the tools and skills to communicate more effectively with patients from diverse backgrounds. The course provides an interactive case study of an African American male with asthma. (Link)
Unnatural Causes: Is Inequality Making us Sick? Produced by California Newsreel, this film is a seven- part documentary series exploring racial and socioeconomic inequalities in health. Discussion Guides for Unnatural Causes to use with the PBS documentary series. Unnatural Causes. (Link)
The Deadliest Disease in America: This is a documentary film produced and directed by Crystal R. Emery, traces the history of racism in American healthcare, beginning with the brutal medical experimentation that slaves were forced to undergo. As this story unfolds over our nation’s history, the very same inequalities and biases continue to plague our healthcare system, creating disparities in the quality of care that Black and Brown people are afforded. Interwoven with the testimonies of experts and medical practitioners are the personal stories of patients who have been victimized by healthcare inequities, including the filmmaker’s own experiences as a quadriplegic African American woman. The COVID-19 pandemic is an exclamation point calling attention to these existing disparities, as we have witnessed communities of color experience disproportionately high rates of infection, staggering losses of life, and increased economic hardship. (Link)
California Newsreel Film and Video. Produces and distributes cutting edge, social justice films that inspire, educate and engage audiences. (Link)
Worlds Apart: A Four-Part Series on Cross Cultural Healthcare. Fanlight Productions. These unique trigger films follow patients and families faced with critical medical decisions, as they navigate their way through the health care system. (Link)
Media Partnerships Diversity Training Videos. Thought provoking and award-winning selection of diversity training videos to help you build a culture of inclusion. (link)
Communicating Effectively Through an Interpreter. This 28-minute video/DVD is designed to help providers in: choosing an appropriate interpreter, recognizing the signs of professional and unprofessional interpretation, working effectively with a trained interpreter, and guiding an untrained interpreter. (Link)Cultural Competence & Diversity Training. This site shows all the website content related to Cultural Competence Training. (Link)
Cultural Issues in the Clinical Setting. Kaiser Permanente’s MultiMedia Communications department and the Educational Theatre Program’s CareActors, the brief but dramatic vignettes are accompanied by support materials for facilitators and participants. These materials will be sent on a compact disc and are included in the price. The vignettes, scripted with the help of physicians, nurses and medical anthropologists, raise numerous issues around differing health beliefs and practices, values in conflict, stereotyping, overt and covert prejudices and language barriers as they occur in healthcare settings. Support materials provide questions and discussion points for each vignette. This format lends itself equally well to a series of short modules (30 minutes) or incorporation into a longer workshop. (Link)
Culturally Competent Healthcare Videos. In 2013, healthcare industry leaders gathered at DiversityInc’s special event, “Culturally Competent Healthcare: How Diversity Creates Better Patient Outcomes,” to discuss health disparities, supplier diversity, clinical trials, Black and Latino physician shortages, and other issues facing patient care today. (Link)
The Angry Heart: Impact of Racism on Heart Disease Among African Americans. By Jay Fedigan. Available from Fanlight Productions. (link)
The Color of Fear (Film). Lee, M., Hunter, M., Goss, R., & Bock, R. (2000). Stir-Fry Productions, & Stir-Fry Seminars & Consulting. (2000). The color of fear: A film [Motion picture]. Oakland, CA: Stir-Fry Seminars & Consulting. (Link)
A Class Divided (Film). Elliott, J. (2003). Yale University, WGBH (Television station: Boston, MA), & PBS DVD (Film). (2003). A class divided [Motion picture]. New Haven, CT: Yale University Films. (Link)
Crash (Film). Haggis, P., and Yari, B. (2004). Crash [Motion picture]. United States: Lions Gate Films. (Link)
Abrums, M., Resnick, J., and Irving, L. (2010). Journey or Destination? Evaluating Student Learning About Race, Class, and Privilege in Health Care. Nursing Education Perspectives. 31(3),160-166.
Ackerman-Barger P. (2010). Embracing multiculturalism in nursing learning environments. Journal of Nursing Education, 49, 677-682
Alexander, K., Dovydaitis, T., Beacham, B., Bohinski, J., Brawner, B., Clements, C., Everett, J., Gomes, M., Harner, H., McDonald, C., Pinkston, E., and Sommers, M. (2011). Learning Health Equity Frameworks Within a Community of Scholars. Journal of Nursing Education, 50(10), 569-574.
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Amerson, R., and Livingston, W. (2014). Reflexive photography: An alternative method for documenting the learning process of cultural competence. Journal of Transcultural Nursing, 25, 202-210.
Andrews, M., and Friesen-Lynn, L. (2011). Finding Electronically Available Information on Cultural Competence in Health Care. Online Journal of Cultural Competence in Nursing and Healthcare, 1(4), 27-43.
Adams, J. (2008). Transcultural Nursing Courses Online: Implications for Culturally Competent Care. Nursing Clinics of North America, 43(4), 567-674.
Arbour, M. Kaspar, R. and Teall, A. (2015). Strategies to Promote Cultural Competence in Distance Education. Journal of Transcultural Nursing, 26(4), 436-440.
Association of American Medial Colleges. (2015). Assessing Change: Evaluating Cultural Competence Education and Training. Washington, D.C.
Axtell, S., Avery, M., and Westra, B. (2010). Incorporating Cultural Competence Content Into Graduate Nursing Curricula Through Community – University Collaboration. Journal of Transcultural Nursing, 21(2), 183-191.
Ballestas, H. and Roller, M. (2013). The Effectiveness of a Study Abroad Program for Increasing Students’ Cultural Competence. Journal of Nursing Education and Practice, 3(6),125-133.
Bauer, K., and Baib, Y. (2015). Innovative Educational Activities Using a Model to Improve Cultural Competency among Graduate Students. Procedia - Social and Behavioral Sciences, 174(12), 705-71.
Beard, K. (2013). Teaching in a Multicultural Society: How Nurse Educators Describe Their Role. The Journal of the National Black Nurses Association, 24(2), 64-71.
Bednarz, H., Schim, S., and Doorenbos, A. (2010). Cultural Diversity in Nursing Education: Perils, Pitfalls and Pearls. Journal of Nursing Education, 49(5), 253-260.
Betancourt, J., and Green, A. (2010). Commentary: Linking Cultural Competence Training to Improved Health Outcomes: Perspectives From the Field. Academic Medicine, 85(4), 583-585. (link)
Billings, M. (2015). Culturally and Linguistically Responsive Teaching: Part II. The Journal of Continuing Education in Nursing, 46(3), 107-108.
Blanchet, A. and Pepin, J. (2015). A constructivist theoretical proposition for cultural competence development in nursing. Nurse Education Today. (Link)
Blanchet, G. and Pepin, J. (2015). Cultural Competence A Constructivist Definition. Journal of Transcultural Nursing, 26, 9-15.
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Botelho, M., and Lima, C. (2020). From Cultural Competence to Cultural Respect: A Critical Review of Six Models. Journal of Nursing Education, 59(6), 311-318.
Brottman, M. R., Char, D. M., Hattori, R. A., Heeb, R., & Taff, S. D. (2020). Toward cultural competency in health care: A scoping review of the diversity and inclusion education literature. Academic Medicine, 95(5), 803-813.
Brown, E. (2013). Develop student compassion through service-learning. Journal of Christian Nursing, 30: 234-237.
Burke, P. (2011). Cultural competency of associate degree nursing faculty (Doctoral dissertation, Capella University).
Burson, R. C., Familusi, O. O., & Clapp, J. T. (2022). Imagining the ‘structural’ in medical education and practice in the United States: A curricular investigation. Social Science & Medicine, 300:114453
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Carpenter, L. and Garcia, A. (2012). Assessing Outcomes of a Study Abroad Course for Nursing Students. Nursing Education Perspectives, 33: 85-89.
Carey, R. (2011). Cultural competence assessment of baccalaureate nursing students: An integrative review of the literature. International Journal of Humanities and Social Science, 1(9),258-266.
Castillo, E. G., Isom, J., DeBonis, K. L., Jordan, A., Braslow, J. T., & Rohrbaugh, R. (2020). Reconsidering systems-based practice: Advancing structural competency, health equity, and social responsibility in graduate medical education. Academic medicine: journal of the Association of American Medical Colleges, 95(12), 1817.
Cerezo, P., Galceran, M., Soriano, M., Camps, L. and Moral, J. (2014). Design and Evaluation of an Educational Course in Cultural Competence for Nursing. Social and Behavioral Sciences, 132: 262- 268.
Chambers, J. E., & Ratliff, G. A. (2019). Structural competency in child welfare: Opportunities and applications for addressing disparities and stigma. J. Soc. & Soc. Welfare, 46, 51.
Chun, M. (2010). Pitfalls to avoid when introducing a cultural competency training initiative. Medical Education, 44(6), 613-620.
Clark, L., Calvillo, E., dela Cruz, F., Fongwa, M., Kools, S., Lowe, J., and Mastel-Smith, B. (2011). Cultural Competencies for Graduate Nursing Education. Journal of Professional Nursing, 27(3), 333-339.
Comer, L., Whichello, R., & Neubrander, J. (2013). An innovative Master of Science program for the development of culturally competent nursing leaders. Journal of Cultural Diversity, 20(2), 89-93.
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Coronado, D. (2013). Cultural competency in health care: Frameworks, training and evaluation a review of the literature. MA: Harvard and Colet. (2016). Cultural Competence Among Students Pilgrim Health Care Foundation, Inc. (Link)
Cupelli, L. (2016). An Innovative Service-Learning Project to Develop Cultural Competency in Undergraduate Nursing Students. Teach Learn Nursing, 11(3), 113-117.
Cushman, L., Delva, M., Franks, C., Jimenez-Bautista, A., Moon-Howard, J., Glover, J. and Begg, M.. (2015). Cultural competency training for public health students: Integrating self, social, and global awareness into a master of public health curriculum. American Journal of Public Health, 105, S132–S140.
Davis, S. and Davis, D. (2010). Challenges and issues facing the future of nursing education: Implications for ethnic minority faculty and students. Journal of Cultural Diversity, 17(4), 122-126.
Dawson, L. (2010). Promoting Cultural Competence in Advanced Pharmacology for Nurse Practitioner Students. Nursing Education Perspectives, 31(3),198-190.
Debrew, K., Lewallen, P., and Chun, E. (2014). Outsiders in Nursing Education: Cultural Sensitivity in Nursing Education. Journal of Professional Nursing, 30(2), 149-154.
Delgado, D., Ness, S., Ferguson, K., Engstrom, P., Gannon, T. & Gillett, C. (2013). Cultural competence training for clinical staff: Measuring the effect of a one-hour class on cultural competence. The Journal of Transcultural Nursing, 24(2), 2014-213.
Dewald, J. (2012). Teaching Strategies That Promote Culturally Sensitive Nursing Education. Nursing Education Perspectives, 33(6), 410-412.
Douglas, M., Rosenkoetter, M., Pacquiao, D., Callister, L., Hattar-Pollara, M., Lauderdale, J., Milstead, J., Nardi, D., and Purnell, L. (2014). Guidelines for Implementing Culturally Competent Nursing Care. Journal of Transcultural Nursing, 25(2), 111-121.
Downey, M. M., & Gómez, A. M. (2018). Structural competency and reproductive health. AMA Journal of Ethics, 20(3), 211-223.
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Fogg, L., Carlson-Sabelli, L., Carlson, K, and Giddens, J. (2013) The Perceived Benefits of a Virtual Community: Effects of Learning Style, Race, Ethnicity, and Frequency of Use on Nursing Students. Nursing Education Perspectives, 34(6), 390-394.
Frank, G. C., Centinaje, E., Gatdula, N., Garcia, M., Nguyen-Rodriguez, S. T., Bird, M., & Rios-Ellis, R. B. (2021). Culturally Relevant Health Education: A Foundation for Building Cultural Competence of Health Professionals. Californian Journal of Health Promotion, 19(1), 13-21.
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Gay, G. (2010). Culturally Responsive Teaching: Theory, Research and Practice. (2nd ed.). New York: Teachers College Press.
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Govere, L., Fioravanti, M., and Tuite, P. (2016). Increasing the Cultural Competence Levels of Undergraduate Nursing Students. Journal of Nursing Education, 55(3), 155-159.
Gower, S., Duggan, R., Dantas, J. and Boldy, D. (2016). Motivations and Expectations of Undergraduate Nursing Students Undertaking International Clinical Placements. Journal of Nursing Education, 55(9), 487-494.
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Grossman, L. G., Mechanic, O. J., Orr, Z., Cioe‐Peña, E. C., Landry, A., Unger, S., ... & Alpert, E. A. (2021). An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States. AEM Education and Training, 5, S28-S32.
Hall, M. and Guidry, J. (2013). Literature Review of Cultural Competence Curriculum within the United States: An Ethical Implication in Academic Preparational Programs. Education in Medicine Journal, 5(1), e6-e13.
Harvey, M., Neff, J., Knight, K. R., Mukherjee, J. S., Shamasunder, S., Le, P. V., ... & Holmes, S. M. (2022). Structural competency and global health education. Global public health, 17(3), 341-362.
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Hansen, H., Braslow, J., & Rohrbaugh, R. M. (2018). From cultural to structural competency—Training psychiatry residents to act on social determinants of health and institutional racism. JAMA psychiatry, 75(2), 117-118.
Hansen, H. & Metzl, J. (2019). Structural Competency in mental health and medicine: A Case-based approach to treating the social determinants of health. NY: Springer Publishers.
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Hassouneh, D. (2013). Unconscious Racist Bias: Barrier to a Diverse Nursing Faculty. Journal of Nursing Education, 52(4), 183-184.
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