Journal of Nursing Education

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Measuring Cultural Awareness in Nursing Students

Lynn Rew, EdD, RNC, HNC, FAAN; Heather Becker, PhD; Jeff Cookston, PhD; Shirin Khosropour, PhD; Stephanie Martinez, MSN, RN

Abstract

ABSTRACT

Recognizing the need for a valid and reliable way to measure outcomes of a program to promote multicultural awareness among nursing faculty and students, the authors developed a cultural awareness scale. In the first phase of the study, a scale consisting of 37 items was generated from a literature review on cultural awareness, sensitivity, and competence in nursing. A Cronbach's alpha reliability coefficient of .91 was obtained from a sample of 72 student nurses. In the second phase, the items were presented to a panel of experts in nursing and culture to determine content validity. A content validity index of .88 was calculated, and the total number of items on the scale was reduced to 36. The scale then was administered to 118 nursing students. Data from the two sampies then were combined, and factor analysis was conducted to support construct validity. Cronbach's alpha for the combined samples was .82.

Abstract

ABSTRACT

Recognizing the need for a valid and reliable way to measure outcomes of a program to promote multicultural awareness among nursing faculty and students, the authors developed a cultural awareness scale. In the first phase of the study, a scale consisting of 37 items was generated from a literature review on cultural awareness, sensitivity, and competence in nursing. A Cronbach's alpha reliability coefficient of .91 was obtained from a sample of 72 student nurses. In the second phase, the items were presented to a panel of experts in nursing and culture to determine content validity. A content validity index of .88 was calculated, and the total number of items on the scale was reduced to 36. The scale then was administered to 118 nursing students. Data from the two sampies then were combined, and factor analysis was conducted to support construct validity. Cronbach's alpha for the combined samples was .82.

To meet the health care needs of a multicultural population, the nursing discipline must educate individuals from diverse cultural and ethnic backgrounds. The American Association of Colleges of Nursing (AACN) issued a position statement in 1997 regarding issues of diversity in nursing and nursing education. The AACN (1997) stated that, due to anticipation of an increasingly more diverse population in the next century, issues related to cultural diversity have become more central to nursing education. Nursing faculty have an obligation to prepare graduates who are aware of and sensitive to cultural issues (Capers, 1992; Chrisman, 1998). A variety of innovative approaches to teaching cultural diversity have been described in the literature and range from entire courses devoted to cultural issues (Lockhart & Resick, 1997) to the introduction of a virtual classroom (Jackson, Yorker, & Mitchem, 1996). Other approaches have used Internet assignments (Kirkpatrick, Brown, & Atkins, 1998) and non-nursing literature (Bartol & Richardson, 1998).

The concept of cultural competence has appeared in the nursing literature more frequently in the past 5 years than ever before and has been defined by the American Academy of Nursing (Lenburg et al., 1995) as "a complex integration of knowledge, attitudes, and skills that enhances cross-cultural communication and appropriate effective interactions with others" (p. 35). Cultural competence has been identified as a critical component of nursing research (Campinha-Bacote & Padgett, 1995), counseling (Pope-Davis, Eliason, & Ottavi, 1994), and continuing nursing education (Campinha-Bacote, 1999). Despite the increased attention to the development of culturally competent nurses through basic and continuing education, little evidence exists regarding objective or formal evaluations of these programs. This may be due, in part, to ambiguity of terms, such as cultural sensitivity, multicultural awareness, and cultural competence, or the lack of psychometrically sound instruments developed specifically for such evaluations. A valid assessment tool can help individuals identify their feelings about cultural diversity, which is prerequisite to deeper understanding of the phenomenon (Randall, 1994).

With a program grant titled, "Pathways for Students with Disadvantaged Backgrounds," funded by the Nursing Division of the U.S. Department of Health and Human Services, faculty at The University of Texas at Austin focused on increasing their own and their students' awareness of multicultural diversity and its relationship to health care. A Pathways Model (Rew, 1996) was developed to focus on the interaction between nursing faculty and students from a variety of backgrounds, including students who were educationally or economically disadvantaged. Using an ecological perspective and a travel metaphor, the Pathways - Model (Rew, 1996, pp. 311-312) contained three major concepts:

* "Diversity of roads traveled by students entering the learning environment..."

* "A learning landscape that contains a wide variety of signs, maps, tour guides, and other resources..."

* "Unique self-built pathways leading the student into the world of professional nursing practice."

To ensure there was a valid measure of program outcomes, the Cultural Awareness Scale (CAS) was developed for use by nursing faculty and students. This article describes the process of developing and testing the scale.

BACKGROUND

Clinton (1996) defined culture as that which helps individuals adapt to their environments. Cultural awareness, sensitivity, and competence are concepts with definitions that are still evolving. Often, these terms are used interchangeably to refer to the same construct. In some cases, their definitions are implied, rather than explicitly stated. As more accreditation and other state agencies establish and attempt to enforce cultural competence guidelines (Lester, 1998), the terms cultural awareness, cultural sensitivity, and cultural competence increasingly are used or perceived as buzzwords. However, it is important not to allow these constructs to be dismissed as another set of new "politically correct" terms whose relevance will pass in time.

In her discussion of a college-level course on cultural diversity for nurses, Clinton (1996) identified cultural awareness and sensitivity as two components of cultural competency. When individuals are conscious that people are different from one another, partly because of their cultural backgrounds, they are culturally aware (i.e., conscious of culture as a contributing factor to all people's personalities, attitudes, and behaviors). When individuals value and respect these cultural differences, they are said to be culturally sensitive. A perception of cultural insensitivity and incompetence in the health care system can generate barriers to seeking health care, in addition to creating uncomfortable experiences. Culturally competent individuals are not only aware of differences in people based on knowledge of their cultures but respect individuals from different cultures and value diversity (Sodowsky, Taffe, Gutkin, & Wise, 1994). Developing cultural competence is a process of learning to work with people from diverse cultural backgrounds, using interpersonai communication, relationship skills, and behavioral flexibility (Lester, 1998).

Therefore, cultural competence can be conceptualized as consisting of four components:

* Cultural awareness (i.e., the affective dimension).

* Cultural sensitivity (i.e., the attitudinal dimension).

* Cultural knowledge (i.e., the cognitive dimension).

* Cultural skills (i.e., the behavioral dimension).

Each of these components of cultural competence should be addressed in nursing classrooms, clinical practice, and research.

Cultural Competence in Nursing Classrooms

The task of delivering culturally competent education belongs to faculty. It begins with faculty members' awareness of how their own cultures affect different aspects of their lives (Schmitz, Paul, & Greenberg, 1992). Marchesani and Adams ( 1992) also acknowledged the role of instructors' awareness of their cultural selves as one of four dimensions of teaching related to cultural diversity:

* Awareness of the role one's cultural background and experiences play in forming beliefs, attitudes, and behaviors.

* Knowledge and understanding of how students from different cultural or ethnic backgrounds may experience the classroom differently.

* Incorporation of diverse cultural and social perspectives in the curriculum.

* Use of a variety of teaching methods to more effectively accommodate learning styles of students from different backgrounds.

Hardiman and Jackson (1992) stressed the importance of faculty members knowing their students and their needs. They asserted that it is faculty's responsibility to understand the stages students go through in developing their own racial identities so faculty can become facilitators in this process. It may be that until a certain stage is reached in the development of their own cultural identities, students will not be ready to assimilate information about people from diverse cultures. Redican, Stewart, Johnson, and Frazee (1994) argued that cultural awareness and sensitivity affect not only the way health care information is delivered but also how students are able to internalize the information.

Assuming the best case scenario - that all faculty in charge of nursing education somehow become proficient in discussing issues related to cultural sensitivity - their effectiveness still will rely, in part, on students' cultural background and differences in learning styles. McCaughrin (1995) found that different ethnic and racial groups of college students had diverse preferences for receiving health-related information from various types of media (e.g., African American students chose television, while Latino students chose newspapers and magazines, as their least preferred method of receiving information about sexually transmitted diseases).

Cultural Competence in Clinical Practice and Research

Beyond the classroom, in which faculty demonstrate their cultural competence by helping students develop cultural awareness and sensitivity, faculty members can facilitate students' development of cultural competence in clinical nursing practice and research (Campinha-Bacote & Padgett, 1995; Porter & VUlarruel, 1993). Measuring outcomes of educational and research efforts related to cultural competence have been hampered by a lack of valid instruments to measure awareness, sensitivity, and competence.

Taking a general approach to the topic, Bernal and Froman (1987) developed a 30-item scale to measure community health nurses' degree of confidence (i.e., self-efficacy) in providing care for African American, Puerto Rican, and Southeast Asian individuals. Based on Bandura's (1977) social learning theory, Bernal and Froman (1987) derived items from transcultural nursing and anthropological literature and presented the items to an expert panel for content validity. They administered the survey to 190 community health nurses and found the scale to be reliable, with an internal consistency estimate of .97. However, they also found that the nurses in their sample did not feel confident in their abilities to provide culturally competent care to these three cultural groups. Similarly, Alpers and Zoucha (1996) used the Cultural Self-Efficacy Scale, developed by Bernal and Froman (1987), in a small study of senior nursing students at a private university and found that students who received some content on culture felt less confident in providing culturally competent care than those who received no such content.

To measure cultural competence of nursing students in clinical practice, Pope-Davis et al. (1994) adapted the Multicultural Counseling Inventory (Sodowsky et al., 1994) and administered the adapted scale to 120 undergraduate nursing students. Their results indicated that students with more work experience had higher scores on general interpersonal skills and knowledge of the role of cultural factors. However, the scores of these more experienced students did not differ significantly from those of other students on measures of cultural awareness and relationships, which was defined as interaction with minority patients.

Warda (1997) developed and tested an 18-item scale specifically to measure components of culturally competent care for Mexican Americans. The instrument has some evidence of construct validity and internal consistency but requires further psychometric evaluation. In addition, it is limited in its focus only on care for Mexican Americans.

The Cultural Awareness Survey, developed by Motwani, Hodge, and Crampton (1995), was designed to elicit institutions' ways of addressing cultural diversity. The instrument is a survey that can be used by employees in various positions within a health care institution and measures employees' experiences of culture shock and perceptions of respect for diversity within the work environment.

Each of these instruments measures a different aspect of cultural competence, and the findings from the studies that have used them exemplify a common and familiar picture - merely raising individuals' conscious awareness of cultural diversity does not ensure cultural competence occurs. Meléis (1996) proposed that more research is needed to establish the knowledge base for providing culturally competent nursing care. To that end, she argued that, at a minimum, nurses need more knowledge about a variety of populations, culture-specific nursing phenomena (e.g., social support), and human responses to diversity, vulnerability, transitions, and marginalization (Meleis, 1996). Meleis (1996) emphasized the importance of studying not only the cultural heritage of diverse nursing patients but how this heritage may have "been used to marginalize people and deprive them of fair and equitable access to health care" (p. 14). However, before nurses can conduct such research, they first must demonstrate cultural awareness, sensitivity, and a minimal degree of cultural competence.

DEVELOPMENT OF THE CULTURAL AWARENESS SCALE

From a literature review on cultural awareness, cultural sensitivity, cultural competence, nursing clinical practice, and nursing education, five key categories were identified to reflect the multidimensional nature of cultural awareness. These categories then were used as a blueprint to develop a scale to measure cultural awareness in nursing students. The original scale contained 37 items using a 7-point Likert response format, ranging from strongly disagree (1) to strongly agree (7). Table 1 summarizes the names of the categories and the number of items representing each category on the total scale.

Phase One

Participants and Procedure. Following approval by the Departmental Review Committee for the protection of human subjects, a pilot version of the scale was administered to students who agreed to participate in a focus group. These participants helped the researchers clarify ambiguous items and develop a scale that accurately represented the students' experiences. Seventy-two students from one nursing school participated in the first phase of the study. All responses were voluntary and anonymous.

Table

TABLE 1Initial Categories for Cultural Awareness Scale

TABLE 1

Initial Categories for Cultural Awareness Scale

Table

TABLE 2Internal Consistency Reliability Estimates for Cultural Awareness Scale by Category (Phase One)

TABLE 2

Internal Consistency Reliability Estimates for Cultural Awareness Scale by Category (Phase One)

Student participants were undergraduate and graduate nursing students at The University of Texas at Austin. Twenty-six were bachelor of science in nursing students (BSN), 26 were in the master's of science in nursing program (MSN), 13 were pursuing a PhD in nursing, and 7 were in the RN-to-BSN program. Sixty-two participants were women, and 10 were men. The sample represented many ethnic groups and included 52 European American, 7 Asian American, 6 African American, 6 Hispanic American, and 1 American Indian students. Students were asked to voluntarily complete the survey at the end of a regularly scheduled class period.

Findings. The internal consistency estimate of reliability for the total scale was .91 for students and .82 for faculty. Cronbach's alpha coefficients for the five categories ranged from .66 (Awareness of Attitudes) to .88 (Clinical Practice and Research Issues) for the student version, and .56 (Classroom and Clinical Instruction) to .87 (General Educational Experiences) for faculty. Internal consistencies are listed in Table 2.

Phase Two

Participants and Procedure. After determining the scale's initial reliability, a second phase of study was conducted to provide evidence of scale validity. Ten nursing faculty representing a variety of institutions and ethnic and racial backgrounds and who had expertise in cultural competence were contacted to form an expert panel. Each faculty member was mailed a copy of the survey items with instructions to indicate how relevant each item was to the overall construct and what category labels should identify the grouped items, based on the literature review. Seven of the faculty members contacted returned usable data, from which a content validity index (CVI) of .88 was calculated, using the method described by Lynn (1986). Six women and 1 man comprised the expert panel. Four panel members self-identified as White, not of Hispanic origin, 2 self-identified as Asian or Pacific Islander, and 1 self-identified as African American.

After a slight rewording of a few items and the elimination of one, a second research proposal was reviewed by the Departmental Review Committee for the protection of human subjects. Following approval, the revised scale was administered to students recruited from various classes at The University of Texas at Austin. One hundred eighteen usable surveys were returned in this phase. The Phase One and Phase Two samples then were combined for all subsequent analyses.

The 190 students in the combined samples included 168 women and 18 men (4 students = missing data). Participants were 76% European American, 10% Hispanic American, 9% Asian American, 4% African American, and 1% American Indian. Three fourths of the participants were BSN students (including RN-to-BSN students), 17% were MSN students, and 8% were pursuing a PhD.

Findings. A factor analysis was conducted using principal components analysis with varimax rotation (n = 159). Five factors, reflecting the categories initially conceptualized in Phase One and validated by the expert panel hi Phase Two, emerged. These five factors accounted for 51% of the variance in scale scores, and this solution was consistent with the "bend" in the Scree plot. Table 3 shows the factor loadings for the five-factor solution. All items, except item 23, loaded above .30 on their respective factors. The first factor contains 14 items, pertaining to general educational experience related to cultural awareness and was labeled General Educational Experience. The second factor contains 7 items and addresses beliefs. It was labeled Cognitive Awareness. The third factor contains 4 items and was labeled Research Issues. The fourth factor contains 6 items that refer to individuals' behaviors toward and comfort with people from different cultural backgrounds. This factor was labeled Behaviors/Comfort with Interactions. The fifth factor contains 5 items related to and labeled Patient Care/Clinical Issues.

Although not all items loaded together as initially developed, the five factors that emerged are consistent with the initial conceptual development of the CAS. The subscales created from these factor loadings were used in subsequent analyses to support construct validity. Table 4 displays the average item means and standard deviations for the total scale and each subscale. Sample size varied across the subscales because individuals with missing data for an item were eliminated from calculation of that subscale. Cronbach's alpha coefficients were computed to assess internal consistency reliability for the total scale and each subscale. As shown in Table 4, the Cronbach's alpha for the total scale was .82. Cronbach's alpha coefficients for the subscales ranged from .7 1 (Behaviors/Comfort with Interactions) to .94 (Research Issues).

Table

TABLE 3Factor Loadings for Cultural Awareness Scale (n = 159)

TABLE 3

Factor Loadings for Cultural Awareness Scale (n = 159)

Table

TABLE 3Factor Loadings for Cultural Awareness Scale (n = 159)

TABLE 3

Factor Loadings for Cultural Awareness Scale (n = 159)

Table 5 shows the intercorrelations among the five subscales. Although some subscales, such as Cognitive Awareness and Patient Care/Clinical Issues, are related, the Behaviors/Comfort with Interactions subscale has low correlations with other subscales (some of which are negative). Note that 5 of the 6 items on the Behaviors/Comfort with Interactions subscale are worded negatively. Perhaps the tendency to answer differently to negatively, as opposed to positively, worded items contributes to this subscale's lack of relationship with other subscales.

Table

TABLE 4Average Items Scores and Cronbach's Alpha Reliabilities for thé Guttural Awareness Scale and Subscales

TABLE 4

Average Items Scores and Cronbach's Alpha Reliabilities for thé Guttural Awareness Scale and Subscales

Table

TABLE 5Intel-correlations Among Subscales of the Cultural Awareness Scale

TABLE 5

Intel-correlations Among Subscales of the Cultural Awareness Scale

To support construct validity, demographic differences on the total scale and subscales were computed. No significant gender differences were found. However, minority students (i.e., all African American, Hispanic American, American Indian, and Asian American students) provided significantly lower ratings on the General Educational Experience subscale (F = 5.79, p < .05, df = 1/177). Scores also were compared among students in the four semesters of the BSN program and among the three types of programs (i.e., BSN, MSN, PhD). The only statistically significant difference among students in various semesters of the BSN program was on Research Issues (F = 3.66, p < .05, df= 3/124). According to post-hoc analyses, there was a linear increase in ratings on this subscale from the first to the fourth semester, with a significant difference between the junior year and the senior year (i.e., when students take a research course)

There also was a statistically significant difference in Research Issues scores across nursing programs (F = 3.4, p < .05, df= 4/170). PhD students scored highest and BSN students lowest on this scale. In addition, a statistically significant difference was observed on the Patient Care/Clinical Issues subscale (F = 3.04, p < .05, df = 4/175). Traditional MSN students scored significantly lower than all other groups, although this finding should be interpreted with caution because only 7 students comprised the traditional MSN group.

One item on the questionnaire asked whether there was a time when participants felt uncomfortable working with a patient from a cultural background different than their own. The only statistically significant difference between students who indicated they were comfortable (n = 137) and those who were not (n = 43) was observed on the Behaviors/Comfort with Interactions subscale. Students who indicated they had been uncomfortable working with a patient from a cultural background different from their own provided significantly lower ratings on this subscale (F = 34.35, p < .001, df= 1/175).

DISCUSSION

Findings from this study should be interpreted with caution because of the relatively small number of participants from one geographic area. In addition, the sample is relatively small for factor analysis. Participants were from a single university, and therefore, findings are not generalizable to all nursing students. Further development of the instrument with larger, diverse populations of students is warranted. However, despite these limitations, evidence exists that the CAS provides valid and reliable scores for measuring the concept of cultural awareness in nursing students.

Data analyses from both study phases support the reliability of scores obtained from the CAS. Data analyzed in Phase Two support the multidimensional nature of cultural awareness. The first subscale (i.e., General Educational Experience) indicates the importance of faculty who can model behaviors that are sensitive to multicultural issues. In their positions as educators, faculty need to serve as culturally competent role models to encourage more individuals from ethnic minority groups to enter the nursing profession. One reason so few members of ethnic minority groups currently are nurses may be their perceptions of nursing faculty as racist (Vaughan, 1997). Data from tools, such as the CAS, may serve the dual purposes of helping faculty become more aware of their inadvertent insensitive behaviors that perpetuate the perception of racism and demonstrating to members of ethnic minority groups that the nursing educational system is striving to address issues related to cultural competence.

The highest ratings provided by participants were in the Patient Care/Clinical Issues subscale. Although it may be encouraging that nurses consider themselves culturally aware in treating patients, it would be wise to consider the possibility that unmeasured differences in cultural awareness may exist between nurses* perceptions and those of their patients. It would be valuable to measure patients' perceptions of their nurses' cultural awareness and compare them to the nurses' ratings.

It is important to note that the variance was highest and the average item score was lowest for the Research Issues subscale. In addition, there were more missing data for this subscale, all of which may reflect participants' lack of information on which to base their ratings. As analysis of this subscale by educational level indicates, there was a significant difference between BSN and PhD students, which most likely reflects differences in their exposure to research. Because the majority of participants were BSN students, this also could account for the lower average score on this subscale.

Overall, participants in this study had high mean scores on the five dimensions of cultural awareness, as measured by the CAS. These scores were obtained following completion of the 3-year Pathways program. Although no preprogram data exist with which to compare, it is possible that cultural awareness among nursing students in this school did increase with program exposure. Further study involving preprogram and postprogram measures using the CAS are warranted.

CONCLUSION

Clearly there is a need to develop culturally competent nurses in the United States. If the goal of nursing education is to educate a diverse population of nurses and to teach all nurses culturally competent practices, then monitoring progress toward these goals is necessary. The CAS provides a tangible method for documenting the first stage of nursing students' development of cultural competence. Based on findings from the initial two phases of development, the CAS should produce valid and reliable data for further study with larger, diverse samples.

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TABLE 1

Initial Categories for Cultural Awareness Scale

TABLE 2

Internal Consistency Reliability Estimates for Cultural Awareness Scale by Category (Phase One)

TABLE 3

Factor Loadings for Cultural Awareness Scale (n = 159)

TABLE 3

Factor Loadings for Cultural Awareness Scale (n = 159)

TABLE 4

Average Items Scores and Cronbach's Alpha Reliabilities for thé Guttural Awareness Scale and Subscales

TABLE 5

Intel-correlations Among Subscales of the Cultural Awareness Scale

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