There has been a concerted effort since the 1960s to include concepts sensitive to cultural diversity in nursing education and practice. The National League for Nursing (NLN), which accredits all nursing programs, has made this requirement mandatory. The NLN stipulates that the nursing curriculum should provide "learning experiences in health promotion and maintenance, illness care and rehabilitation for clients from diverse and multicultural populations throughout the life span" (NLN, 1983, p. 7).
Few nursing programs included content related to cultural diversity in their curricula in the 1960s when the idea of transcultural nursing was first introduced (Glynn & Bishop, 1986). Some progress had been made since then, but only recently have programs been systematically incorporating culturally diverse nursing care concepts into their curricula, and there are still too few curricula that do. According to Leininger (1984), in 1983, only 18% of the NLN-accredited baccalaureate nursing schools included cultural content in their curricula. As of 1989, there were five master's programs and four doctoral programs in the United States offering degrees in transcultural or multicultural nursing. This paucity of research and programs on multiculturalism in nursing education provided the basis of this study. It was based on the premise that concepts of cultural diversity related to health care must be cognitively and affectively understood, and incorporated into nursing practice on a systematic basis, if the multicultural dimension of nursing is to become a reality (Glynn & Bishop, 1986).
This exploratory study examined the knowledge and attitudes of nurses toward patients of diverse cultural backgrounds through the use of the Cultural Fitness Survey (CFS). In order to fulfill the purpose of this investigation, two questions needed to be answered:
1. What level of basic knowledge do nurses have about culturally different patients?
2. What are the attitudes of nurses toward patients whose backgrounds differ from their own?
The expectation was that answers to these research questions would provide directions for improving the health care field in general, and the development of multicultural nursing education curricula in particular.
The subjects of the study were randomly selected from a target population of 3,242 registered nurses currently practicing in nine acute care hospitals located in an urban midwestern county. These nine hospitals have a total of 2,693 beds, employ 3,242 registered nurses, and serve 451,273 patients annually. The geographic parameter was chosen because it is an area rich in cultural diversity. The ethnic makeup of the county is 63.7% white; 24.1% Black American; 8.4% Hispanic, and 3.8% Asian American (Bureau of the Census, 1982).
A sample of nurses employed in these hospitals was selected using the proportionate sampling of elements method: 20% of the nurses in each of the nine acute care hospitals were randomly selected for participation in the study. Given the variety of statistical analyses applied to the data, approximately 300 subjects were required to supply the statistical power desired to perform these analyses adequately (Cohen, 1977). A total of 649 questionnaires were initially distributed. Of those, 319 were returned with usable data. This accounted for a 52% return rate, gathered across a period of six weeks and two distribution cycles.
The subject sample was predominantly female (96.6%). The small number of males precluded meaningful analysis ofthat subgroup. Eighty-nine percent of the population was white with the other three ethnic groups comprising a total of less than 11% of the sample. Nonwhites were excluded from the analyses as their small numbers precluded meaningful analysis. The final sample size, after adjustment for gender and ethnicity, was 274. This reduction in sample size had a minimal effect on the power of the overall study. Sixty-one percent of the sample were graduates of associate degree in nursing (ADN) programs. The remaining participants included 16.9% who received bachelor's (BSN) degrees, and 21.6% who held diplomas. Most of the nurses who took part in the study (74.5%) had worked between one and 15 years in the health care profession. Participants were asked to estimate the percentage of patients for whom they cared whose cultural backgrounds differed from their own in order to determine the degree of interpersonal contact with such patients- Over 53% of the nurses indicated that 21% to 60% of the patients they cared for were culturally different from themselves, while 19.4% reported that more than 60% of their patients were. These data confirmed that feature of the research study which was designed to collect data in a culturally diverse community and health care context. The respondents were fairly evenly divided as to whether the nursing program from which they graduated provided content on cultural diversity as it relates to health care. The affirmative responses were 55.5% and the negative were 44.5%.
The CFS, a self-administered three-sectioned questionnaire, was used to collect the data for this study. Two of the sections were developed by the researcher. The third was an adaptation of an experimental tool previously developed by Bonaparte (1979).
Section 1 of the CFS dealt with knowledge of cultural diversity, including questions about culturally specific diseases and symptoms, values, and issues related to family orientation of specific cultural groups. Approximately equal numbers of questions were selected for each of the three minority groups (Black Americans, Hispanics, and Asian Americans) that appear in the attitude section of the questionnaire.
In order to determine if these questions were representative of basic knowledge about how cultural diversity affects health care, they were submitted to a committee of three nurse educators with expertise in multicultural nursing education. This panel, which included representation from the Black American, Hispanic, and Asian American cultures, reviewed the questions for clarity, level of knowledge tested, and appropriateness of content. Questions were then revised and deleted based on feedback from these individuals. The original list of 30 items was reduced to 22 questions. These questions were pilot-tested on a sample of 32 registered nurses with a variety of educational backgrounds (diploma, ADN, BSN, MSN) and years of experience (ranging from four to 29 years). The overall mean number of correct responses on the knowledge component of the CFS was 15.41, and the standard deviation was 2.44. The reliability (KR-20) was reported at .71. In addition to the total content score, knowledge subscores were generated for Black Americans, Hispanics, and Asian Americans.
Section 2 of the CFS was the Cultural Attitude Scale (CAS), which measured nurses' attitudes toward culturally different patients. The CAS, developed by Bonaparte (1979), is a 34-item Likert-type questionnaire with five response options (ranging from strongly disagree to strongly agree) for four different vignettes describing four ethnic individuals (Hispanic, Black American, Asian American, and Anglo-American). Each vignette describes the family unit, type of employment, church affiliation, and health care practices of the patient, in addition to ethnic identity.
The coefficient alpha for each of the four scales on the attitude component of the CFS was .88 for white, .92 for Black American, .87 for Asian American, and .92 for Hispanic. In addition to these total scores, three cultural bias scores were generated from the data, one for each ethnic minority group. These scores were calculated by subtracting the respective different-race attitude score from the white attitude score. The higher the cultural bias score, the greater the bias; a score of zero represented no bias.
Section 3 of the CFS was composed of eight questions designed to collect demographic information on the respondents, including age, gender, ethnic identity, educational preparation, year of graduation, and professional experiences. This part of the questionnaire was also used to gather information about the cultural diversity of the patients cared for by the nurses, and their exposure to content related to cultural diversity and health care. As described earlier, gender and ethnicity were dropped from the final analyses because small numbers of males and nonwhites precluded meaningful analyses.
Repeated Measures MANOVA of Mean Content Subscores on the CFS
Both the knowledge and attitude components of the CFS were analyzed using repeated measures MANOVA, multiple regression, and one-way ANOVAs. The mean content, attitude, and cultural bias scores were analyzed using repeated measures MANOVA. Multiple regression analyses were used to predict knowledge (overall and for each of the three ethnic groups), attitude, and bias as a function of the demographic variables, level of educational preparation (ADN, BSN, or diploma), and cultural diversity content in education. One-way ANOVAS were used to determine if knowledge (overall and for each of the three ethnic groups), and attitude were a function of the three levels of educational preparation.
To determine if there were any differences in nurses' level of basic knowledge about culturally different patients, a repeated measures MANOVA was performed on the mean scores of the three subscales for cultural content from the responses on the CFS. The results of these analyses are summarized in Table 1.
The size of the F value and associated small probability level indicated in Table 1 confirmed the presence of statistically significant differences in mean content subscores for the three ethnic groups. The large effect size (eta2 = .70) obtained indicated that the mean differences were substantial, and that there were significant dissimilarities in nurses' knowledge of different cultural groups.
A set of three orthogonal contrasts was conducted to determine the specific nature of the significant mean differences produced by the MANOVA. The results of the three orthogonal contrasts revealed that the knowledge nurses have about Asian-American cultural content was significantly higher than for the Blacks and Hispanics. Their knowledge of Black and Hispanic cultures and health care practices was essentially equivalent.
Four multiple regression analyses were conducted in an attempt to predict how six sociodemographic variables would be related to total cultural knowledge scores and the knowledge subscores for the ethnic groups under study (Black Americans, Asian Americans, and Hispanics). These six predictor variables were age, year of graduation, years practicing as a registered nurse, percent of patients cared for whose cultural background differed from that of the nurse, level of educational preparation, and whether the nursing program graduated from provided content on cultural diversity. Results of the stepwise multiple regression analyses indicated two significant predictors of knowledge about Black cultural content. These were diploma educational preparation and ADN educational preparation. The overall Rp 2 of .05 for these two predictors was significant at the .006 level (F= 5.26; d/2,200).
While the multiple regression analyses determined that there were differences in levels of cultural knowledge of nurses related to their educational preparation, they did not explain the details of those differences. Therefore, analysis of variance was used to examine more fully the relationship between knowledge and educational preparation. A series of three, one-way ANOVAS was conducted analyzing three cultural content scores (Black, Asian American, and Hispanic) as a function of the three levels of educational preparation (ADN, BSN, and diploma). The results produced one statistically significant finding on content about Black Americans. An overall difference in mean content scores on the questions relating to Black Americans for each of the three education preparation categories (ADN, 3.62; BSN, 3.19; diploma, 3.87) was obtained. Post-hoc analysis of these three means using the Scheffe procedure indicated that the mean for BSN graduates was significantly lower than the means for ADN and diploma graduates. Hence, the results of the MANOVA were confirmed and further clarified. ADN and diploma-educated nurses in this sample have more knowledge of Black cultural content than do BSN-educated nurses.
To determine if differences existed in nurses' attitudes toward culturally different patients, a repeated measure MANOVA of mean attitude scores on the CFS toward the four ethnic groups examined in the study (whites, Black Americans, Hispanics, and Asian Americans) was performed. Results of the MANOVA are summarized in Table 2.
The size of the F value and the associated small probability level confirmed the presence of statistically significant differences in mean attitudes for the three ethnic groups. The corresponding large effect size (etap 2 = .57) indicated that those differences were substantial.
Repeated Measures MANOVA of Mean Attitude Scores on the CFS
Orthogonal contrasts were conducted on attitudes. The results of the three orthogonal contrasts demonstrated that the attitudes of nurses toward whites were more favorable than those toward Blacks, which in turn were more favorable than the attitudes expressed about Asian Americans, and these were more positive than their attitudes toward Hispanics.
As with content and attitudes, a repeated measures MANOVA of mean cultural bias scores toward Blacks, Hispanics, and Asian Americans was also conducted. Results indicated statistical differences among cultural biases expressed by white nurses toward their culturally different patients (F= 116.68; df 2.00; p<.001).
The results of the two orthogonal contrasts that were conducted to determine the nature of the differences in cultural biases nurses expressed toward Blacks, Hispanics, and Asian Americans indicated that the nurses who participated in this study were most biased toward Hispanic patients and least biased toward Blacks.
In a similar manner, three multiple regression analyses were conducted in an attempt to predict cultural bias scores of nurses toward Hispanics, Black Americans, and Asian Americans. Results of the stepwise regression analysis for cultural bias toward Hispanics produced one significant predictor. This was ADN educational preparation. The overall R2 of .02 was significant at the .03 level CF =4.58; df 1,201). An examination of the regression coefficient for ADN and the associated pattern of subgroup means for the three levels of educational preparation (ADN, BSN, Diploma) revealed that ADN graduates tended to be less biased toward Hispanics than non-ADN graduates.
Summary of Findings
Several major findings emerged from the study. First, the nurses who participated in this investigation know more about the culture and health care practices of Asian Americans than those of Hispanics and Black Americans. Second, the knowledge these nurses have about culturally different patients is related to their level of educational preparation. Third, these nurses have different attitudes toward the cultures and health practices of ethnic groups. In sequential order of most to least positive attitudes, the ranking was whites, Black Americans, Asian Americans, and Hispanics. Fourth, cultural bias appeared to be a function of cultural attitudes. The directionality of their cultural biases toward different ethnic groups paralleled that of their attitudes. Of the six demographic variables, only educational preparation proved to be a significant predictor of knowledge or bias toward cultural groups.
Limitations of the Study
The sample in this study is limited to registered nurses currently practicing in acute care hospitals in one midwestern, metropolitan county rich in cultural diversity. Therefore, the results of this study cannot be generalized to other counties that may have a homogeneous population or even to others with diverse populations.
This study did not include registered nurses practicing in other health care settings, such as extended care facilities, home health agencies, physicians' offices, or industrial settings. There was no way of determining if or to what extent the findings were influenced by the contexts of where the nursing care occurred. Thus, the extent of the generalizability of the results is limited to registered nurses working in those particular acute care hospitals under study.
There are inherent weaknesses in survey research and the use of a self-report tool such as the CFS. In such research studies, the respondents can manipulate the scores through their responses. Respondents may inflate or underestimate their knowledge, or give socially acceptable answers. However, surveys have been found to be excellent tools for measuring attitudes in that they provide a means of determining prevailing attitude trends. A self-administered questionnaire is preferable when questions are highly personal and sensitive, as was the case in this investigation. Respondents may be more willing to answer questions honestly and may have greater trust in the confidentiality of a paper-and-pencil questionnaire than oral interviews. The validity of the results of survey research depend on frank and honest responses on the part of the respondents. Even though the subjects in this study were assured anonymity, there is no way to know with certainty that they provided candid, not socially accepted, responses.
Another limitation of this study is that the survey dealt with attitudes. There may be existing biases among the respondents, such as pre-existing prejudices toward one or more of the ethnic groups under study, and inaccurate assumptions or generalizations based on limited personal experiences with a few members of the ethnic group. These biases could have unduly skewed, either positively or negatively, the results obtained, but these could not be readily identified or controlled by the researcher.
The small effect size between the two significant predictors of knowledge (R = . 05) as well as for the single significant predictor of cultural bias (H = . 02) suggests a weak relationship. If these results are replicated beyond this preliminary exploratory effort, such results would provide useful direction to researchers by suggesting that the search for other causal factors be expanded.
The findings of this study confirmed some premises, yet raised a number of questions for consideration about cross-cultural interactions in health care environments. One of these assumptions is that individuals are likely to be more positive toward their own ethnic and cultural group than others. This premise was partially validated. The white nurses who participated in this study had the most positive attitudes toward white patients. Because the subjects included no other ethnic group, it was impossible to determine if this behavior was an isolated occurrence unique to whites or would apply equally as well among other ethnic groups.
A logical assumption is that cultural attitudes and cultural biases will be positively correlated because cultural bias, as operationalized in this study, was derived from attitude scores. It was substantiated by the results of this study in that the greatest cultural bias and most negative cultural attitudes were expressed toward Hispanics, whereas the least cultural bias and most positive attitudes were demonstrated toward Blacks, with Asian Americans falling in between.
The only demographic variable that emerged as a significant predictor of both knowledge and attitude was level of educational preparation. This result raised some questions that could not be answered. What are the differences in the curricula of these educational experiences that account for the variations? Why did nurses who graduated from ADN programs have significantly more knowledge about Black American cultural content and less biased attitudes toward Hispanice than those who attended BSN programs? Are these differences attributable to variations in curriculum content and educational experiences about cultural diversity and health care at the various levels of educational preparation? If the differences are due to curricula variations, what specifically are these? Were these real differences or personal attributes of individuals who happened to comprise this subgroup of the subjects? These questions are critical and need to be answered before reliable decisions can be made as to whether the results of this study can or should be used as bases for revisions in the education of nurses.
The findings obtained from this research were more instructive than conclusive. Because the subjects in the present study were all Anglo-American nurses working in acute care settings, the findings obtained are, at best, applicable to other Anglo nurses working in similar settings. This study should be replicated using nurses from a variety of ethnic identities and cultural backgrounds working in diversified health care settings. For example, the study could include nurses from different ethnic minority groups such as Hispanice, Asian Americans, and Black Americans working in acute care hospitals or extended care facilities. This selection process could broaden the scope of the research to include the perspectives of minority nurses whose professional experiences include both the acute care setting and other health care facilities. In doing so, not only would the knowledge and attitudes of minority nurses be examined, but the influence on knowledge and perceptions of where nursing care was performed could be assessed.
The results of this investigation seem to suggest that nurse educators need to examine the differences in objectives, content, and learning experiences related to cultural diversity that may account for differences in knowledge and attitudes of nurses prepared at the various levels of nursing education. Such an examination is essential in order to prepare nurses to practice in a global society.
- Bonaparte, B.H. (1979). Ego defensiveness, open-closed mindedness, and nurses' attitude toward culturally different patients. Nursing Research, 28, 166-172.
- Bureau of the Census, U.S. Department of Commerce. (1982). General population characteristics: Indiana. Washington, DC: Author.
- Cohen, J. (1977). Statistical power analysis for the behavioral sciences (rev. ed.). New York: Academic Press.
- Glynn, N.J., & Bishop, G.R. (1986). Multiculturalism in nursing: Implications for faculty development. Journal of Nursing Education, 25, 39-41.
- Leininger, M. (1984). Transcultural nursing: An overview. Nursing Outlook, 32, 72-73.
- National League for Nursing. ( 1983). Criteria for the evaluation of baccalaureate and higher degree programs in nursing (NLN Publication No. 15-125-1A). New York: Author.
Repeated Measures MANOVA of Mean Content Subscores on the CFS
Repeated Measures MANOVA of Mean Attitude Scores on the CFS