In recent years, researchers have recognized the need for multicultural education in counseling (Sue & Sue, 1990), in institutions of higher education (Barr, 1984), and in health care (Leininger, 1990). The "melting pot" view of assimilation into the dominant culture has been replaced with a more culturally relevant view that supports and affirms cultural diversity. As a result, students and professionals are required to be more culturally aware, knowledgeable, and skilled at working with culturally diverse individuals.
In health care, where nurses comprise a large percentage of the work force, there is a growing need for multicultural education and training due to the increasing diversity of our society (U.S. Census Bureau, 1989). Additionally, there is the ethical responsibility to provide sensitive and quality health care to all clients. However, much of the discussion in health care has focused on access to services for members of minority groups (Pinn-Wiggins, 1988). While this is an important concern, an equally important issue is the attitudes of nurses when interacting with culturally diverse clients.
Leininger (1984) observed that only 18% of undergraduate and 13% of graduate nursing programs included course content that addressed multicultural issues. More recently, she pointed out that there still remains limited content on cultural diversity in nursing education and practice, and suggested that "a knowledge of comparative ethical and moral values of multiculturee is essential today to help nurses make meaningful care judgments, decisions, and actions* (Leininger, 1990, p. 50).
Sohier (1988) reports that most American nursing students have little knowledge about any culture other than their own, and that nurses remain primarily white and middle class. As a result, when white nurses encounter culturally different clients in their practice, there is potential for conflicts, miscommunication, or dehumanized care (Cushner & Trifonovitch, 1989). Anderson (1990) has observed that health care practitioners often perceive culturally different clients as "noncompliant" without considering what effects their instructions might have on cultural values. Nursing ethics have also tended to focus on universal ethical principles or standards of human behavior that essentially deny cultural and individual differences. Leininger (1990) suggests that it is only in challenging the use of such universal principles that consideration of cultural differences will begin to emerge, encouraging nurses to interact with clients as individuals.
Pedersen (1988) suggests that multicultural education should proceed in a logical, linear sequence of increasing awareness, enhancing knowledge, and acquiring appropriate skills so that quality relationships between the care provider and client can be developed. He notes, however, that false awareness based on stereotypes must be corrected before knowledge and skills can be effectively learned. Dispelling stereotypes and providing accurate information can be difficult because there is tremendous variability within and between cultural groups.
Measuring multicultural competencies of nursing students may help determine the needs of students and educational programs. Therefore, the purpose of this study was to investigate undergraduate nursing students' multicultural competencies in working with culturally diverse clients. Given the exploratory nature of this study, research questions investigated differences in multicultural skills, knowledge, awareness, and relationships among nursing students across variables such as age, gender, work experience, and academic class standing.
The sample consisted of 120 undergraduate nursing students (112 women and 8 men) from a lifespan developmental psychology course in the College of Nursing at a large Midwestern university who agreed to participate in this investigation. The majority of students were from suburban, urban, or rural areas throughout the Midwest. The participants ranged in age from 18 to 43 with a mean age of 19.93 and a standard deviation of 2.68 years. Ninety-six percent of the participants were white.
Sixty-seven percent of the participants indicated that they had no work experience in the nursing field. Of the 33% who had experience in the nursing field, half had worked with a minority client within the last three months and the other half had worked with a minority client more than three months previously. The 120 participants constituted 78% of the course enrollment and were representative of the entire student population in the College of Nursing in terms of gender, ethnicity, and prior work experience.
The participants were asked to complete the Multicultural Counseling Inventory (Sodowsky, Taffe, Gutkin, & Wise, in press) adapted for nursing students, and a demographic questionnaire that was developed for this investigation.
Multicultural Counseling Inventory (MCI). This inventory was developed by Sodowsky et al. (in press) to measure self-reported multicultural competency areas. These areas are measured on four subscales:
* Skills: 11 items measuring general interpersonal skills and specific multicultural interpersonal skills. Sample items include, "When working with minority individuals, I form effective working relationships with the individual," and "When working with minority clients, I monitor and correct my defensiveness" (e.g., anxiety, overconfidence, denial).
MCI Subscale and Total Means and Standard Deviation for Nursing Students by Work Experience
Alpha Coefficients and lntercorrelatlons for MCI Subscales (N = 120)
* Knowledge: 11 items measuring care planning, conceptualization of client problems, and multicultural health care research. Sample items include, "When working with minority clients, I keep in mind recommendations about minorities' individual preferences in health care," and "When working with minority clients, I apply the histories of the clients' respective minority groups to understand them better."
* Awareness: 10 items measuring multicultural sensitivity, multicultural interactions, and advocacy in everyday Ufe activities and professional activities. Sample items include, "I am involved in advocacy efforts against institutional barriers in health services for minority clients* (e.g., lack of bilingual staff, multiculturally skilled nursing) and "When working with international patients or clients, I have knowledge of legalities of visa, passport, green card, and naturalization."
* Relationship: 8 items measuring nurses' interaction with minority clients (e.g., comfort level, world view, trustworthiness). Sample items include, "When working with minority clients, I am confident that my conceptualization of the individual or their problems does not consist of stereotypes and biases," and "When working with minority clients, I perceive that my race causes the client to mistrust me."
The 40 items of the MCI assess selfperceived competencies on a four-point Likert scale (l = very inaccurate, 4 = very accurate). Scale scores are obtained by adding the items specific to each scale; higher subscale means indicated greater self-perceived multicultural competence in the respective subscale areas.
Demographic Questionnaire. Participants reported information regarding ethnic background, age, gender, academic class standing, field of study, and work experience.
The instruments were administered during two concurrent academic semesters in the common order of consent form, demographic questions, and MCI. Participants completed the instruments at their own pace and returned them when completed.
Subscale means, total scores, and standard deviations of nursing students are presented in Table 1. For convenience, averages were computed so that scores could be interpreted with reference to the original four-point Likert scale. Mean scores ranged from 1 to 4 for each eubscale. Higher mean scores indicates more selfreported multicultural competency in the respective subscale area. Since the scale midpoint is 2.5, it is evident from Table 1 that the participants, in general, reported a reasonable level of multicultural competency, particularly concerning multicultural relationships. Multicultural awareness fell below the midpoint.
Reliability and validity of measure
In the development of the MCI, a large Midwestern sample of counseling, school, and clinical psychology graduate students (n = 165) and counseling professionals (n - 771) were surveyed. Factors were chosen on the basis of both a scree plot of the eigenvalues and the factor interpretability. This analysis resulted in four subscales, Multicultural Skills, Knowledge, Awareness, and Relationship, with internal consistency reliabilities of .83, .79, .83, and .71, respectively. There were low to moderate intersubscale correlations, ranging from r = .52 to r = .23.
Additional research has also shown content validity evidence for the MCI. The MCI revealed significant self-reported multicultural competency change in counseling graduate students (n = 42) from the beginning to the end of multicultural counseling courses in three separate semesters. In a sample of the counseling professionals, significant MCI subscale and total score differences were found between counselors who did 50% or more of their work in multicultural counseling (n = 82) and those who did less than 50% work in multicultural counseling (n = 82), supporting the content validity of the instrument (Sodowsky et al., in press).
Alpha coefficients and intercorrelations for the MCI subscales for the current sample are presented in Table 2. Internal consistency estimates for the four subscales were .81, .74, .76, and .69. These estimates approximate the reliabilities reported by Sodowsky et al. (in press). Intercorrelations of the four subscales for the MCI showed a reasonable level of internal consistency for use with this sample of nursing students. Moderate to low correlations were found between the four subscales, ranging from r = .52 tor =.17. These correlations approximate MCI subscale correlations found during instrument development and suggest that the inventory is measuring related but different constructs. However, further scale refinement is needed.
Analysis of demographic effects
To determine whether nursing students' self-reported multicultural competencies differed with respect to demographic variables, multivariate analysis of variance (MANOVA) and univariate analysis of variance (ANoVA) were conducted. A significance level of .05 was adopted for each analysis. Students did not differ significantly across the self-reported variables of age or class standing. However, a significant multivariate main effect was found for work experience (F[4, 1151=2.98, /><.05). Follow-up ANOVAs for the individual subscales revealed a significant work experience main effect for multicultural skills (F[I, 118) = 9.09, p<.01) and for multicultural knowledge (F[1, 118] = 7.27, p<.01). Students with work experience had higher multicultural skill levels and multicultural knowledge levels than students without work experience. Students with work experience reported more skills in interpersonal communication, cultural consideration, and knowledge of cultural factors and appropriateness when interacting with minority clients.
The results of this exploratory investigation indicate that students who have had some work experience had significantly more self-perceived multicultural skill and knowledge but not more multicultural awareness or relationship than students who have had no work experience. This finding suggests that experience in the field had an impact on two multicultural competencies of nursing students. These results are interesting, given that none of the nursing students who participated in this investigation had completed a course or seminar addressing multicultural issues in nursing.
The finding that nursing students with work experience had greater self-perceived multicultural skills and knowledge than other students may have a number of possible explanations. If Pedersen (1988) is correct and awareness must precede knowledge and skills, then these students may have acquired a "false cultural awareness* based on stereotypes. Also, they may have developed a set of general skills and knowledge for the work environment without fully comprehending why these skills are necessary. Additionally, students may in fact subscribe to the universal principle and truly believe that they treat all clients alike and therefore perceive themselves as interacting the same with all clients without consideration for cultural differences. Thus, they may have the knowledge and skills to care for clients without any awareness or sensitivity that culturally diverse clients may have different needs. Further research is needed to explicate the results.
Nursing educators should consider carefully how to incorporate multicultural education into their nursing programs. Since work experience appears to be related to greater awareness of multicultural issues, then issues may be best received by students after they have had some clinical experience. Currently, the field of nursing is determining how to define culture in the education of nursing students. A broad example is Leininger (1984), who defined culture as the beliefs, value practices, and norms that are learned and shared by a particular group.
Textbooks on multicultural nursing (e.g., Giger & Davidhizar, 1991; Specter, 1991) generally address only ethnic and racial subgroups and ignore other forms of diversity such as disability, age, sexual orientation, and religion. Such texts may actually perpetuate stereotypes by presenting highly specific information that does not consider differences within groups. Thus, when multicultural education is incorporated into the curriculum, it must be done in a manner that stimulates students to think about cultural differences and provides general guidelines for dealing with ethnically diverse clients. It cannot be prescriptive or precise.
Equally important is the notion of being multiculturally aware and having the capacity to develop a relationship. While no significant differences were found on these subscales in this investigation, researchers (Sue & Sue, 1990) clearly point out the need to increase multicultural awareness as a means of minimizing stereotypical responses and enhancing multicultural relationships.
Questions still remain as to whether multicultural issues should be addressed in specific courses or incorporated into the curriculum of many courses. Identifying specific characteristics or experiences that make an individual more competent with culturally diverse clients deserves further study in the field of nursing.
Limitations of this investigation relate to the use of self-report measures. The participants may have selected responses that they thought were socially desirable rather than being entirely honest. They may have assessed behaviors that they anticipated rather than actual behaviors, and they may have interpreted items differently. These issues point out the ongoing need for the development of a reasonable and appropriate instrument that addresses multicultural competencies of nursing students while taking into consideration these limitations.
Despite these limitations, this investigation does suggest a relationship between work experience and multicultural competencies of nursing students. However, given the exploratory nature of this investigation, further research is needed to examine the relationship between work experience and multicultural competencies. Additionally, differences between nurses practicing in the field and those in training, differences between ethnically diverse nurses, and the impact of multicultural education on the attitudes of nurses should be examined.
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MCI Subscale and Total Means and Standard Deviation for Nursing Students by Work Experience
Alpha Coefficients and lntercorrelatlons for MCI Subscales (N = 120)