Cultural competency is an important quality to address the multicultural, multilingual, and multiracial needs of the ever-increasing diverse population in the United States and serves as an effective strategy to reduce disparities in health and health care (Betancourt et al., 2003; Campinha-Bacote, 2002; Henderson et al., 2018; Repo et al., 2017). The literature agrees that cultural competency training for health care providers improves outcomes for patients from diverse and minority backgrounds (Healey et al., 2017; Majumdar et al., 2004). Although various studies have been conducted on the cultural competency skills of licensed health care professionals, few have addressed the impact of training during nursing school (Cai et al., 2017; Watt et al., 2016).
Service-learning (SL) is learning that actively involves students in a broad range of experiences that benefit the community while also advancing the goals of a given curriculum (McElfish et al., 2018). It is a widely used teaching modality that promotes cultural competency and advocacy for diverse and disadvantaged populations. However, despite the high prevalence of SL opportunities in nursing education, quantitative evidence to support the efficacy of SL for developing cultural competency is sparse (DeBonis, 2016).
Many SL opportunities in health care education occur in the setting of volunteer experiences that would potentially bias the assessment of cultural competency as the participants have chosen to work with diverse, often resource-poor populations. For this study, we are evaluating required experiential activities that take place in a variety of settings. In some of these experiential activities, students provide direct patient care (i.e., they use their medical knowledge and clinical training to directly assess patient's symptoms and overall health status). In other activities, students do not provide direct patient care but participate in patient education, supervision of children, or limited health screenings.
University of Central Florida (UCF) College of Nursing students participate in required SL and community outreach in many communities in Central Florida. These activities include required participation in multidisciplinary farmworkers clinics, free nonprofit clinics, federally qualified health centers (FQHCs), and the Boys & Girls Club, as well as voluntary participation in local health fairs and short-term international medical mission trips. The following SL activities involved direct patient care: multidisciplinary farmworkers clinics, FQHCs, and short-term international medical mission trips. The roles that students served in the free nonprofit clinics, Boys & Girls Clubs, and local health fairs did not involve direct patient care.
UCF is a diverse, public university with a large urban campus serving a significant number of low-income, Hispanic and Black students. Several studies have examined the role of race, ethnicity, and socioeconomic background on cultural competency and some suggest underrepresented minorities report higher levels of cultural competence (Deliz et al., 2020). Similarly, Spanish language has been shown to correlate with higher levels of cultural competence (Sherrill et al., 2016; VanTyle et al., 2011). A prior study demonstrated that voluntary SL participation promotes increased cultural competency in UCF medical students (Helm, 2018), but the value of nonvoluntary UCF College of Nursing SL programs has not been assessed.
The purpose of this study was to examine the role of innate sociodemographic, social, language factors as well as experiential (i.e., SL, required, and voluntary) in developing cultural competency. The primary objective of this study was to determine whether required SL opportunities are an effective way for nursing students to develop cultural competency. A secondary objective was to determine if any demographic, language, and social factors promote cultural competency. A third objective was to assess the contribution of voluntary experiences, including a short-term international medical mission trip, on cultural competency. We hypothesize that exposure to SL environments targeted to care of underserved, culturally diverse populations would improve cultural competency in both students who were required to participate, and those who did so voluntarily. We also hypothesized that students from marginalized backgrounds would demonstrate higher levels of cultural competency.
This is a survey research study of undergraduate nursing students from UCF conducted in March 2019. The survey was sent to 250 students enrolled at UCF College of Nursing Bachelor of Science in Nursing program, divided equally between third-and fourth-year students.
The inclusion criteria included being currently enrolled at UCF College of Nursing and ages 18 and older. Respondents were recruited via email LISTSERVs® and paid $5 for their participation. The researchers consulted with our institution's institutional review board who determined that this study was exempt.
A survey adapted from the previously validated Clinical Cultural Competency Questionnaire (CCCQ) was distributed to all students at UCF College of Nursing (N = 480) via an online Qualtrics® survey (Echeverri et al., 2010; Helm, 2018; Like et al., 2004). The CCCQ has been previously used to assess cultural competency in physicians, nurses, and pharmacy students (Echeverri et al., 2010). The CCCQ was developed by Dr. R.C. Like and Dr. M.C. Fulcomer of The Center for Healthy Families and Cultural Diversity at UMDNJ-Robert Wood Johnson Medical School. The CCCQ examines four domains associated with the delivery of culturally competent health care to diverse patient populations: (a) Knowledge, (b) Skills, (c) Comfort with Encounters/Situations, and (d) Attitudes. Participants indicate perceived level of knowledge, skill, comfort, and attitude by selecting from response options on a 5-point Likert scale (1 = not at all, 2 = a little, 3 = somewhat, 4 = quite a bit, and 5 = very).
We used an adapted version of the questionnaire to fit the goals of our study related to exploring the relationship between SL, language ability, and cultural competency (Helm, 2018). The four domains of Knowledge, Skills, Comfort with Encounters/Situations, and Attitudes are consistent with models for cultural competency (e.g., the multidimensional model of cultural competency) (Campinha-Bacote, 2002; Sue, 2001. Our research team developed this adapted CCCQ using an item and factor analysis approach used in prior validated research studies (Helm, 2018). Furthermore, additional questions were added about Spanish language proficiency. Self-reported Spanish proficiency was examined using a validated scale from a prior study of medical students (Reuland et al., 2009).
Students completed the survey in Qualtrics and their deidentified information was stored in our database. The quantitative data were analyzed using SPSS® (version 24.0). The total cultural competency score was calculated as a sum of knowledge, skills, attitudes, and comfort with clinical encounters and situations. The Mann-Whitney U test was used to explore the association between gender, year in school, ethnicity (Latino versus Non-Latino), and Spanish proficiency with the total cultural competency score. One-way analysis of variance (ANOVA) was used to explore the relationship between race, parents' country of origin, and socioeconomic status with total CCCQ score. Pearson's correlation was performed to look at correlations between the SL location and total CCCQ score.
One hundred sixty undergraduate nursing students completed the survey. Complete sociodemographic information of the sample is listed in Table 1. A Shapiro Wilk test was performed to test for normality of variables such as gender, race, ethnicity, socioeconomic status, parents' immigration status, and previous SL experience. Based on the results of the normality test, oneway ANOVA was performed for Spanish language proficiency, parents' immigration status, and race.
Sample Sociodemographic Information (N = 160)
Spanish proficiency was measured in three levels: (a) native speakers, (b) nonnative speakers, and (c) no proficiency. Spanish proficiency significantly predicted higher total cultural competency scores [F = 3.93 (2,157), p = .022]. However, post hoc analysis with Tukey's test showed a significant difference between nonnative Spanish Speakers and native-Spanish speakers (p = .017). A similar pattern was seen for parents' immigration status, where, overall, parents' immigration status did help predict significant levels of difference in total cultural competency score [F = 3.83 (2,157), p = .024]. However, post hoc analysis with Tukey's test showed a significant difference among people who had both parents born outside the United States compared with people whose parents were both born in the United States (p = .025). Race was not a significant predictor for CCCQ scores [F = 0.390 (3,123), p = .761].
For variables such as gender, school year, ethnicity, socioeconomic status, and previous SL experience, the distribution did not meet the normality assumption; therefore, a Mann-Whitney U test was performed. There was a significant difference in total cultural competency between men and women among the nursing students (U = 1814.5, p = .004). Women had higher total cultural competency scores (median = 122) compared with men (median = 109.50). Being a third-year student or a fourth-year student did not have any significant difference for total cultural competency score (U = 2937, p = .5). The total cultural competency score was also significantly different for Latinos versus non-Latinos (U = 1491, p = .045). Latinos had higher total competency scores (median = 122.00) compared with non-Latinos (median = 117.00). The total cultural competency score was also significantly higher among students who identified as low socioeconomic status (median = 126.00) versus students who did not (median = 115.50) identify as low socioeconomic status (U = 2117, p = .026). Previous SL experiences did not affect the total cultural competency score (U = 3106.5, p = .755).
Because all the locations where the students participated in SL activities were different, further analysis of the correlation between the type of location and corresponding CCCQ scores was performed. Results showed that participation in two of the required experiences, multidisciplinary farmworkers clinic (r = .374, p = .013) and FQHC (r = .387, p = .032), as well as the voluntary short-term international medical mission trip (r = .433, p = .021), were significantly positively correlated with increasing cultural competency scores. Participation in free nonprofit clinics, Boys & Girls Clubs, the required Caribbean health fair, and voluntary local health fairs were not significantly correlated with increasing CCCQ scores (p > .05).
Impact of Experiential Factors
This study found that students who participated in SL opportunities where they provided direct care for minority and disadvantaged communities reported higher levels of cultural competency (i.e., FQHCs, multidisciplinary farmworkers clinics, and short-term international medical mission trips), whereas activities involving primarily patient education or nonclinical settings did not promote higher cultural competency.
For example, nursing students assigned to the FQHCs functioned as medical assistants, triaging patients before physician appointments. Similarly, students who participated in the multidisciplinary farmworkers clinic assisted with the provision of care. In both activities, students provide direct patient care in a nursing role, and participation positively correlated with significantly higher cultural competency scores.
Although some activities serving predominately low-income patient populations such as the FHQC and farmworkers clinic had a significant impact on cultural competency, others did not, which led us to examine more closely what roles the students performed in each activity. Specifically, participation in free nonprofit clinics, Boys & Girls Clubs, and local health fairs was not significantly correlated with increasing cultural competency scores (p > .05). At the free nonprofit clinic, students did not provide direct patient care, but provided patient education in the lobby. Students working at the Boys & Girls Club created and taught educational lessons at after-school and summer programs for children. The students participating in local health fairs provided patient education and general health screenings. Local health fairs were usually 1-day commitments or over the span of a weekend, which may not have allowed the students adequate time to develop connections with individual patients that may help to develop their cultural competence. Students in these programs lacked direct patient care experiences and did not show improved cultural competency. These findings may suggest that direct patient care experiences promote the development of cultural competency, whereas providing patient education or volunteering in after-school programs may not.
In the multidisciplinary farmworkers clinic, third- and fourth-year nursing students visit the farms, make acquaintances with the managers and farmworkers, and ultimately provide direct care to patients in their place of work. Students who volunteered in the short-term international medical mission trip provided direct patient care for underserved patients of rural regions of Peru, in an immersive environment in an agricultural community, living in the rural clinic for a week. Both voluntary, service-oriented activities involved onsite immersion, Spanish-language skills, and direct patient care opportunities. These aspects combined likely contribute to the higher cultural competence found in the students who participated in these activities. Taken together, these findings indicate that health care professional programs may benefit from identifying diverse opportunities for SL that provide more direct patient care opportunities to develop cultural competence. This is consistent with prior literature that suggests that nursing education should provide continuous opportunities for students to interact with different cultures and develop linguistic skills (Repo et al., 2017).
Impact of Sociodemographic Factors and Spanish Language Proficiency
The study also confirmed that several sociodemographic characteristics are associated with increased levels of cultural competency. Students from minority backgrounds (i.e., Spanish speakers, Latinos, students from low-socioeconomic backgrounds) reported higher levels of cultural competency compared with students who did not come from those backgrounds, providing additional support of the merits of a diverse health professional workforce and student body. This study did not directly examine whether peer mentors raised the bar of cultural competency, but the possibility that peer mentors may model cultural competency could add to the body of literature supporting the recruitment of a diverse student body (Effland et al., 2020; Etowa et al., 2005; Noone, 2008).
Race itself was not a significant predictor of increased cultural competency scores, perhaps due to our limited sample size or due to incongruence between the racial background of participants and the populations served. Female nursing students had significantly higher cultural competency scores than their male counterparts (p = .004). There is little research on male versus female cultural competency scores. A study by Zhang and Liu (2016) concluded men face stigma when serving in a “caring” nursing role and that they are less likely to connect with patients using touch, which may affect their cultural competency. Increasing the sample of male nursing students and exploring the mechanisms underlying women's higher cultural competency scores is a recommendation for future research.
Limitations, Strengths, and Future Directions
The results of this study should be interpreted with caution based on several limitations. First, this study used a self-report measure to assess cultural competency, which is vulnerable to potential reporting bias. Additionally, this study used a moderate sample size consisting of nursing students from a single university (and therefore one location) which limits its scope. To confirm and generalize these preliminary findings, future research with a broader scope should consider using observational measures, random assignment of learning clinics, and multisite evaluation. Future directions include expanding to other universities and comparing the influence of required versus voluntary SL participation on cultural competency in the same country and conducting qualitative research (e.g., focus groups for nursing students).
Participation of nursing students in SL opportunities involving care for minority and disadvantaged communities—whether required or voluntary—was correlated with higher cultural competency scores, as long as the experiences involved direct patient care responsibilities. This suggests that strategic identification of SL opportunities involving direct patient care will promote the development of cultural competence in nursing students.
- Betancourt, J. R., Green, A. R., Carrillo, J. E. & Ananeh-Firempong, O. II. . (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118(4), 293–302 doi:10.1016/S0033-3549(04 [CrossRef] PMID:12815076
- Cai, D., Kunaviktikul, W., Klunklin, A., Sripusanapan, A. & Avant, P. K. (2017). Developing a cultural competence inventory for nurses in China. International Nursing Review, 64(2), 205–214 doi:10.1111/inr.12350 [CrossRef] PMID:28102571
- Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), 181–184 doi:10.1177/10459602013003003 [CrossRef] PMID:12113146
- DeBonis, R. (2016). Effects of service-learning on graduate nursing students: Care and advocacy for the impoverished. Journal of Nursing Education, 55(1), 36–40 doi:10.3928/01484834-20151214-09 [CrossRef] PMID:26812381
- Deliz, J. R., Fears, F. F., Jones, K. E., Tobat, J., Char, D. & Ross, W. R. (2020). Cultural competency interventions during medical school: A scoping review and narrative synthesis. Journal of General Internal Medicine, 35(2), 568–577 doi:10.1007/s11606-019-05417-5 [CrossRef] PMID:31705475
- Echeverri, M., Brookover, C. & Kennedy, K. (2010). Nine constructs of cultural competence for curriculum development. American Journal of Pharmaceutical Education, 74(10), 181 doi:10.5688/aj7410181 [CrossRef] PMID:21436922
- Effland, K. J., Hays, K., Ortiz, F. M. & Blanco, B. A. (2020). Incorporating an equity agenda into health professions education and training to build a more representative workforce. Journal of Midwifery & Women's Health, 65(1), 149–159 doi:10.1111/jmwh.13070 [CrossRef] PMID:31957220
- Etowa, J. B., Foster, S., Vukic, A. R., Wittstock, L. & Youden, S. (2005). Recruitment and retention of minority students: Diversity in nursing education. International Journal of Nursing Education Scholarship, 2(1), 13 doi:10.2202/1548-923X.1111 [CrossRef] PMID:16646907
- Healey, P., Stager, M. L., Woodmass, K., Dettlaff, A. J., Vergara, A., Janke, R. & Wells, S. J. (2017). Cultural adaptations to augment health and mental health services: A systematic review. BMC Health Services Research, 17(1), 8 doi:10.1186/s12913-016-1953-x [CrossRef] PMID:28056967
- Helm, Z. (2018). How different service learning opportunities effect cultural competency and group dynamics: A comparison of nursing and medical students using a validated survey. Class of 2021: Final Research Proposals.
- Henderson, S., Horne, M., Hills, R. & Kendall, E. (2018). Cultural competence in healthcare in the community: A concept analysis. Health & Social Care in the Community, 26(4), 590–603 doi:10.1111/hsc.12556 [CrossRef] PMID:29516554
- Like, R. C., Fulcomer, M. C., Kairys, J., Wathington, K. D. & Crosson, J. (2004). Assessing the impact of cultural competency training using participatory quality improvement methods. Aetna Foundation.
- Majumdar, B., Browne, G., Roberts, J. & Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal of Nursing Scholarship, 36(2), 161–166 doi:10.1111/j.1547-5069.2004.04029.x [CrossRef] PMID:15227764
- McElfish, P. A., Moore, R., Buron, B., Hudson, J., Long, C. R., Purvis, R. S., Schulz, T. K., Rowland, B. & Warmack, T. S. (2018). Integrating interprofessional education and cultural competency training to address health disparities. Teaching and Learning in Medicine, 30(2), 213–222 doi:10.1080/10401334.2017.1365717 [CrossRef] PMID:29190158
- Noone, J. (2008). The diversity imperative: Strategies to address a diverse nursing workforce. Nursing Forum, 43(3), 133–143 doi:10.1111/j.1744-6198.2008.00105.x [CrossRef] PMID:18715346
- Repo, H., Vahlberg, T., Salminen, L., Papadopoulos, I. & Leino-Kilpi, H. (2017). The cultural competence of graduating nursing students. Journal of Transcultural Nursing, 28(1), 98–107 doi:10.1177/1043659616632046 [CrossRef] PMID:26873438
- Reuland, D. S., Frasier, P. Y., Olson, M. D., Slatt, L. M., Aleman, M. A. & Fernandez, A. (2009). Accuracy of self-assessed Spanish fluency in medical students. Teaching and Learning in Medicine, 21(4), 305–309 doi:10.1080/10401330903228489 [CrossRef] PMID:20183357
- Sherrill, W. W., Mayo, R. M., Truong, K. D., Pribonic, A. P. & Schalkoff, C. A. (2016). Assessing medical student cultural competence: What really matters. International Journal of Medical Education, 7, 248–254 doi:10.5116/ijme.578b.687c [CrossRef] PMID:27474895
- Sue, D. W. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), 790–821 doi:10.1177/0011000001296002 [CrossRef]
- VanTyle, W. K., Kennedy, G., Vance, M. A. & Hancock, B. (2011). A Spanish language and culture initiative for a doctor of pharmacy curriculum. American Journal of Pharmaceutical Education, 75(1), 4 doi:10.5688/ajpe7514 [CrossRef] PMID:21451756
- Watt, K., Abbott, P. & Reath, J. (2016). Developing cultural competence in general practitioners: An integrative review of the literature. BMC Family Practice, 17(1), 158 doi:10.1186/s12875-016-0560-6 [CrossRef] PMID:27846805
- Zhang, W. & Liu, Y.-L. (2016). Demonstration of caring by males in clinical practice: A literature review. International Journal of Nursing Sciences, 3(3), 323–327 doi:10.1016/j.ijnss.2016.07.006 [CrossRef]
Sample Sociodemographic Information (N = 160)
| Male||46 (29.1)|
| Female||112 (70.9)|
| Third||73 (45.6)|
| Fourth||87 (54.4)|
| African American/Black||19 (11.9)|
| American Indian/Alaskan Native||9 (5.6)|
| Asian||15 (9.4)|
| Latino/Hispanic||30 (18.8)|
| Native Hawaiian/Other Pacific Islanderb||1 (0.6)|
| White||84 (52.5)|
|Parent's immigration status|
| Both parents born in the United States||100 (62.5)|
| One parent born outside the United States||26 (16.2)|
| Both parents born outside the United States||34 (21.2)|
|Bilingual (or multilingual)|
| No||88 (55)|
| Yes||72 (45)|
| No proficiency||34 (21.3)|
| Nonnative Spanish Speaker||101 (63.1)|
| Native Spanish Speaker||25 (15.6)|
|Low socioeconomic status|
| No||111 (69.4)|
| Yes||49 (30.6)|