The United States is rapidly becoming a culturally and ethnically diverse country, with projections indicating that 56% of the total U.S. population will be composed of various minority groups by 2060 (U.S. Census Bureau, 2015). Health care providers will need to become increasingly culturally competent to provide high-quality care for more patients from diverse groups as they enter the health care system. In the past decade, there has been an increase in cultural competence training in health care related academic curricula and hospital organizations to address the needs of diverse groups (Darnell & Hickson, 2015; Purnell, 2016). This may be attributed primarily to guidelines from national organizations and accrediting bodies that recommend that health care institutions deliver culturally appropriate services (The Joint Commission, 2014; National Quality Forum, 2009; U.S. Department of Health and Human Services, 2015). At the organizational level, quality initiatives to promote cultural competence and address institutional barriers have resulted in improvements in diversity competency (Ogbolu, Scrandis, & Fitzpatrick, 2017; Weech-Maldonado et al., 2018). At the individual provider level, progress has been made in the quality of culturally appropriate provider–patient communication, tailored care, and patient satisfaction (Crawford, Candlin, & Roger, 2017; Powell, 2016).
RNs are largely responsible for most of the direct care provided for patients and their families. Nurses should exhibit culturally congruent behaviors, eliminate bias, and cultivate cultural awareness (Darnell & Hickson, 2015). The American Association of Colleges of Nursing (AACN, 2019) statement on diversity in the nursing workplace emphasized the need for nurses to be culturally competent for the purpose of providing quality care. Recent research suggests that nurses desire greater knowledge about providing culturally competent care (Eche & Aronowitz, 2017) but lack access to culturally specific resources (Ogbolu et al., 2017). In addition, 77% of the three million nurses comprising the current workforce are White (Bureau of Labor Statistics, 2018). Despite efforts to increase diversity among newly enrolled nursing students, only 32% of the students enrolled in baccalaureate nursing programs were from minority backgrounds (AACN, 2018).
A variety of factors have been reported to influence nurse cultural competence such as age, years of experience, educational level, and frequency of diversity experiences (Cicolini et al., 2015; Lin, Mastel-Smith, Alfred, & Lin, 2015; Schim, Doorenbos, Benkett, & Miller, 2007; Young & Guo, 2016). Diversity training has been recommended, but optimal pedagogical methods remain unclear and influenced by resource constraints (McElroy, Smith-Miller, Madigan, & Li, 2016; Ogbolu et al., 2017). Academic educators have espoused threading diversity training through the curriculum, simulation activities, and the use of linguistic frameworks (Bahreman & Swoboda, 2016; Crawford et al., 2017). Clinical educators in hospitals have used training videos, group discussions, journaling, and case-based scenarios (McElroy et al., 2016; Warren, Baptiste, Foronda, & Mark, 2017). Targeting cultural competence at the hospital organizational level has also been successful (McElroy et al., 2016).
In a recent systematic review of 51 qualitative studies that examined the experiences of hospitalized minority patients, Degrie et al. (2017) identified four main themes. The themes depicted the encounter between two different cultural contexts (provider and patient); the dynamics of ongoing relationships with different providers; efforts by the patient to achieve a balance between the two contexts to maintain their own individual traditions and values within the limitations and realities of the hospital care environment; and mediators of family, communication, organizational culture, and humanness. This description highlights the complexity of interactions between people from different cultures and potentially modifiable organizational and human factors. Clearly, nurse cultural competence is highly desirable to optimize care for minority patients, and improvements have been made in recent years. However, a greater understanding of the factors influencing cultural competence among RNs is needed to strategically develop efficient methods to target improvements in nurse cultural competence. The purpose of this study was to identify factors associated with cultural competence among nurses working in hospital settings. This study addressed the following question: Is there a relationship between cultural competence and nurses' age, years of education, diversity experience, and diversity training?
The Model of Culturally Congruent Care
The theoretical model of culturally congruent care guided the current study (Schim et al., 2007). The model was envisioned using the metaphor of a puzzle, with each piece representing parts of the final picture—culturally congruent care (Schim et al., 2007). Key concepts (i.e., puzzle pieces) in the model included cultural diversity, awareness, sensitivity, and culturally competent behaviors (Schim et al., 2007). Cultural diversity was described as the quality and quantity of cross-cultural experiences. Cultural awareness was described as knowledge about cultural contexts (i.e., history and background) and influence on health care. Cultural sensitivity encompassed attitudes toward self and others and a willingness to appreciate different cultures. Culturally competent behaviors reflected actions as responses to cultural diversity, awareness, and sensitivity and demonstrated in practice.
In this descriptive, cross-sectional study, a paper survey was distributed to RNs on two different medical–surgical units at one southeastern urban medical center. Nursing unit directors on the respective units were contacted and approval was received to distribute the surveys in nurse's mailboxes. Surveys contained an information sheet explaining the purpose, risks, benefits, anonymity, and contact information. No identifiers or protected health information were collected. Nurses were given 2 weeks to complete the survey. Participation was voluntary, and a $5.00 gift card was awarded upon completion. Nurses returned completed surveys to a designated box located on each nursing unit.
After receiving approval from the institutional review board and following ethical procedures for the protection of human subjects, the one-time survey was completed by the convenience sample of 76 RNs. Approximately 110 surveys total were distributed to the RNs (55 per unit), which equated to an acceptable 69% response rate (Nulty, 2008). Two surveys were not included due to more than 50% missing data. The final sample (n = 74) consisted primarily of White nurses (63%), with a mean age of 40.6 years and a bachelor's degree or higher in nursing (60%).
The survey consisted of 33 items, including the Cultural Competence Assessment (CCA) (25 items), Diversity Training (two items), Diversity Experience (two items), Self-Assessed Cultural Competence (one item), and demographic information (three items) (Schim, Doorenbos, & Borse, 2005). The CCA consisted of two subscales that assess cultural awareness and sensitivity (CAS) and culturally competent behaviors (CCB). The CAS subscale contained 11 items, with 5-point Likert scale response options from strongly agree to strongly disagree. An example of a question from the CAS subscale is “I understand that people from different cultures may define the concept of ‘health care’ in different ways.” The CCB subscale contained 14 items, with 5-point Likert scale options from always to never. Items for each subscale were summed (some items reverse scored) and divided by the number of items, with higher scores (range = 1 to 5) indicating greater cultural awareness and sensitivity or culturally competent behaviors. An example of a question from the CCB subscale is “I find ways to adapt my services to individuals and group cultural preferences.” Overall cultural competence (CCA) was calculated by summing the two subscale (CAS + CCB) scores. In this study, overall (total score) CCA was used as the dependent variable.
Cultural diversity training was measured with two questions that asked whether the nurse had ever received cultural diversity training (yes or no) and, if so, to identify the different types of training received from a list of eight options. A total score for diversity training was calculated by a count of the options selected, with higher numbers indicating greater diversity training. Cultural diversity experience was measured with two items that asked participants to identify the number of individuals from other cultural groups they had worked with or cared for (respectively) in the past 12 months, with up to eight options to select. The questions were scored with a count of the number of groups indicated, with higher numbers meaning greater diversity experience. The Self-Assessed Cultural Competence question asked participants to rate their own perceived cultural competence on a 5-point Likert scale, with options from very incompetent to very competent, with higher scores indicating greater cultural competence.
Demographic items included questions about age, self-identified race and ethnicity, and level of educational attainment (high school, associate, bachelor's, or graduate degree). Gender was not included on the survey because of the possibility that participants could be identified if combined with other demographics. The survey took approximately 10 minutes to complete. The CCA has been tested in a variety of health care settings and has demonstrated good internal consistency reliability (α = .88, .76, .89) (Benkert, Templin, Schim, Doorenbos, & Bell, 2011; Cicolini et al., 2015; Doorenbos, Schim, Benkert, & Borse, 2005), represented respectively. In the current study, overall internal consistency reliability for the CCA was .78.
Data were analyzed using SPSS® version 24.0. The level of significance was set at .05. Missing data (random) were addressed by listwise deletion (Acock, 2005). Descriptive analyses were used to calculate frequencies, percentages, means, and standard deviations (n = 74). After recoding the type of education (degree) to a continuous variable indicating years of education, Pearson's correlation analyses were used to determine associations among the variables. Rule of thumb estimates for sample size in linear regression analyses were used to determine that 10 to 15 participants per variable would be adequate (Austin & Steyerberg, 2015; Green, 1991; Schmidt, 1971). For four predictor variables and 15 participants per variable, a sample size of 60 would be required. Predictors of cultural competence were determined with multiple linear regression analyses, regressing cultural competence total scores (CCA) on age, years of education, diversity experience, and diversity training, after testing for assumptions.
All but one of the participants reported having received some form of diversity training (yes or no). Eighty-one percent received one or two types of diversity training, whereas 19% received three or more different types. Employer-sponsored programs (n = 59) and those that were part of a college course (n = 29) were the most frequently reported, followed by continuing education programs (n = 10), Web-based training modules (n = 9), professional development conferences (9), separate college courses (n = 8), and other types (n = 7) (Figure 1). Most of the nurses (66%) encountered five or more different racial or ethnic groups in their work environment (M = 4.8, SD = 1.1) with African American (100%), Hispanic (97%), Asian (87%), and Arab American (62%) cited most frequently. Most nurses (64%) perceived themselves to be culturally competent (M = 4.5, SD = .76) (Table 1).
Number (frequency) and types of diversity training.
Characteristics of the Sample (N = 74)
Results of the Pearson correlation analyses indicated there were significant positive associations between years of education and amount of diversity training with overall cultural competence (r = .24, p < .05; r = .46, p < .01). Years of education were also positively correlated with amount of diversity training (r = .31, p < .01). A multiple linear regression analysis was calculated to predict overall cultural competence based on age, years of education, diversity training, and diversity experience. A significant regression equation was found [F(4, 65) = 4.78, p = .002], with an R2 of .23. Only amount of diversity training (β = .4, p = .001) predicted overall cultural competence, explaining 23% of the variance (Table 2).
Correlations and Linear Regression for Predictors of Nurse Cultural Competence
Most of the nurses in this sample cared for a wide variety of racially and ethnically diverse people and perceived themselves as culturally competent, congruent with the high score of measured cultural competence. Although educational level and diversity training were associated with cultural competence, only diversity training emerged as significant in the final model. This study contributes unique findings about the value of relationship between cultural diversity training and overall cultural competence among RNs employed in hospitals.
Prior studies have linked cultural diversity training (yes or no) with greater overall cultural competence; however, this study contributes new information about the number and types of diversity training (Doorenbos & Schim, 2004; Schim et al., 2005). Many of the respondents had completed two or more different types of training with the most frequently endorsed method being an employer-sponsored program followed by college courses. A multisite survey credited employer-based diversity training for the variation in cultural competence for oncology surgeons (n = 253) but did not include a list of different types of training (Doorenbos, Morris, Haozous, Harris, & Flum, 2016).
Almost all of the nurses in this study had completed diversity training, compared with 50% and 87%, respectively, as reported by Cicolini et al. (2015) and Benkert et al. (2011). This suggests that nurses experiencing more and different types of training is an important component of improving cultural competence. These findings highlight the importance of diversity training offered by hospitals as contributing to nurse cultural competence. Future research to identify optimal types and dose of training that are most effective are needed. Investigating interprofessional training and team-based care delivery models in the context of improving cultural competence may be worthwhile initiatives (Easter & DeWalt, 2017). As the United States becomes more racially and ethnically diverse and health care systems are increasingly challenged to deliver cost-effective and high-quality care, it is of critical importance that health care providers are culturally competent.
Nurse education levels vary considerably across hospitals in the United States, with reports for proportions of nurses with baccalaureate degrees or higher, ranging from 0% to 77%, and 61% in teaching hospitals (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Nationally, across all types of hospitals, an overall average of 55% of nurses have baccalaureate degrees (Health Resources & Services Administration, 2013), with higher educational levels in Magnet® hospitals (Kelly, McHugh, & Aiken, 2012). The educational level of the nurses in the sample was slightly higher than national averages, with 63% having a bachelor's degree or higher; these findings may have contributed to the nurses in this sample reporting “in college” as the second largest source of diversity training.
Results from this study should be considered in the context of the following limitations. The study was conducted in one major medical center in the southeast, therefore restricting generalizability to other settings. Geographic variations in cultural diversity, as well as differences in organizational culture and type of hospital (size, urban versus rural, community hospital versus large urban medical center), may have affected the findings. It is also possible that more nurses who were culturally aware and sensitive self-selected to participate in the study or that their responses were biased because of concerns about social norms. In addition, this sample was highly educated, with 15% pursuing a baccalaureate or graduate degree and 15% having already attained a graduate degree—both factors that may have influenced the findings. Because this was a self-report instrument, there may have been some internal bias on the part of the participants. In this convenience sample, participants were predominantly White and female, limiting generalizability to other groups. Statistical reporting using regression analyses does not imply causality. Therefore, the direction of the relationship between diversity training and overall cultural competence cannot be distinguished.
Because the U.S. population is expected to be largely composed of minorities in the next few decades, many health care providers will be caring for people from other cultures and ethnicities. Improvements in cultural competence have been made at the provider level, with education and training programs, and at the health care institutional level partly because of recommendations from national organizations and accrediting bodies. Cultural competence training programs that address both cultural awareness and sensitivity and culturally competent behaviors are needed to ensure that health care providers will be able to attend to the needs of these vulnerable groups. The results from this study suggest that more and different types of diversity training were important predictors of cultural competence; however, more research is needed to further elucidate optimal methods and amounts of training.
- Acock, A.C. (2005). Working with missing values. Journal of Marriage and Family, 67, 1012–1028. doi:10.1111/j.1741-3737.2005.00191.x [CrossRef]
- Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M. & Silber, J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290, 1617–1623. doi:10.1001/jama.290.12.1617 [CrossRef]14506121
- American Association of Colleges of Nursing. (2018). Race/ethnicity of graduates from generic (entry-level) baccalaureate, master's, and doctoral (research-focused) programs in nursing, 2008–2017. Retrieved from https://www.aacnnursing.org/Portals/42/News/Surveys-Data/EthnicityTbl.pdf
- American Association of Colleges of Nursing. (2019). Enhancing diversity in the workforce. Retrieved from https://www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity
- Austin, P.C. & Steyerberg, E.W. (2015). The number of subjects per variable required in linear regression analyses. Journal of Clinical Epidemiology, 68, 627–636. doi:10.1016/j.jclinepi.2014.12.014 [CrossRef]25704724
- Bahreman, N.T. & Swoboda, S.M. (2016). Honoring diversity: Developing culturally competent communication skills through simulation. Journal of Nursing Education, 55, 105–108. doi:10.3928/01484834-20160114-09 [CrossRef]26814822
- Benkert, R., Templin, T., Schim, S.M., Doorenbos, A.Z. & Bell, S.E. (2011). Testing a multi-group model of culturally competent behaviors among underrepresented nurse practitioners. Research in Nursing & Health, 34, 327–341. doi:10.1002/nur.20441 [CrossRef]
- Bureau of Labor Statistics. (2018). Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity. Retrieved from https://www.bls.gov/cps/cpsaat11.htm
- Cicolini, G., Della Pelle, C., Comparcini, D., Tomietto, M., Cerratti, F., Schim, S.M. & Simonetti, V. (2015). Cultural competence among Italian nurses: A multicentric survey. Journal of Nursing Scholarship, 47, 536–543. doi:10.1111/jnu.12165 [CrossRef]26444447
- Crawford, T., Candlin, S. & Roger, P. (2017). New perspectives on understanding cultural diversity in nurse–patient communication. Collegian, 24, 63–69. doi:10.1016/j.colegn.2015.09.001 [CrossRef]
- Darnell, L.K. & Hickson, S.V. (2015). Cultural competent patient-centered nursing care. Nursing Clinics, 50, 99–108.25680490
- Degrie, L., Gastmans, C., Mahieu, L., Dierckx de Casterlé, B. & Denier, Y. (2017). How do ethnic minority patients experience the intercultural care encounter in hospitals? A systematic review of qualitative research. BMC Medical Ethics, 18, 2. doi:10.1186/s12910-016-0163-8 [CrossRef]
- Doorenbos, A.Z., Morris, A.M., Haozous, E.A., Harris, H. & Flum, D.R. (2016). ReCAP: Assessing cultural competence among oncology surgeons. Journal of Oncology Practice, 12, 61–62. doi:10.1200/JOP.2015.006932 [CrossRef]
- Doorenbos, A.Z. & Schim, S.M. (2004). Cultural competence in hospice. American Journal of Hospice and Palliative Care, 21, 28–32. doi:10.1177/104990910402100108 [CrossRef]14748520
- Doorenbos, A.Z., Schim, S.M., Benkert, R. & Borse, N.N. (2005). Psychometric evaluation of the cultural competence assessment instrument among healthcare providers. Nursing Research, 54, 324–331. doi:10.1097/00006199-200509000-00006 [CrossRef]16224318
- Easter, J.C. & DeWalt, D.A. (2017). The medication optimization value proposition: Aligning teams and education to improve care. North Carolina Medical Journal, 78, 168–172. doi:10.18043/ncm.78.3.168 [CrossRef]28576953
- Eche, I.J. & Aronowitz, T. (2017). Evaluating cultural competence of pediatric oncology nurses at a teaching hospital: A pilot study. Journal of Pediatric Oncology Nursing, 34, 422–426. doi:10.1177/1043454217713452 [CrossRef]28660797
- Green, S.B. (1991). How many subjects does it take to do a regression analysis?Multivariate Behavioral Research, 26, 499–510. doi:10.1207/s15327906mbr2603_7 [CrossRef]
- Health Resources and Services Administration. (2013). The U.S. nursing workforce: Trends in supply and education. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nursingworkforcetrendsoct2013.pdf
- The Joint Commission. (2014). Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Retrieved from https://www.jointcommission.org/roadmap_for_hospitals/
- Kelly, L.A., McHugh, M.D. & Aiken, L.H. (2012). Nurse outcomes in Magnet® and non-Magnet hospitals [Supplemental material]. Journal of Nursing Administration, 42, S44–S49. doi:10.1097/01.NNA.0000420394.18284.4f [CrossRef]
- Lin, C.N., Mastel-Smith, B., Alfred, D. & Lin, Y.H. (2015). Cultural competence and related factors among Taiwanese nurses. Journal of Nursing Research, 23, 252–261.26562456
- McElroy, J., Smith-Miller, C.A., Madigan, C.K. & Li, Y. (2016). Cultural awareness among nursing staff at an academic medical center. Journal of Nursing Administration, 46, 146-153. doi:10.1097/NNA.0000000000000315 [CrossRef]26906519
- National Quality Forum. (2009). Safe practices for better healthcare—2009 update: A consensus report. Washington, DC: Author. Retrieved from http://www.qualityforum.org/Publications/2009/03/Safe_Practices_for_Better_Healthcare-2009_Update.aspx
- Nulty, D.D. (2008). The adequacy of response rates online and paper surveys: What can be done?Assessment and Evaluation in Higher Education, 33, 301–314. doi:10.1080/02602930701293231 [CrossRef]
- Ogbolu, Y., Scrandis, D.A. & Fitzpatrick, G. (2017). Barriers and facilitators of care for diverse patients: Nurse leader perspectives and nurse manager implications. Journal of Nursing Management, 26, 3–10. doi:10.1111/jonm.12498 [CrossRef]29076628
- Powell, D.L. (2016). Social determinants of health: Cultural competence is not enough. Creative Nursing, 22, 5–10. doi:10.1891/1078-45188.8.131.52 [CrossRef]
- Purnell, L. (2016). Are we really measuring cultural competence?Nursing Science Quarterly, 29, 124–127. doi:10.1177/0894318416630100 [CrossRef]26980891
- Schim, S.M., Doorenbos, A., Benkett, R. & Miller, J. (2007). Culturally congruent care: Putting the puzzle together. Journal of Transcultural Nursing, 18, 103–110. doi:10.1177/1043659606298613 [CrossRef]17416711
- Schim, S.M., Doorenbos, A.Z. & Borse, N.N. (2005). Cultural competence among Ontario and Michigan healthcare providers. Journal of Nursing Scholarship, 37, 354–360. doi:10.1111/j.1547-5069.2005.00061.x [CrossRef]
- Schmidt, F.L. (1971). The relative efficiency of regression and simple unit predictor weights in applied differential psychology. Educational and Psychology Measurement, 31, 699–714. doi:10.1177/001316447103100310 [CrossRef]
- U.S. Census Bureau. (2015). New census bureau report analyzes U.S. population projections. Retrieved from https://www.census.gov/newsroom/press-releases/2015/cb15-tps16.html
- U.S. Department of Health and Human Services, Office of the Secretary, Office of the Assistant Secretary for Planning and Evaluation and Office of Minority Health. (2015). HHS action plan to reduce racial and ethnic health disparities: Implementation progress report 2011–2014. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation.
- Warren, N., Baptiste, D.L., Foronda, C. & Mark, H.D. (2017). Evaluation of an intervention to improve clinical nurse educators' knowledge, perceived skills, and confidence related to diversity. Nurse Educator, 42, 320–323. doi:10.1097/NNE.0000000000000355 [CrossRef]28045738
- Weech-Maldonado, R., Dreachslin, J.L., Epané, J.P., Gail, J., Gupta, S. & Wainio, J.A. (2018). Hospital cultural competency as a systematic organizational intervention: Key findings from the national center for healthcare leadership diversity demonstration project. Health Care Management Review, 43, 30–41. doi:10.1097/HMR.0000000000000128 [CrossRef]
- Young, S. & Guo, K.L. (2016). Cultural competence for health care providers and in nursing practice. Health Care Management (Fredrick), 26(3), 234–239.
Characteristics of the Sample (N = 74)
|Variablea||Frequency n (%)||M (SD)|
|Age (years)a||40.6 (11)|
|Education (nursing degree)|
| Associate's||18 (25)|
| Pursuing bachelor's||6 (8)|
| Bachelor's||32 (45)|
| Pursuing graduate||5 (7)|
| Graduate||11 (15)|
| White/Caucasian||45 (63)|
| Asian||13 (18)|
| Black/African American||6 (8)|
| Hispanic||2 (3)|
| Arab American||1 (1)|
| Other||5 (7)|
|Diversity experiencea||4.8 (1.1)|
| Seven groups||4 (5)|
| Six groups||12 (16)|
| Five groups||33 (45)|
| Four groups||18 (24)|
| Three groups||6 (8)|
| Two groups||1 (1)|
|Diversity training||1.7 (1.1)|
| Six types||1 (1)|
| Four types||5 (7)|
| Three types||7 (10)|
| Two types||17 (24)|
| One type||41 (57)|
| Zero types||1 (1)|
|Cultural competence, self-rated||4.5 (0.8)|
|Cultural competence assessment (α = .78)||7.3 (0.8)|
Correlations and Linear Regression for Predictors of Nurse Cultural Competence
|1. Age (years)||-||.00||.01||.01|
|2. Education (years)||.06||-||.05||.07||.09|
|3. Diversity experience||.03||.08||-||.09||.08||.13|
|4. Diversity training||.06||.31**||.13||-||.28||.08||.40***|
|5. Cultural competence||.04||.24*||.17||.46**|