Nurse Education Today 88 (2020) 104385

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Effects of a cultural competence education programme on clinical nurses: A T

randomised controlled trial
⁎
Mei-Hsiang Lina, Hsiu-Chin Hsub,
a
School of Nursing, National Taipei University of Nursing and Health Sciences, Taiwan, R.O.C.
b
Graduate Institute of Gerontology and Health Care Management, Chang Gung University of Science and Technology, Taiwan, R.O.C.

A R T I C LE I N FO A B S T R A C T

Keywords: Background: The cultural competence education programme for health professionals aimed to ensure that all
Cultural competence people receive effective health care, particularly those from culturally diverse backgrounds.
Nurses Objectives: The purpose of this study was to investigate the effect of a cultural competence educational course on
In-service education nurses' self-assessment of their cultural competence.
Cultural diversity
Design: A single-blind, randomised control trial design was employed.
Participants and settings: Eligible nurses were recruited from a northern Taiwan medical centre with 2089 beds.
Methods: A permuted block of four was used to randomly assign participants to the experimental (n = 47) and
control groups (n = 50). The educational course comprised four units and was conducted once weekly for four
weeks, with each session lasting 3 h.
Results: A significant group-time interaction was identified regarding self-learning cultural ability, verifying the
education intervention's effect on self-learning cultural ability after a two-month intervention. In addition, a
significant main effect over time was discovered for total cultural competence; there was no significant inter-
action effect.
Conclusions: The study provided evidence that an educational programme effectively improved cultural com-
petence in clinical nurses. The results provide a reference for health care providers to design in-service cultural
competence education for improving quality of care.

1. Introduction Time devoted to cultural competence education varies from 1 h to

one year. Debiasi and Selleck (2017) designed a one-hour self-running
Enhancing healthcare professionals' cultural competence has been PowerPoint presentation that served as a cultural competence educa-
shown to diminish gaps in health care caused by cultural diversity. tion module for nurse practitioners, and distributed the presentation to
Therefore, cultivating cultural competence in health care providers has participants through email. Module content included problem reflec-
become crucial worldwide (Allen et al., 2013). Arbour et al. (2015) tions and case studies. The results showed increased cultural compe-
asserted that the optimal goal of cultural competence education is to tence among the nurse practitioners who participated. Chapman et al.
enhance the abilities of the nursing care provider to respect and satisfy (2014) organised a six-hour seminar for Australian emergency unit care
patients' various needs. Since adequate nursing student preparation can personnel that involved face-to-face teaching and self-reflection to
guarantee future capable nursing practices, education programmes that provide attendees with comprehensive knowledge of indigenous cul-
train nursing students to provide culturally appropriate care can have a tures and ideologies. The results suggested that the education course
positive impact on clinical care (Cruz et al., 2018). Shih et al. (2019) changed the participants' cultural awareness but did not alter their
adapted a cultural competence curriculum for twenty students that cultural attitude toward indigenous peoples. Several researchers have
included lectures and field practices to highlight the differences be- reported that cultural competence is learned over time (Gower et al.,
tween local cultures and medical systems in Taiwan and Australia. The 2019; Liu et al., 2018). Liu et al. (2018) designed a one-day workshop
results showed that participants found similarities between different to assess the short- and long-term impact on the cultural skills of un-
cultures and used diverse concepts to care for patients. dergraduate nursing students in China. Data were collected before the

⁎
Corresponding author at: Graduate Institute of Gerontology and Health Care Management, Chang Gung University of Science and Technology. Department of
Internal Medicine, Chang Gung Memorial Hospital., No. 261, Wen-Hwa 1st Rd. Kwei-Shan, Tao-Yuan, Taiwan.
E-mail address: [email protected] (H.-C. Hsu).

https://doi.org/10.1016/j.nedt.2020.104385
Received 26 September 2019; Received in revised form 18 December 2019; Accepted 27 February 2020
0260-6917/ © 2020 Elsevier Ltd. All rights reserved.

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
M.-H. Lin and H.-C. Hsu Nurse Education Today 88 (2020) 104385

intervention, immediately after the intervention, and at one-month and or living abroad.
three-month follow-ups. The results showed that participants' overall
cultural ability scores, cultural awareness, cultural knowledge, cultural 2.2.2. Nursing Cultural Competence Scale (NCCS)
understanding, and cultural skills were significantly improved. The NCCS was developed by Lin et al. (2016) for assessing the
Social cognitive theory—including observational learning, social cultural competence of clinical nurses and consists of 19 items in five
support, proactive thinking, and opportunity provision concepts dimensions: cultural awareness ability, cultural action ability, cultural
(McAlister et al., 2008)—emphasises that self-efficacy and outcome resource application ability, and self-learning cultural ability. The
expectations affect personal behaviour (Tsai and Cheng, 2010). Pro- overall Cronbach's alpha was 0.88, with subscale values ranging from
viding culturally competent health care can enhance the health condi- 0.82 to 0.86, showing acceptable internal consistency. The scale-level
tions of patients with various ethnicities and cultural backgrounds who content validity index was 0.91. Each item was scored on a 5-point
have differing care needs. Nursing educators have adopted multiple Likert scale from 0 (rarely) to 4 (always), with higher scores indicating
strategies to improve students' cultural skills, including lectures, guest higher degrees of cultural competence.
speakers, and case discussions after watching culturally relevant client
videos (Chang et al., 2019; Long, 2012). 2.2.3. Cultural competence intervention course
Cultural competence has been identified as an essential course ele- Cultural competence is developed through cultural interactions in
ment for undergraduate and graduate nursing courses in Taiwan various situations; hence, intervention programmes should employ di-
(Chang et al., 2019), and nursing educators are beginning to integrate verse strategies (Garneau and Pepin, 2015). The present study referred
cultural competence into Taiwanese nursing courses (Lin et al., 2015). to the cultural competence course developed by Campinha-Bacote
Chang et al. (2019) found that newly graduated nurses could recall (2002) for content and structural design. To develop the cultural
cultural competence knowledge learned at school, and mentors could competence course employed in this study, three related education
adopt education strategies to improve their cultural abilities. The aim of experts were invited to provide feedback regarding cultural topics and
the present study was to investigate the effectiveness of a cultural modify the course according to participant feedback.
competence education programme on the cultural competence of clin- The education-based intervention plan comprised four units lasting
ical nurses. The authors hypothesised that cultural competence would 3 h each and was administered on a weekly basis. The total intervention
be higher in participants who received the cultural competence edu- time was 12 h. Unit 1 introduced information on the cultural compe-
cation programme than in participants who did not undergo the in- tence of clinical nurses and issues related to cultural diversity, then
tervention. explained the cultural competence education intervention programme's
procedures. In Unit 2, invited experts experienced in interacting with
2. Methods new immigrant families from diverse cultural backgrounds used foreign
picture books to increase participants' empathy toward new immigrants
2.1. Design and participants through storytelling. Participants were expected to be aware of non-
verbal messages conveyed directly and indirectly with regard to cul-
This study adopted a single-blind, randomised controlled trial de- tural and linguistic differences. Unit 3 involved watching a movie on
sign. G Power3.1 software was employed to estimate the sample size. the racial war between two countries to encourage participants to re-
Repeated-measures between-factors analysis of variance was used to flect on their ideas about culture. By highlighting the importance of
perform two sets of statistical tests with α = 0.05 and power = 0.8. historical and cultural backgrounds, this unit prompted participants to
The medium Cohen's effect size was set to 0.25. Because the time in- examine their prejudices and stereotypes regarding other cultures.
teraction was 50%, participant autocorrelation was set at 0.5. Data Participants were encouraged to understand the process of prejudice
were collected from the experimental and control groups at the be- and stereotype formation through self-reflection, critiquing, and in-
ginning of the study (T0); post-tests were administered immediately novation, thereby establishing a positive attitude and a prompt to
after completing the education programme (T1); and follow-up tests consistently review their thoughts and behaviours when encountering
were administered two months post-intervention (T2). different cultures. In Unit 4, the authors used structured role play ac-
The optimal sample size was estimated to be 82 participants; we set tivities to enable the participants to experience inequality in designed
the final sample size at 100 to adjust for a potential 20% attrition rate. scenarios, which triggered reflections on how prejudices and privileges
The inclusion criteria were (1) licensed nurse who had received formal influence people's lives. The unit also addressed ways to establish an
nursing education and (2) clinical nurses who had been in their job for empathetic and trustful relationship with people of different ethnicities
at least one year. The target population included 1228 registered nurses and realise the importance of respecting cultural diversity. All courses
working in northern Taiwan medical centres. All registered nurses were were instructed by two lecturers currently working toward a Ph.D. in
invited to participate in the study and the first 100 who indicated in- nursing who were trained in cultivating multicultural competence.
terest were recruited to participate. A permuted block of four was
employed to assign random serial numbers to participants, which were 2.3. Data collection
then used to divide the participants evenly into the experimental and
control groups. The random serial numbers were generated by a re- The study was conducted from August 2017 to July 2018.
search assistant using a random allocation software package. The re- Participants were recruited after the researchers obtained approval
search assistant placed each serial number into a non-transparent en- from the institutional review board of their affiliated institution.
velope. Participants who agreed enrol in the study opened their own Participants who consented to participate in this study provided written
envelope to learn whether they were in the experimental or control informed consent. Only the experimental group attended the inter-
group. The research assistant only assisted in recruiting participants vention courses. Both groups completed a pre-test before the inter-
and was not involved in data collection and analysis. vention to collect baseline data (T0). The experimental group received
12 h of cultural competence intervention over four consecutive weeks.
2.2. Measures A post-test was completed by both groups immediately after interven-
tion completion (T1) to evaluate the intervention's immediate effect.
2.2.1. Demographic data Subsequently, a follow-up test was conducted two months after the
Collected characteristics included age, marital status, educational intervention (T2) to assess the delayed effect. Participants can be af-
attainment, nursing seniority, department, experience caring for for- fected by researchers' behavioural manifestations while completing a
eigners, experience attending cultural courses, and experience studying questionnaire, responding in ways that support an intervention's

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
M.-H. Lin and H.-C. Hsu Nurse Education Today 88 (2020) 104385

effectiveness, and leading to an experimenter effect that threatens the the control group in cultural action ability before the intervention (2.72
internal validity of the study. Therefore, a single research assistant was vs. 2.87, respectively); however, two months after the intervention, the
responsible for all three instances of data collection to decrease the experimental group scored higher than the control group (2.92 vs. 2.81,
potential research bias from an experimenter effect. respectively; Table 2).

2.4. Data analysis 3.3. Cultural competence education programme effectiveness

Data were analysed using IBM SPSS Statistics for Windows version No interaction was found between group and time for total cultural
20.0 (IBM Inc., New York, USA). Descriptive statistical analysis was competence. The “experimental group × T1” (Wald χ2 = 0.55,
used to analyse participants' demographic data. Independent-sample t- p > .05) and the “experimental group × T2” (Wald χ2 = 1.98,
tests and chi-square tests were used to identify between-group demo- p > .05) indicated that pre-test/post-test change in total cultural
graphic. A generalised estimating equation was used to determine the competence was not significantly different between the two groups.
intervention effect. In two-tailed tests, the statistical significance level Further examination of the main effect revealed that time was sig-
was set at p < .05. nificant (B = 0.10, Wald χ2 = 4.31, p = .04). Overall, the average
score at T2 was 0.10 higher than that at T0 (Table 3). In terms of self-
2.5. Ethical considerations learning cultural ability, a significant interaction with time was ob-
served at T2 (B = 0.51, Wald χ2 = 5.97, p = .015). Thus, the ex-
The study obtained approval from the institutional review board of perimental and control groups exhibited significantly different over-
a medical centre in northern Taiwan (approval No. 17MMHIS096e). time variation in self-learning cultural ability. Overall, the average
The researchers clearly explained the research objectives and research score of the experimental group was 0.51 higher than that of the control
process to potential participants who were assured that data would be group (Table 3).
collected on an anonymous basis, with each participant given a code
number to safeguard their identity, and that all information obtained 4. Discussion
from the questionnaire would be kept safe and used only for academic
research purposes. The researchers also explained that no dangerous or In the present study, a four-week intervention covering four cultural
concomitant complications would be caused by the research and that competency units was implemented. There was no significant difference
the participants were free to leave the study at any time during the between the two groups with regard to overall cultural competence;
research period without penalty. however, the experimental group's scores did increase slightly. This is
similar to the results of a quasi-experiment conducted by Moleiro et al.
3. Results (2011), who held three education sessions (2.5 h each) on cultural di-
versity and discovered no significant improvement but only a small
A total of 100 participants were recruited and randomly assigned to constant education effect. The results of the present study exhibited an
the experimental (n = 50) and control (n = 50) groups. Three parti- over-time main effect regarding total cultural competence, with the
cipants withdrew during the research period; two participants left after experimental group's average T2 score 0.104 higher than their T0 score.
the intervention (after T1) to give birth, and another participant left This finding is consistent with that obtained by Thom et al. (2006), who
two months after the intervention (at T2) because she had quit her job reported that measured behavioural change was strengthened by in-
for personal reasons (Fig. 1). creasing education time and frequency.
Additionally, the present study found that the experimental group's
3.1. Demographic characteristics average score for self-learning cultural ability at T1 was 2.59 ± 0.86
higher than that of the control group, and that its T2 score was also
Participants' average age was 36.49 ± 10.14 years, and partici- higher than that of the control group, suggesting a time-group inter-
pants in the experimental group (35.98 ± 9.99 years) were younger on action. This result was consistent with that of an in-depth qualitative
average than the control group. Overall, average nursing seniority was interview study on clinical nurses' cultural competence and experience
14.78 ± 10.31 years, and for the experimental group was conducted by Lin et al. (2019), who noted that when discerning dif-
14.40 ± 10.17 years. The majority of all participants were unmarried ferences in values between themselves and patients, nurses often be-
(60%), and 66% of the experimental group were unmarried. The came aware that their competence regarding foreign cultures was de-
highest educational attainment for most participants was a bachelor's ficient and would use various channels to increase the professionalism
degree (68%); 37% of participants worked in internal medicine. No of their culture-related care. In addition, Campinha-Bacote (2009)
significant differences in demographic variables were observed be- specified that health care providers' cultural competence is the result of
tween the groups, except for department (p = .006) (Table 1). consistent cultivation and education in multiple aspects; medical care
providers exhibit cultural competence by continually seeking to provide
3.2. Between-group score distributions effective and high quality medical care services while considering pa-
tients' cultural backgrounds. In the present study, there were significant
The results showed that there were no significant between-group between-group pre-test/post-test differences in self-learning cultural
differences in the pre-test scores for total cultural competence abilities. A possible explanation is that the experimental group had
(t = −0.19, p = .84), cultural awareness ability (t = 0.32, p = .74), more exposure to caring for culturally diverse patients between T1 and
cultural action ability (t = −0.99, p = .32), cultural resources appli- T2. Further research should assess the potential time bias in the as-
cation ability (t = −0.95, p = .34), and self-learning cultural ability sessment of the transition process.
(t = 0.85, and p = .39). Thus, the two groups initially exhibited similar We found that the experimental group's average scores on cultural
cultural competence (Table 2). awareness ability and cultural resources application ability were higher
At T0, the experimental group scored lower on total cultural com- at T1 than at T0; however, the scores dropped for both groups at T2.
petence (average score: 3.09) than the control group (average score: Delgado et al. (2013) implemented a one-hour cultural education in-
3.11); however, they scored higher (3.17 at T1 and 3.23 at T2) than the tervention with a group of clinical staff and conducted a post-test six
control group (3.04 at T1 and 3.17 at T2) after the intervention. Both months later, obtaining results similar to the present study findings.
the control and experimental groups' scores fluctuated throughout the Delgado et al. indicated that the participants exhibited enhanced cul-
research period (Table 2). The experimental group scored lower than tural awareness immediately after the cultural competence

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
M.-H. Lin and H.-C. Hsu Nurse Education Today 88 (2020) 104385

Participant enrollment (N=100)

Enrollment

Allocation Randomized (N =100)

T0: baseline Experimental group (N =50) Control group (N= 50)

data

Cultural competence No intervention

intervention course course

T1: 12wks Post-test (N= 50)

Miss evaluation
follow- up Post-test (N= 48)
(To give birth) (N= 2)

T2: 2M Follow- up Miss evaluation

follow- up (Quit job) (N= 1) Follow- up (N= 50)
(N= 47)

Fig. 1. Flow diagram of this study.

intervention; however, this change diminished over time when no after completing the educational programme. Nevertheless, cultural
follow-up measures were employed. This is consistent with our findings resource accessibility is only weakly emphasised in clinical care. A re-
that the experimental group's scores for cultural awareness ability and lative deficiency in cultural knowledge may have caused the partici-
cultural resources application ability both dropped at T2. A possible pants to highlight the technical aspects of their nursing skills when
explanation is that participants completed the T1 testing immediately taking care of patients. Without follow-up reinforcement strategies, the

Table 1
Sociodemographic characteristics of participants and comparisons between the two groups.
Variables Total (n = 100) Experimental group (n = 50) Control group (n = 50) Homogenous testa

n % n % n % χ2 p

Marital status Married 40 40.0 17 34.0 23 46.0 1.50 .22

Unmarried 60 60.0 33 66.0 27 54.0
Educational attainment Diploma 28.0 28.0 12 24.0 16 32.0 4.57 .102
Bachelor's degree 68.0 68.0 34 68.0 34 68.0
Master's degree 4.0 4.0 4 8.0 0 0
Department Internal medicine 37 37.0 22 44.0 15 30.0 16.22 .006
Surgery 9 9.0 9 18.0 0 0
Obstetrics & gynecology 15 15.0 5 10.0 10 20.0
Pediatric 10 10.0 5 10.0 5 10.0
Intensive care unit 14 14.0 4 8.0 10 20.0
Other 15 15.0 5 10.0 10 20.0
Experience in caring for foreigners No 7 7.0 3 6.0 4 8.0 0.154 .69
Yes 93 93.0 47 94.0 46 92.0
Experience of attending cultural courses No 95 95.0 48 96.0 47 94.0 0.21 .64
Yes 5 5.0 2 4.0 3 6.0
Experience of studying or living abroad No 95 95.0 46 92.0 49 98.0 1.89 .16
Yes 5 5.0 4 8.0 1 2.0

Mean SD Mean SD Mean SD t p

Age 36.49 10.14 35.98 9.99 37.00 10.37 −0.501 .618

Nursing seniority (year) 14.78 10.31 14.40 10.17 15.16 10.54 −0.36 .716
a
Baseline (T0) data conduct homogenous test.

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
M.-H. Lin and H.-C. Hsu Nurse Education Today 88 (2020) 104385

Table 2
Distribution of the scores obtained from the three tests on NCCS total and subscale scores.
Components Time Experimental group Control group Time The within group difference ta
(P)
Experimental group Control group

M SD M SD MD. GEE(p) MD. GEE(p)

Total scoreb T0 3.09 0.41 3.11 0.46 T1-T0 0.01 0.89 −0.01 0.92 −0.19
T1 3.17 0.40 3.04 0.49 T2-T0 −0.03 0.72 0.01 0.87 (.84)
T2 3.23 0.43 3.17 0.45 T2-T1 −0.04 0.57 0.02 0.77
Cultural awareness ability T0 3.77 0.75 3.72 0.83 T1-T0 0.04 0.57 −0.02 0.77 0.32
T1 3.91 0.70 3.59 0.78 T2-T0 0.03 0.72 −0.01 0.87 (.74)
T2 3.72 0.90 3.80 0.81 T2-T1 −0.01 0.89 0.01 0.92
Cultural action ability T0 2.72 0.76 2.87 0.70 T1-T0 −0.01 0.89 −0.08 0.55 −0.99
T1 2.70 0.79 2.78 0.80 T2-T0 −0.02 0.86 −0.09 0.44 (.32)
T2 2.92 0.77 2.81 0.79 T2-T1 −0.001 0.98 −0.01 0.94
Cultural resources application ability T0 3.36 0.81 3.52 0.87 T1-T0 0.14 0.28 −0.28 0.04 −0.95
T1 3.50 0.88 3.24 1.03 T2-T0 −0.11 0.32 0.03 0.75 (.34)
T2 3.46 0.98 3.46 0.93 T2-T1 −0.25 0.08 0.31 0.02
Self-learning cultural ability T0 2.52 1.00 2.33 1.17 T1-T0 0.07 0.66 0.22 0.24 0.85
T1 2.59 0.86 2.56 1.06 T2-T0 0.007 0.95 0.27 0.14 (.39)
T2 2.82 0.97 2.62 1.02 T2-T1 −0.06 0.62 0.04 0.75

Note: T0: baseline; T1: post test; T2: follow up test; NCCS: Nursing Cultural Competence Scale; M: mean; SD: standards derivation; GEE: the generalised estimating
equation; MD: mean difference; p: p value.
a
Baseline (T0) data conduct homogenous test between the two groups.
b
Total cultural competence.

participants were unable to appropriately address topics related to di- use alternative treatments to maintain their health or treat health
verse cultures in a clinical scenario. problems. The intervention in the present study comprised four units:
The cultural awareness ability and cultural resources application Unit 2 covered communication and awareness of the diverse cultures of
ability scores were also both lower at T2 than at T1 in the experimental new immigrants; Unit 3 analysed racial prejudices and stereotypes
group, which is consistent with Delgado et al. (2013), who maintained using a movie; and Unit 4 emphasised the importance of respecting
that cultural competence education should be a continuous process cultural diversity. In education content designed for future research,
involving continual strengthening of cultural education. We also found culturally specific content can be strengthened to include the perspec-
that the implemented cultural competence intervention did not exert tives of different patients regarding health beliefs and treatment ap-
significant effects on cultural action ability and cultural resources ap- proaches, assisting participants' learning. Second, in terms of teaching
plication ability, which are similar to results obtained by Thom et al. strategies, Campinha-Bacote (2002), and Haugan et al. (2012) reported
(2006), who implemented a cultural competence education course for that reflection is the most critical part of activity design. Haugan et al.
53 physicians but discovered no significant effect. Thom et al. claimed (2012) maintained that cultural competence education must focus on
that if physicians' clinical cultural competence is to be maintained, reflection and feedback. During the process of reflecting, participants
diverse intervention and education courses should be incorporated into must integrate theoretical issues into their clinical practice in addition
cultural competence education, and should provide sufficient practice to incorporating relevant theories and feedback. In the teaching stra-
time along with a combination of education content and real-world tegies used in the present study, only Unit 3 included self-reflection.
interactions in a medical environment. Hence, subsequent research should strengthen the use of reflection.
The assessment tool may play an important role in measuring the Behavioural changes can occur in control groups despite that they
effectiveness of the intervention. In the present study, a self-report in- do not participate in the intervention. Smedley et al. (2003) asserted
ventory was employed to assess changes in the participants' cultural that cross-cultural education should be part of early continuing edu-
competence, which may have indirectly affected the results. Doorenbos cation for health care service providers, and that real cases must be
et al. (2005) noted that assessing health care providers' cultural com- used to provide practical and strictly assessed education. The average
petence must focus on inventory selection, research participants, and years of service of all participants in this study was
the intervals between multiple tests. These factors are crucial to re- 14.78 ± 10.31 years, and the control group had more years of service
search inferences but are challenges that still need to be solved. In than the experimental group. Cultural-competence-related in-service
addition to obtaining quantitative data, future studies should include education during their years of service may have affected the partici-
observational records of teaching activities to understand participants' pants' cultural competence in the present study. The control group
learning experiences as well as their reactions to interventions. scored higher than the experimental group in cultural action ability at
The lack of a significant intervention effect in the present study can T0 and T1 and in cultural awareness ability at T2. Therefore, future
be attributed to several factors. First, a systematic review indicated that research should consider participants' years of service as a control
education containing culturally specific units is more likely to generate variable to avoid underestimating an intervention's effectiveness.
significant positive effects than general cultural interventions (Beach The duration of an education intervention can also influence its
et al., 2005). Accordingly, culturally specific units should be in- effectiveness. Cerezo et al. (2014) reported that six weeks of cultural
corporated into cultural competence interventions or serve as crucial awareness education increased employees' cultural awareness, parti-
factors when designing courses. Lin et al. (2019) asserted that clinical cularly their cultural knowledge and cultural perceptions, and sug-
care nurses should strengthen the nursing specialists' relevant cultural gested that the effectiveness may have been related to the education
competencies, to meet the individual patients' cultural care needs. As an programme duration. Cerezo et al. (2014) noted that the duration of
example, Campinha-Bacote (2009) reported that some African Amer- cultural competence interventions reported in the literature varies from
icans hold a doubtful attitude toward medical and health professionals. 3 h to several weeks. The present study implemented an education in-
They tend to visit physicians only when absolutely necessary and may tervention programme with a total time of 12 h. The results

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
M.-H. Lin and H.-C. Hsu Nurse Education Today 88 (2020) 104385

Table 3 should be interpreted with caution and cannot be generalised to all

The effects of intervention on NCCS total and subscale scores. clinical nurses. Future studies should use a larger sample and include a
Parameter B S.E. Wald χ2 95% confidence p value venue analysis; furthermore, the duration should be extended to obtain
interval more objective research inferences. In addition, a self-report inventory
was employed in the present study to evaluate the effectiveness of the
Total scorea
intervention. In the future, researchers can collect empirical evidence
Intercept 3.10 0.06 3087.03 [2.98, 3.20] < .001
Group
through direct observation or recording behaviours to conduct an in-
Experimentalb 0.01 0.07 0.03 [−0.11, 0.14] .87 depth exploration of the courses' benefits and influencing factors. The
Timec present study participants expressed a willingness to participate in the
T1 0.01 0.05 0.02 [−0.09, 0.10] .88 study and their results may differ from those who did not volunteer to
T2 0.104 0.05 4.31 [0.006, 0.20] .04
participate, as a result of selection bias. Despite these limitations, this
Group × Timed
Experimental × T1 0.06 0.09 0.55 [−0.11, 0.24] .46 study advanced what is known about cultural competence intervention,
Experimental × T2 0.13 0.09 1.98 [−0.05, 0.30] .16 deepening the understanding of nurses' cross-cultural competence.
Cultural awareness ability
Intercept 3.71 0.104 1287.46 [3.51, 3.91] < .01 5. Conclusion
Group
b
Experimental 0.06 0.128 0.27 [−0.18, 0.31] .60 The cultural competence intervention implemented in the present
Timec
T1 0.02 0.08 0.04 [−0.14, 0.18] .84
study exerted a significant positive effect on nurses' self-learning cul-
T2 0.02 0.08 0.07 [−0.09, 0.23] .79 tural ability, an aspect of cultural competence. Although not all aspects
Group × Timed of cultural competence were significantly improved after the inter-
Experimental × T1 0.22 0.1640 1.73 [−0.10, 0.53] .18 vention, progressive improvements were observed, indicating appro-
Experimental × T2 0.01 0.1645 0.002 [−0.31, 0.32] .96
priateness. Although this study did not verify the effect of cultural
Cultural action ability competence education in clinical nurses, it can serve as a basis for fu-
Intercept 2.82 0.095 869.54 [2.63, 3.00] < .001 ture research in this field.
Group
Experimentalb −0.05 0.11 0.17 [−0.26, 0.17] .67
Timec Author statement
T1 −0.05 0.08 0.36 [−0.22, 0.11] .54
T2 0.07 0.08 0.69 [−0.09, 0.24] .40 Lin Mei-Hsiang: Conceptualization, Methodology, Visualization,
Group × Timed
Software, Writing - original draft preparation.
Experimental × T1 −0.16 0.15 1.15 [−0.47, 0.13] .28
Experimental × T2 0.07 0.15 0.17 [−0.24, 0.37] .67 Hsu Hsiu-Chin: Data curation, Visualization, Investigation. Writing -
reviewing and editing.
Cultural resources application ability
Intercept 3.47 0.11 841.23 [3.23, 3.70] < .01
Group Funding
Experimental b
−0.16 0.15 0.19 [−0.43, 0.29] .66
Timec The Ministry of Science and Technology of Taiwan for funding
T1 −0.08 0.08 0.86 [−0.25, 0.09] .35
[grant number: MOST 105-2511-S-227-002-MY2].
T2 0.02 0.09 0.03 [−0.16, 0.19] .85
Group × Timed
Experimental × T1 −0.04 0.18 0.14 [−0.40, 0.32] .71 Declarations of competing interest
Experimental × T2 −0.07 0.18 0.05 [−0.40, 0.32] .83

Self-learning cultural ability The authors declare that there no conflicts of interest.
Intercept 2.38 0.12 338.25 [2.12, 2.63] < .01
Group Acknowledgements
Experimentalb 0.09 0.15 0.31 [−0.22, 0.39] .57
Timec
T1 0.15 0.11 1.91 [−0.06, 0.35] .16 The authors would like to thank the nurses who participated in this
T2 0.31 0.11 7.98 [0.09, 0.51] .005 study.
d
Group × Time
Experimental × T1 0.26 0.21 1.53 [−0.14, 0.66] .21
References
Experimental × T2 0.51 0.21 5.97 [0.10, 0.91] .015

Note: T0: baseline test; T1: post-test; T2: follow up test; NCCS: Nursing Cultural Allen, J., Brown, L., Duff, C., Nesbitt, P., Hepner, A., 2013. Development and evaluation
Competence Scale. of a teaching and learning approach in cross-cultural care and antidiscrimination in
a university nursing students. Nurse Educ. Today 33 (12), 1592–1598. https://doi.org/
Total cultural competence. 10.1016/j.nedt.2012.12.006.
b
Reference: control group. Arbour, M., Kaspar, R.W., Teall, A.M., 2015. Strategies to promote cultural competence in
c
Reference: baseline T0. distance education. J. Transcult. Nurs. 26 (4), 436–440. https://doi.org/10.1177/
d 1043659614547201.
Reference: control group × baseline T0.
Beach, M.C., Price, E.G., Gary, T.L., Robinson, K.A., Gozu, A., Palacio, A., ... Cooper, L.A.,
2005. Cultural competence a systematic review of health care provider educational
demonstrated a main effect of time on total cultural competence and interventions. Medical Care 43 (4), 356–373. https://doi.org/10.1097/01.mlr.
self-learning cultural ability; additionally, self-learning cultural ability 0000156861.58905.96.
Campinha-Bacote, J., 2002. The process of cultural competence in the delivery of
showed an interaction in the follow-up (T2). In future studies, the in-
healthcare services: a model of care. J. Transcult. Nurs. 13 (3), 181–184. https://doi.
tervention time can be extended to enable examination of other aspects org/10.1177/10459602013003003.
of cultural competence education effectiveness. Campinha-Bacote, J., 2009. A culturally competent model of care for African Americans.
This study was restricted to one medical centre in northern Taiwan Urol. Nurs. 29, 49–54.
Cerezo, P.G., Galceran, M.S., Soriano, M.G., Camps, M.L., Moral, J.M.L., 2014. Design and
and did not use a large sample or long-term follow-up. Although the evaluation of an educational course in cultural competence for nursing. Procedia Soc.
participants were divided into experimental and control groups, the Behav. Sci. 132, 262–268. https://doi.org/10.1016/j.sbspro.2014.04.308.
intervention did not meet the requirements of a randomised double- Chang, L.C., Chiu, C.W., Hsu, C.M., Liao, L.L., Lin, H.L., 2019. Examining the im-
plementation of teaching and learning interactions of transition cultural competence
blind trial because the intervention programme was conducted in a through a qualitative study of Taiwan mentors untaking the postgraduate nursing
natural context. Therefore, this study's results and statistical inferences program. Nurse Educ. Today 79, 74–79. https://doi.org/10.1016/j.nedt.2019.05.

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
M.-H. Lin and H.-C. Hsu Nurse Education Today 88 (2020) 104385

020. Competency Assessment Index and Developing as Well as Evaluating the Intervention
Chapman, R., Martin, C., Smith, T., 2014. Evaluation of staff cultural awareness before Program. (Research Grant MOST-105-2511-S-227-002-MY2). Ministry of Science and
and after attending cultural awareness training in an Australian emergency depart- Technology, Taipei City, Taiwan, ROC.
ment. International Emergency Nursing 22 (4), 179–184. https://doi.org/10.1016/j. Lin, M.H., Wu, C.Y., Hsu, H.C., 2019. Exploring the experiences of cultural competence
ienj.2013.11.001. among clinical nurses in Taiwan. Appl. Nurs. Res. 45, 6–11. https://doi.org/10.1016/
Cruz, J.P., Aguinaldo, A.N., Estacio, J.C., Alotaib, A., Arguvanli, S., Cayaban, A.R., ... j.apnr.2018.11.001.
Sebaeng, J., 2018. A multicountry perspective on cultural competence among bac- Liu, W., Stone, T.E., McMaster, R., 2018. Increasing undergraduate nursing students’
calaureate nursing students. Journal of Nursing Scholarship 50 (1), 92–101. https:// cultural competence: an evaluation study. Global Health Research and Policy 3 (7).
doi.org/10.1111/jnu.12350. https://doi.org/10.1186/s41256-018-0062-2.
Debiasi, L.B., Selleck, C.S., 2017. Cultural competence training for primary care nurse Long, T.B., 2012. Overview of teaching strategies for cultural competence in nursing
practitioners: an intervention to increase culturally competent care. J. Cult. Divers. students. J. Cult. Divers. 19 (3), 102–108.
24 (2), 39–45. McAlister, A.L., Perry, C.L., Parcel, G.S., 2008. How individuals, environmental, and
Delgado, D.A., Ness, S., Ferguson, K., Engstrom, P.L., Gannon, T.M., Gillett, C., 2013. health behavior interact: social learning theory. In: Glanz, K., Lewis, F.M., Rimer, B.K.
Cultural Shih competence training for clinical staff measuring the effect of a one-hour (Eds.), Health Behavior, and Health Education Theory, Research and Practice. Jossey-
class on cultural competence. J. Transcult. Nurs. 24 (2), 204–213. https://doi.org/10. Bass Inc., San Francisco.
1177/1043659612472059. Moleiro, C., Marques, S., Pacheco, P., 2011. Cultural diversity competencies in child and
Doorenbos, A.Z., Schim, S.M., Benkert, R., Borse, N.N., 2005. Psychometric valuation of youth care services in Portugal: development of two measures and a brief training
the cultural competence assessment instrument among healthcare providers. Nurs. program. Child Youth Serv. Rev. 33 (5), 767–773. https://doi.org/10.1016/j.
Res. 54 (5), 324–331. https://doi.org/10.1097/00006199-200509000-00006. childyouth.2010.11.022.
Garneau, A.B., Pepin, J., 2015. Cultural competence: a constructivist definition. J. Shih, H.I., Cheung, C.H.A., Huang, I.H., Huang, M.C., Kao, C.Y., 2019. Development of a
Transcult. Nurs. 26 (1), 9–15. https://doi.org/10.1177/1043659614541294. transcultural nursing program for nursing students in Taiwan. J. Med. Educ. 23 (2),
Gower, S., Duggan, R., Dantas, J.A.R., Boldy, D., 2019. One year on: cultural competence 100–111. https://doi.org/10.6145/jme.201906_23 (2).0004.
of Australian nursing students following international service-learning. J. Nurs. Educ. Smedley, B.D., Stith, A.Y., Nelson, A.R., 2003. Unequal Treatment Confronting Racial and
58 (1), 17–26. https://doi.org/10.3928/01484834-20190103-04. Ethnic Disparities in Health Care. National Academies Press, Washington, D.C.
Haugan, G., Sørensen, A.H., Hanssen, I., 2012. The importance of dialogue in student Thom, D.H., Tirado, M.D., Woon, T.L., McBride, M.R., 2006. Development and evaluation
nurses’ clinical education. Nurse Educ. Today 32 (4), 438–442. https://doi.org/10. of a cultural competency training curriculum. BMC Medical Education 26 (6), 38.
1016/j.nedt.2011.03.011. https://doi.org/10.1186/1472-6920-6-38.
Lin, C.J., Chang, P.R., Wang, L.H., Huang, M.C., 2015. Cultural competence course for Tsai, M.T., Cheng, N.C., 2010. Programmer perceptions of knowledge-sharing behavior
nursing students in Taiwan: a longitudinal study. Nurse Educ. Today 35 (12), under social cognitive theory. Expert Syst. Appl. 37 (12), 8479–8485. https://doi.
1268–1274. https://doi.org/10.1016/j.nedt.2015.05.023. org/10.1016/j.eswa.2010.05.029.
Lin, M.H., Hsu, L.L., Chang, T.H., 2016. Constructing the Connotation of Nursing Cultural

Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on November 13, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.