526253
research-article2014
TCNXXX10.1177/1043659614526253Journal of Transcultural NursingHalter et al.
Education Department
Transcultural Self-Efficacy Perceptions of Baccalaureate Nursing Students
Journal of Transcultural Nursing 2015, Vol. 26(3) 327–335 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614526253 tcn.sagepub.com
Margaret Halter, PhD, APRN1, Faye Grund, PhD, APRN, BC1, Mark Fridline, PhD2, Sharon See, MSN, RNC1, Lisa Young, DNP, APRN1, and Carol Reece, DNP, PNP1
Abstract Addressing the health care needs of a 21st-century nation that is experiencing increased diversity and disparity will require new models of educating future providers. The cultural competence and confidence model was the guiding framework in a study evaluating the influence of cultural educational offerings on the transcultural self-efficacy (TSE) perceptions in baccalaureate nursing students. The Transcultural Self-Efficacy Tool was used to measure perceived TSE in a pretest (N = 260), posttest (N = 236) study over an academic year. Significant changes were demonstrated in overall self-efficacy and on the cognitive, practical, and affective subscales. A classification and regression tree analysis identified social orientation as the demographic variable most predictive of the TSE level. This study supports previous research where positive changes were found in students’ TSE based on the inclusion of cultural interventions in the nursing curriculum. Keywords work force diversity, correlational design, health disparities, transcultural health, baccalaureate programs The United States has experienced waves of immigration since the 1600s, and currently there are over 50 million immigrants, which equal more than one sixth of its residents (Camarota, 2012). The United States has more foreign-born residents than any other country in the world, 3 times as many than number two–ranked Russia (Population Reference Bureau, 2010). Recent trends in immigration are different and more profound. Early immigrants tended to be European with Judeo-Christian religious beliefs. Current waves of immigrants have been mostly Asian and Hispanic (Population Reference Bureau, 2010); Asian heritage accounts for the largest influx. By ethnicity, more than half of the growth seen in the United States from 2000 to 2010 was due to an increase in the Hispanic population (U.S. Census Bureau, 2010). Additionally, the U.S. Census Bureau (2012) announced that for the first time in history, 50.4% of children younger than 1 year by July 1, 2011, were members of minority groups. Addressing the health care needs of our 21st-century nation that is experiencing increased diversity and disparity will require new models of training future providers. Increasingly, organizations are emphasizing the need for attitudes, skills, and knowledge that are consistent with the needs of a diverse patient population. Nurse educators are charged with instilling and nurturing attitudes, skills, and knowledge, or cultural competence, among nursing students that will serve as a basis for lifelong growth in providing transcultural care for an increasingly diverse population (American Association of Colleges of Nursing, 2008; American Nurses
Association, 2010). The National Center for Cultural Competence (2013) describes cultural competence as a developmental process that occurs over time. When this process is supported, cultural awareness, knowledge, and skills are heightened; attitudes toward practice are influenced; and motivation and confidence to further knowledge and skills are developed. Bandura (1986) suggests that confidence, or self-efficacy perceptions, influences learning and motivation. Selfefficacy is associated with greater perseverance and commitment despite obstacles. Jeffreys (2010a) incorporates the concept of self-efficacy into learning culturally competent care. Jeffreys’s cultural competency and confidence (CCC) model identifies the concept of transcultural self-efficacy (TSE) as an essential ingredient in the cultural competency learning process. TSE perceptions refer to students’ belief in their ability to learn or perform skills related to transcultural care. The purpose of the current study was to evaluate the influence of a variety of cultural educational offerings on TSE perceptions in baccalaureate nursing students. Information 1
Ashland University, Mansfield, OH, USA University of Akron, Akron, OH, USA
2
Corresponding Author: Faye Grund, PhD, APRN bc, Ashland University, 401 College Avenue, Ashland, OH 44805. Email: [email protected]
328 gained from this study will be used to plan for future educational offerings and curriculum development. Specific research questions in this study were the following: Research Question 1: What is the influence of select demographic variables on TSE perceptions in baccalaureate nursing students? Research Question 2: What are the changes in TSE perceptions following formalized educational and other learning experiences integrated throughout the curriculum? The hypothesis for the first question was that there would be no relationship between demographic variables and TSE perceptions. The hypothesis for the second question was that students’ TSE perceptions would be enhanced after involvement in formalized cultural education.
Conceptual Framework and Background Individuals need to feel confident in their ability to develop cultural competence. Bandura (1986, 1989) asserts that individuals with strong self-efficacy (confidence) are able to withstand failure, perceive doubt as challenge, and engage in preparatory efforts to enhance performance. Jeffreys (2010a) applied Bandura’s (1986, 1989) model in asserting that individuals with strong perceptions of self-efficacy are motivated to actively seek knowledge in an effort to maximize their transcultural nursing skill and develop cultural competence. Jeffreys’ (2010a) CCC model is a theoretical framework useful in teaching cultural competence. It incorporates the construct of TSE as a factor that influences learning cultural competence and the skills necessary to provide culturally congruent care. Jeffreys describes cultural competence as “an ongoing, multidimensional learning process that integrates transcultural nursing skills in three dimensions (cognitive, practical, and affective)” (p. 52). Jeffreys (2010a) identifies more than a dozen assumptions that are associated with the CCC model. Research supports the assumption that students are most confident about their attitudes (affective dimension) and least confident about transcultural nursing knowledge (cognitive dimension). Another empirically supported and intuitively sound assumption is that novice students tend to have lower selfefficacy perceptions than advanced students. A related assumption is that students with lower self-efficacy perceptions benefit most from exposure to transcultural education and immersion in transcultural experiences. Although lower self-efficacy is of concern, students who are overly confident may also be at risk due to inadequate preparation for cultural care. Based on this theory, educators should strive to integrate cultural content across the curriculum in order to provide students with foundational cultural care concepts and opportunities to develop transcultural nursing skills. This foundation
Journal of Transcultural Nursing 26(3) will provide graduates with the ability to continue to grow in cultural competency as a lifelong learning process. The impetus for more clearly including cultural content in the curriculum and subsequently measuring it was a Health Resources and Service Administration grant. The objectives of the grant include increasing baccalaureate enrollment, increasing the graduation rate particularly of students from diverse backgrounds, and improving students’ cultural competence. Although faculty had addressed culture in the curriculum prior to the grant, there was no specific and systematic focus on cultural content.
Method The setting for this study was a private rural university in the Midwest. Approval for the study was obtained from the university’s human subjects review board. Students in the traditional 4-year baccalaureate program, the accelerated second-degree program, and the RN (registered nurse) to BSN (bachelor of science in nursing) program were asked to participate. Students in the traditional program complete core curriculum and support courses during the freshmen and sophomore years and begin the nursing curriculum in the junior year. The accelerated second-degree program is 15 months in length. The RN to BSN program is completely online. Data were collected at the beginning of the fall 2011 semester and again at the end of the spring 2012 semester for traditional and RN to BSN students and summer 2012 semester for accelerated students whose program ends at that time. For the fall data collection study, participants were not asked to supply identifiers because the researchers originally planned to report only aggregate results. Subsequently, a longitudinal 3-year study was planned and participant identifiers were added to the spring and summer administration for inclusion in future data analyses. Throughout the academic year, students were exposed to and participated in a variety of cultural interventions. All oncampus students were asked to participate in a conference presented by a national expert in transcultural nursing. Students participated in one of several university-wide global awareness symposia, which were offered on a monthly basis. Since the RN to BSN program is fully online, the transcultural conference and symposia were made available to them through video recording online. The curriculum committee coordinated the incorporation of cultural care topics in all nursing coursework; culture-specific course outcomes were added throughout the curriculum. Clinical simulations and case study scenarios were revised to include topics related to care appropriate for patients representing minority cultures. Assessment Technology Institute’s Real Life Scenarios™ were added into laboratory classes, and culture was a focus in the debriefing sessions. In the clinical setting, students completed cultural assessments as part of the general assessment, and an emphasis on cultural care was included in postconferences.
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Halter et al. Table 1. Teaching Learning Interventions 2011-2012. Intervention Symposia “Against Global Indifference”
Presentation “Developing Cultural Competencies: A Life Long Journey for Nurses”
Presentation “The Power of Community Engagement to Reduce Health Disparities” “Mitigating Health Disparities” Cultural immersion: South Africa Nicaragua Navajo reservation Virtual learning: Assessment Technology Institute Real Life Scenarios™ Cultural care content: Focused coursework in all nursing and clinical courses
Exposure time and semester
Learning domain
Offered monthly, one 1-hour symposium required for each semester
Cognitive Affective
All
4-hour, fall
Cognitive Affective
All
2-hour, spring
Cognitive Affective
All
1 week: fall/spring/ summer
Cognitive Practical Affective
Self-selected
12-hour, spring
Cognitive Practical Affective
Seniors
Varied, fall/spring
Cognitive Practical Affective
All except freshmen and sophomore traditional students
Multiple studies have demonstrated that immersion experiences improve cultural competence/TSE perceptions (Amerson, 2010, Kollar & Ailinger, 2002; Larsen & Reif, 2011; Mixer, 2008). Special cultural immersion experiences were made available to students in the present study, including travel to South Africa, a Navajo reservation, and Nicaragua. Participation in these immersion experiences was voluntary. A summary of teaching learning interventions for the first academic year of the study is presented in Table 1.
Instrument The Transcultural Self-Efficacy Tool (TSET) was used to measure undergraduate nursing students’ TSE perceptions. This tool was retrieved from the Cultural Competence Education Resource Toolkit online (Jeffreys, 2010b; it is also available in a print version, Teaching Cultural Competence in Nursing and Health Care (Jeffreys, 2010a). A license for use of the TSET was acquired from the publisher.
Students involved
Learning strategies Lecture
Lecture with audience participation Written paper Reading literature from cultural journals Lecture with audience participation Immersion experience Interview Guided computer-based simulation with debriefing Varied by course Reading literature from cultural journals Computer-based instruction Films with cultural themes Assessment and interviews with individuals from varied cultures Shared and guided self-reflection
The TSET is an 83-item tool with response choices from 1 (not confident) to 10 (totally confident). Self-efficacy strength (SEST) refers to the average strength of self-efficacy perceptions within a particular subscale. Summing the items within the subscale and then dividing the total sum by the number of items results in the SEST. The cognitive subscale measures confidence in knowledge of cultural factors that may influence nursing care. The practical subscale measures confidence in interviewing clients with diverse cultural backgrounds to learn their values and beliefs. The affective subscale measures confidence in identifying cultural attitudes, values, and beliefs. For the purpose of this study, the self-efficacy level (SEL; Jeffreys, 2010a) quartile classification was based on data collected during the fall semester. Three SEL classifications were a function of these quartiles, where the “low” classification were outcomes less than the first quartile, the high classification were outcomes greater than the third quartile, and the remaining outcomes were classified as “medium.” Classifications such as these can help track progress over
330 time and also identify “at-risk” inefficacious students who may report very low self-efficacy perceptions or supremely efficacious students who may report overly high self-efficacy perceptions. Multiple studies have confirmed the reliability and validity of the TSET (Jeffreys, 2000, 2010c; Jeffreys & Dogan, 2010). According to Jeffreys and Dogan (2011), the TSET has reported content validity, criterion-related validity, and construct validity, as well as adequate reliability for internal consistency (Cronbach’s α = .92 to .98) and stability (test–retest reliability = .64 to .75). Additionally, Jeffreys and Dogan (2012) conducted a factor analysis with new estimates of internal consistency that resulted in .99 for total and .95 to .99 for the three subscales. In the present study Cronbach’s alpha was calculated for the total instrument and each subscale for both administrations of the survey. High estimates of reliability of at least .95 were recorded, which indicates that the assumption of internal consistency for the tool was met. In addition to the TSET, students completed a demographic tool. One variable on this tool measured social orientation. Students were asked to describe themselves as extremely liberal, liberal, somewhat liberal, moderate, somewhat conservative, conservative, or extremely conservative. The postadministration of the surveys included a checklist of transcultural nursing experience interventions that were provided throughout the academic year. The students were asked to respond whether they had participated in these activities.
Data Collection Faculty in the College of Nursing were asked to provide time for data collection through written correspondence and in a faculty meeting. For consistency in data collection, one faculty member took the lead in data collection and administered the TSET at the beginning and at the end of the academic year to all students. The paper-and-pencil tool was administered in person in the classroom setting for most of the students. Students enrolled in the online RN to BSN program completed the instrument electronically. Students were provided with informed consent either verbally or electronically depending on the setting. They were assured of confidentiality and that participation was voluntary and would not affect their grade. For those students who chose to participate, the completion time was about 20 minutes.
Results Data Analysis Procedures The data were analyzed using IBM’s Statistical Package for the Social Sciences (SPSS Version 19). All missing value percentages were acceptable, with two exceptions. In the spring semester there were two surveys with a large missing value percentage; these responses were not included in the
Journal of Transcultural Nursing 26(3) analyses. Given the low percentage of missing values for the remaining respondents, an imputation method was not necessary for the missing TSET survey responses. Univariate analysis was repeated for the fall and spring semester where the means and standard deviations were compared. For all the statistical inferential tests, the significance level was set at p < .05. The standard parametric two-sample t test was completed to determine if there was any statistical difference between two population means. To determine if the sampled populations are normally distributed, graphical procedures were observed to view shapes and the presence of outliers. Statistical power for the independent t tests exceeded .90. Contingency tables were employed to analyze categorical data with more than one variable. A classification and regression tree (CART) was used as an exploratory analytical technique to observe how a categorical response variable changes given a series of explanatory variables. Breiman, Friedman, Olshen, and Stone (1984) originally proposed the CART algorithm. This decision tree partitions the data into statistically significant subgroups that are mutually exclusive and exhaustive. This nonparametric classification procedure produces a visual tree image with easily understood results.
Sample Characteristics In the fall semester, 260 students out of 285 (91%) agreed to participate and submitted useable surveys; in the spring semester, 236 students out of 286 (83%) agreed to participate and submitted useable surveys. For both semesters, most (95%) of the sample was female and non-Hispanic White. About 75% were younger than 25. A majority (87%) of the sample was enrolled in the traditional undergraduate program. Nearly half of the students had family income levels of less than $49,999, and nearly half had previous health care experience. Most of the students considered their social orientation to be either moderate (46% fall semester, 43% spring semester) or conservative (32% fall semester, 40% spring semester).
Demographic Variables and Self-Efficacy Perceptions The first research question was “What is the influence of select demographic variables on TSE perceptions in baccalaureate nursing students?” There were no significant differences found for the variables of gender, age, income, race/ ethnicity, or social orientation in relationship to TSE. During the fall semester, there were significant differences found for the cognitive subscale by class rank. Freshmen and seniors scored significantly higher than sophomores (p < .012). Using a two-sample t test for the variable of previous health care experience, significance was demonstrated for the cognitive subscale in the first semester. Students with
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Figure 1. Overall SEL CART algorithm for fall semester 2011.
Note: SEL = self-efficacy level; CART = classification and regression tree. Nonconservative: extremely liberal, liberal, somewhat liberal, moderate; Conservative: somewhat conservative, conservative, extremely conservative.
previous health care experience had a cognitive mean score of 6.82 (SD = 1.55) compared to students without health care experience who had a mean score 6.25 (SD = 2.11). The relationship between demographic variables and SEL classification was also explored using a CART decision tree algorithm. This exploratory technique determines what combinations of demographic variables are most predictive of the SEL classification variable. The algorithm traces each path from the root (top) of the tree to each of the terminal
nodes (bottom of a branch). The benefit of this nonparametric classification procedure is that it can visually depict the relationship between the SEL classification dependent variable and the explanatory variables in a tree image. Figure 1 displays the four-level CART tree derived in SPSS for the fall semester only. The root node (Node 0) reveals that of the 260 nursing students who participated in the fall 2011 administration of the TSET, 25% were classified as low, 50% were classified as medium, and 25% were
332 classified as high. The first variable that was strongly associated with the students’ SEL classification was social orientation (see the first level of tree). As the tree splits individuals by social orientation and moves on to other variables, additional factors arise as predictive for scores. As seen in the second level of the tree, previous health care experience and family income proved to be the next best predicting variable for SEL classification. Without previous health care experience, 34% of liberal-moderate (nonconservative) students fell into the low classification; with previous health care experience 18% fell into the low group. At this level, the variable that affects conservative students’ classification is family income. Conservative students who had a family income less than $50,000 had a higher percentage of the low classification (46.4%) compared to students with a family income greater than $50,000 (23.6%). As seen in the third level of the tree, family income and social orientation were considered to be the most predictive of SEL classification among students on the nonconservative side of the decision tree. It should be noted that gender was the only variable expressed in the fourth level of the tree.
Journal of Transcultural Nursing 26(3) Table 2. Fall Semester 2011 and Spring Semester 2012 Mean Self-Efficacy Strength Scores.
Overall Fall Spring Cognitive Fall Spring Practical Fall Spring Affective Fall Spring
M
SD
7.24 7.97
1.35 1.14 t = 6.51 (p = .000) 1.90 1.48
6.51 7.54 t = 6.716 (p = .000)
1.95 1.58
6.61 7.47 t = 5.393 (p = .000)
1.17 1.0
8.44 8.80 t = 3.693 (p = .000)
Transcultural Self-Efficacy Perceptions Self-efficacy strength refers to the average strength of selfefficacy perceptions within a particular subscale (i.e., cognitive, practical, and affective; Jeffreys, 2000). There is also an overall SEST score that refers to the average strength of selfefficacy perceptions aggregated across all dimensions. The second research question, “What are the changes in TSE perceptions following formalized educational and other learning experiences integrated throughout the curriculum?” is addressed in Table 2. It shows the overall and subscale mean scores for both the fall semester and spring semester SEST scores after an academic year of transcultural interventions. The results indicate that the spring semester scores were significantly affected on all three subscales (cognitive, practical, and affective). Figure 2 represents the shape of the TSET outcomes by semester with a smooth density curve. Whereas the overall TSET mean outcomes were both symmetrical, the center location of the spring semester results was shifted to the right with less variability. This locational shift and reduced variability indicate that the overall SEST scores improved after a year of transcultural interventions. TSET scores for nursing students from the fall and spring semesters showed an overall difference among the group means (t = 6.51, p < .001) based on t test scores. The change in the cognitive subscale between the fall and spring semester was statistically significant (t = 6.72, p < .001). The practical subscale also demonstrated a statistically significant difference between fall and the spring semester (t = 5.39, p < .001). Finally, the change in the affective subscale was also statistically significant (t = 3.69, p < .001).
Figure 2. Overall TSET outcomes for fall semester 2011 and spring semester 2012. Note: TSET = Transcultural Self-Efficacy Tool.
Chi-square analysis revealed that the distribution of percentages from the fall semester SEL classification was significantly different in the spring semester (p < .001; Table 3). Specifically, the spring semester had fewer students classified in the “low” group compared to the fall semester for the overall SEL classification and for each subscale. There was a positive correlation (p = .046) between the total number of cultural experiences in which students engaged and total TSET scores. There were few significant correlations between specific cultural experiences and TSET scores. For seniors, the Assessment Technology Institute Real Life Scenarios for seniors was associated with improved cognitive scores (p = .001) and improved affective scores (p = .034). Cultural immersion experiences in the Navajo
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Halter et al. Table 3. Self-Efficacy Level (SEL) Results for Fall and Spring Semester Students. Fall semester, % Overall Low SEL Medium SEL High SEL Cognitive Low SEL Medium SEL High SEL Practical Low SEL Medium SEL High SEL Affective Low SEL Medium SEL High SEL
25 50 25 χ2 = 33.1 (p < .001)
Spring semester, % 7 52 41
25 50 25 χ2 = 33.3 (p < .001)
8 48 44
25 50 25 χ2 = 24.9 (p < .001)
8 60 32
25 50 25 χ2 = 11.8 (p < .001)
14 52 34
reservation, Nicaragua, and South Africa were associated with improved affective scores (p = .057).
Discussion The current study evaluated two research questions, one involving the relationship of demographic variables to perceived TSE and the other the impact of transcultural experience interventions over the course of the academic year. Although there was no significant relationship found between most demographic variables and perceived TSE, there were significant findings by academic level and prior health care experience. As in other studies (Lim, Downie, & Nathan, 2004; Jeffreys & Dogan, 2012), class rank was generally associated with increasing scores on the TSET, suggesting that new information and experiences support self-efficacy. For this study, there were significant differences found by academic level in both fall and spring. In the fall, freshmen and senior cognitive scores were significantly different from sophomores, with freshmen and senior scores significantly higher than sophomore scores. Freshmen students scored high on the subscales and the SEST despite having little formal cultural education and no practical (clinical) experience at the baccalaureate level. Prior studies explained this type of highly efficacious selfappraisal among lower level students (Jeffreys & Smodlaka, 1999). Jeffreys and Smodlaka determined that the early identification of highly efficacious individuals allows for more appropriate interventions aimed at preparing them with transcultural nursing skills. Other researchers, in the
field of education, suggested that such optimism is a mechanism that helps the novice survive difficult situations (Minniti, 2013). This is an area for further exploration. A qualitative study with individuals who identify early in the nursing program as supremely efficacious would provide greater understanding regarding effective strategies for their development of transcultural nursing skills as they progress through the program. Students with previous health care experience scored higher on the cognitive subscale in the fall semester. This might be expected as students who work in health care likely have some level of exposure to the cultural care needs of patients. This finding is similar to Jeffreys and Dogan (2012), who found that the strongest statistically significant predictors of cognitive TSE were semester (level) and previous health care experience. A unique aspect of this study relates to the use of the CART algorithm. This decision tree allowed the researchers to identify personal attributes that were associated with more or less accepting attitudes toward culturally informed care. One example of a demographic variable worthy of further examination is that of social orientation, an oftenoverlooked, yet essential dynamic in determining attitudes and behaviors related to cultural issues. The analysis found that liberal to moderate socially oriented students reported lower TSE levels than conservative students. Variables in combination that influenced perceived SEL were previous health care experience, family income, and gender. Based on this research, educational interventions can be developed and tested in future research to target demographicbased variables that predispose students to decreased cultural sensitivity. The second research question examined whether transcultural educational interventions were associated with change in TSE. Three types of analyses were used that resulted in significant findings. Analysis included whether there was statistical significance in the overall scores and three subscales following interventions, whether there was significance in the TSE level following interventions, and whether overall and specific interventions led to statistically significant findings. Scores in the cognitive, affective, and practical domains were significantly improved over the course of the academic year. This finding supports that cultural competence education in the curriculum leads to improved TSE perceptions. As in other studies (Amerson, 2012; Jeffreys & Dogan, 2012), students felt most confident in the affective/attitude domain. Overall, SEST scores improved from the fall to the spring semester. The SEL of students was significantly different for the overall score and the three subscales, affective, practical, and cognitive. Over the course of the academic year, following interventions, there were fewer students who fell within the “low” SEL. This finding demonstrates the aggregate effectiveness of the targeted interventions to improve TSE.
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The impact of the overall interventions and individual interventions was examined to determine if there were significant differences found in the students’ scores. A positive correlation was found between the total number of cultural experiences the students participated in and student’s overall TSE. Also, two specific interventions led to significant findings; they were the Assessment Technology Institute’s Real Life Scenarios and cultural immersion experiences. The simulated patient scenarios are relatively new and no studies in the literature address Assessment Technology Institute’s Real Life Scenarios and cultural competence. However, this study found significance in increasing both cognitive and affective TSE based on the numbers of the scenarios completed by senior-level students. This is important to educators as seek new ways of improving students’ cultural competence in the provision of care. Cultural immersion experience opportunities were made available to students in three locations: a Navajo reservation, Nicaragua, and South Africa. Students who participated in one or more of these experiences had higher mean affective scores. This is consistent with Amerson’s (2010) findings that immersion experiences improve cultural competency. The intensity of living, interacting, and providing care for people from another culture is likely to induce profound emotional responses.
program have limited exposure to the nursing curriculum until the junior year and may not have understood some of the questions. One question, “How confident are you that you recognize the need for cultural care repatterning/restructuring?” may have been problematic for novice nursing students.
Limitations
Implications
Aggregate data are helpful in understanding that student scores on the TSET were influenced by the cultural interventions that were provided. However, it explains little about which specific interventions may have provided the greatest impact. Also, aggregate data do not account for students who left the institution from one semester to the next and those who enrolled only for spring semester. The modified pool of students may have affected results. Presumably, students who stayed versus those who left were more committed to their education and more confident in their overall abilities. Coded identifiers will be added in future studies. This longitudinal data analysis approach is similar to one used by Jeffreys and Dogan (2012) and will allow for more powerful tests by tracking individual changes. The absence of a control group was another limitation in this study; other forces such as the influence of the normal college experience or maturation may account for changes in SEST scores and SEL. The addition of a comparison group, perhaps from another school, would increase the ability to measure change based on the interventions. Students were asked to complete the 83-item TSET twice in an academic year. After the first year of the study, the design was altered to administer the TSET only in the spring semester in order to decrease the exposure effect (familiarity principle) that could potentially influence results. Some of the TSET items are complex and more reflective of upperclassmen knowledge and ability. Students in this
Nurse educators can make a difference by thoroughly integrating transcultural nursing content and experiences into the curriculum. Models such as the CCC provide the framework for developing educational design, implementation strategies, and evaluation of nursing curricula. Tools such as the TSET have been tested extensively and provide useful evaluative information regarding the effectiveness of specific transcultural interventions. Understanding demographic variables that affect cultural competence, such as social orientation, should continue to be explored. Based on this study, computer-assisted learning experiences and immersion experiences are two positive methods to enhance and support culture competence.
Conclusion The American Association of Colleges of Nursing (2008) asserts that organizational commitment to enhancing the cultural competence of faculty and students is vital. The intentional and systematic inclusion of cultural content and experiences in nursing education across the United States is overdue and necessary in a health care environment that is no longer isolated by geographic boundaries. This study did not find significant relationships between TSE and most demographic variables examined; the results did support that student perceptions of TSE can be modified by formalized educational and other culturally relevant learning experiences. Immersion experiences and the use of computer-assisted scenarios are two valuable methods for improving TSE. As this study is continued over the next 2 academic years, additional knowledge will be gained regarding how student TSE is affected when educators intentionally integrate transcultural care concepts throughout the curriculum.
Acknowledgment This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by a Health Resources and Service
Halter et al. Administration Grant #D11HP22187-01-00, I CARE: Increasing Baccalaureate Nursing Enrollment, Nurse Education, Practice, Quality and Retention (NEPQR), provided to Ashland University.
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335 Jeffreys, M. R., & Dogan, E. (2010). Factor analysis of the Transcultural Self-Efficacy Tool (TSET). Journal of Nursing Measurement, 18, 120-139. Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students’ transcultural selfefficacy perceptions. Journal of Transcultural Nursing, 23, 188-197. Jeffreys, M. R., & Smodlaka, I. (1999). Construct validation of the Transcultural Self-Efficacy Tool. Journal of Nursing Education, 38, 222-227. Kollar, S. J., & Ailinger, R. A. (2002). International clinical experiences: Long-term impact on students. Nurse Educator, 27, 28-31. Larsen, R., & Reif, L. (2011). Effectiveness of cultural immersion and culture classes for enhancing nursing students’ transcultural self-efficacy. Journal of Nursing Education, 50, 350-354. Lim, J., Downie, J., & Nathan, P. (2004). Nursing students’ selfefficacy in providing transcultural care. Nurse Education Today, 24, 428-434. Minniti, M. (2013). The dynamics of entrepreneurship. Oxford, England: Oxford University Press. Mixer, S. J. (2008). Use of culture care theory and ethnonursing method to discover how nursing faculty teach culture care. Contemporary Nursing, 28, 23-36. National Center for Cultural Competence. (2013). Cultural competence health practitioner assessment. Retrieved from http:// nccc.georgetown.edu/features/CCHPA.html Population Reference Bureau. (2010). Population bulletin update: Immigration in America 2010. Retrieved from http://www.prb. org/Publications/PopulationBulletins/2010/immigrationupdate1.aspx U.S. Census Bureau. (2010). 2010 Census shows America’s diversity. Retrieved from http://2010.census.gov/news/rele-ases/ operations/cb11-cn125.html U.S. Census Bureau. (2012). Most children younger than age 1 are minorities, Census Bureau reports. Retrieved from http:// www.census.gov/newsroom/releases/archives/population/ cb12-90.html
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research-article2014
TCNXXX10.1177/1043659614526253Journal of Transcultural NursingHalter et al.
Education Department
Transcultural Self-Efficacy Perceptions of Baccalaureate Nursing Students
Journal of Transcultural Nursing 2015, Vol. 26(3) 327–335 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614526253 tcn.sagepub.com
Margaret Halter, PhD, APRN1, Faye Grund, PhD, APRN, BC1, Mark Fridline, PhD2, Sharon See, MSN, RNC1, Lisa Young, DNP, APRN1, and Carol Reece, DNP, PNP1
Abstract Addressing the health care needs of a 21st-century nation that is experiencing increased diversity and disparity will require new models of educating future providers. The cultural competence and confidence model was the guiding framework in a study evaluating the influence of cultural educational offerings on the transcultural self-efficacy (TSE) perceptions in baccalaureate nursing students. The Transcultural Self-Efficacy Tool was used to measure perceived TSE in a pretest (N = 260), posttest (N = 236) study over an academic year. Significant changes were demonstrated in overall self-efficacy and on the cognitive, practical, and affective subscales. A classification and regression tree analysis identified social orientation as the demographic variable most predictive of the TSE level. This study supports previous research where positive changes were found in students’ TSE based on the inclusion of cultural interventions in the nursing curriculum. Keywords work force diversity, correlational design, health disparities, transcultural health, baccalaureate programs The United States has experienced waves of immigration since the 1600s, and currently there are over 50 million immigrants, which equal more than one sixth of its residents (Camarota, 2012). The United States has more foreign-born residents than any other country in the world, 3 times as many than number two–ranked Russia (Population Reference Bureau, 2010). Recent trends in immigration are different and more profound. Early immigrants tended to be European with Judeo-Christian religious beliefs. Current waves of immigrants have been mostly Asian and Hispanic (Population Reference Bureau, 2010); Asian heritage accounts for the largest influx. By ethnicity, more than half of the growth seen in the United States from 2000 to 2010 was due to an increase in the Hispanic population (U.S. Census Bureau, 2010). Additionally, the U.S. Census Bureau (2012) announced that for the first time in history, 50.4% of children younger than 1 year by July 1, 2011, were members of minority groups. Addressing the health care needs of our 21st-century nation that is experiencing increased diversity and disparity will require new models of training future providers. Increasingly, organizations are emphasizing the need for attitudes, skills, and knowledge that are consistent with the needs of a diverse patient population. Nurse educators are charged with instilling and nurturing attitudes, skills, and knowledge, or cultural competence, among nursing students that will serve as a basis for lifelong growth in providing transcultural care for an increasingly diverse population (American Association of Colleges of Nursing, 2008; American Nurses
Association, 2010). The National Center for Cultural Competence (2013) describes cultural competence as a developmental process that occurs over time. When this process is supported, cultural awareness, knowledge, and skills are heightened; attitudes toward practice are influenced; and motivation and confidence to further knowledge and skills are developed. Bandura (1986) suggests that confidence, or self-efficacy perceptions, influences learning and motivation. Selfefficacy is associated with greater perseverance and commitment despite obstacles. Jeffreys (2010a) incorporates the concept of self-efficacy into learning culturally competent care. Jeffreys’s cultural competency and confidence (CCC) model identifies the concept of transcultural self-efficacy (TSE) as an essential ingredient in the cultural competency learning process. TSE perceptions refer to students’ belief in their ability to learn or perform skills related to transcultural care. The purpose of the current study was to evaluate the influence of a variety of cultural educational offerings on TSE perceptions in baccalaureate nursing students. Information 1
Ashland University, Mansfield, OH, USA University of Akron, Akron, OH, USA
2
Corresponding Author: Faye Grund, PhD, APRN bc, Ashland University, 401 College Avenue, Ashland, OH 44805. Email: [email protected]
328 gained from this study will be used to plan for future educational offerings and curriculum development. Specific research questions in this study were the following: Research Question 1: What is the influence of select demographic variables on TSE perceptions in baccalaureate nursing students? Research Question 2: What are the changes in TSE perceptions following formalized educational and other learning experiences integrated throughout the curriculum? The hypothesis for the first question was that there would be no relationship between demographic variables and TSE perceptions. The hypothesis for the second question was that students’ TSE perceptions would be enhanced after involvement in formalized cultural education.
Conceptual Framework and Background Individuals need to feel confident in their ability to develop cultural competence. Bandura (1986, 1989) asserts that individuals with strong self-efficacy (confidence) are able to withstand failure, perceive doubt as challenge, and engage in preparatory efforts to enhance performance. Jeffreys (2010a) applied Bandura’s (1986, 1989) model in asserting that individuals with strong perceptions of self-efficacy are motivated to actively seek knowledge in an effort to maximize their transcultural nursing skill and develop cultural competence. Jeffreys’ (2010a) CCC model is a theoretical framework useful in teaching cultural competence. It incorporates the construct of TSE as a factor that influences learning cultural competence and the skills necessary to provide culturally congruent care. Jeffreys describes cultural competence as “an ongoing, multidimensional learning process that integrates transcultural nursing skills in three dimensions (cognitive, practical, and affective)” (p. 52). Jeffreys (2010a) identifies more than a dozen assumptions that are associated with the CCC model. Research supports the assumption that students are most confident about their attitudes (affective dimension) and least confident about transcultural nursing knowledge (cognitive dimension). Another empirically supported and intuitively sound assumption is that novice students tend to have lower selfefficacy perceptions than advanced students. A related assumption is that students with lower self-efficacy perceptions benefit most from exposure to transcultural education and immersion in transcultural experiences. Although lower self-efficacy is of concern, students who are overly confident may also be at risk due to inadequate preparation for cultural care. Based on this theory, educators should strive to integrate cultural content across the curriculum in order to provide students with foundational cultural care concepts and opportunities to develop transcultural nursing skills. This foundation
Journal of Transcultural Nursing 26(3) will provide graduates with the ability to continue to grow in cultural competency as a lifelong learning process. The impetus for more clearly including cultural content in the curriculum and subsequently measuring it was a Health Resources and Service Administration grant. The objectives of the grant include increasing baccalaureate enrollment, increasing the graduation rate particularly of students from diverse backgrounds, and improving students’ cultural competence. Although faculty had addressed culture in the curriculum prior to the grant, there was no specific and systematic focus on cultural content.
Method The setting for this study was a private rural university in the Midwest. Approval for the study was obtained from the university’s human subjects review board. Students in the traditional 4-year baccalaureate program, the accelerated second-degree program, and the RN (registered nurse) to BSN (bachelor of science in nursing) program were asked to participate. Students in the traditional program complete core curriculum and support courses during the freshmen and sophomore years and begin the nursing curriculum in the junior year. The accelerated second-degree program is 15 months in length. The RN to BSN program is completely online. Data were collected at the beginning of the fall 2011 semester and again at the end of the spring 2012 semester for traditional and RN to BSN students and summer 2012 semester for accelerated students whose program ends at that time. For the fall data collection study, participants were not asked to supply identifiers because the researchers originally planned to report only aggregate results. Subsequently, a longitudinal 3-year study was planned and participant identifiers were added to the spring and summer administration for inclusion in future data analyses. Throughout the academic year, students were exposed to and participated in a variety of cultural interventions. All oncampus students were asked to participate in a conference presented by a national expert in transcultural nursing. Students participated in one of several university-wide global awareness symposia, which were offered on a monthly basis. Since the RN to BSN program is fully online, the transcultural conference and symposia were made available to them through video recording online. The curriculum committee coordinated the incorporation of cultural care topics in all nursing coursework; culture-specific course outcomes were added throughout the curriculum. Clinical simulations and case study scenarios were revised to include topics related to care appropriate for patients representing minority cultures. Assessment Technology Institute’s Real Life Scenarios™ were added into laboratory classes, and culture was a focus in the debriefing sessions. In the clinical setting, students completed cultural assessments as part of the general assessment, and an emphasis on cultural care was included in postconferences.
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Halter et al. Table 1. Teaching Learning Interventions 2011-2012. Intervention Symposia “Against Global Indifference”
Presentation “Developing Cultural Competencies: A Life Long Journey for Nurses”
Presentation “The Power of Community Engagement to Reduce Health Disparities” “Mitigating Health Disparities” Cultural immersion: South Africa Nicaragua Navajo reservation Virtual learning: Assessment Technology Institute Real Life Scenarios™ Cultural care content: Focused coursework in all nursing and clinical courses
Exposure time and semester
Learning domain
Offered monthly, one 1-hour symposium required for each semester
Cognitive Affective
All
4-hour, fall
Cognitive Affective
All
2-hour, spring
Cognitive Affective
All
1 week: fall/spring/ summer
Cognitive Practical Affective
Self-selected
12-hour, spring
Cognitive Practical Affective
Seniors
Varied, fall/spring
Cognitive Practical Affective
All except freshmen and sophomore traditional students
Multiple studies have demonstrated that immersion experiences improve cultural competence/TSE perceptions (Amerson, 2010, Kollar & Ailinger, 2002; Larsen & Reif, 2011; Mixer, 2008). Special cultural immersion experiences were made available to students in the present study, including travel to South Africa, a Navajo reservation, and Nicaragua. Participation in these immersion experiences was voluntary. A summary of teaching learning interventions for the first academic year of the study is presented in Table 1.
Instrument The Transcultural Self-Efficacy Tool (TSET) was used to measure undergraduate nursing students’ TSE perceptions. This tool was retrieved from the Cultural Competence Education Resource Toolkit online (Jeffreys, 2010b; it is also available in a print version, Teaching Cultural Competence in Nursing and Health Care (Jeffreys, 2010a). A license for use of the TSET was acquired from the publisher.
Students involved
Learning strategies Lecture
Lecture with audience participation Written paper Reading literature from cultural journals Lecture with audience participation Immersion experience Interview Guided computer-based simulation with debriefing Varied by course Reading literature from cultural journals Computer-based instruction Films with cultural themes Assessment and interviews with individuals from varied cultures Shared and guided self-reflection
The TSET is an 83-item tool with response choices from 1 (not confident) to 10 (totally confident). Self-efficacy strength (SEST) refers to the average strength of self-efficacy perceptions within a particular subscale. Summing the items within the subscale and then dividing the total sum by the number of items results in the SEST. The cognitive subscale measures confidence in knowledge of cultural factors that may influence nursing care. The practical subscale measures confidence in interviewing clients with diverse cultural backgrounds to learn their values and beliefs. The affective subscale measures confidence in identifying cultural attitudes, values, and beliefs. For the purpose of this study, the self-efficacy level (SEL; Jeffreys, 2010a) quartile classification was based on data collected during the fall semester. Three SEL classifications were a function of these quartiles, where the “low” classification were outcomes less than the first quartile, the high classification were outcomes greater than the third quartile, and the remaining outcomes were classified as “medium.” Classifications such as these can help track progress over
330 time and also identify “at-risk” inefficacious students who may report very low self-efficacy perceptions or supremely efficacious students who may report overly high self-efficacy perceptions. Multiple studies have confirmed the reliability and validity of the TSET (Jeffreys, 2000, 2010c; Jeffreys & Dogan, 2010). According to Jeffreys and Dogan (2011), the TSET has reported content validity, criterion-related validity, and construct validity, as well as adequate reliability for internal consistency (Cronbach’s α = .92 to .98) and stability (test–retest reliability = .64 to .75). Additionally, Jeffreys and Dogan (2012) conducted a factor analysis with new estimates of internal consistency that resulted in .99 for total and .95 to .99 for the three subscales. In the present study Cronbach’s alpha was calculated for the total instrument and each subscale for both administrations of the survey. High estimates of reliability of at least .95 were recorded, which indicates that the assumption of internal consistency for the tool was met. In addition to the TSET, students completed a demographic tool. One variable on this tool measured social orientation. Students were asked to describe themselves as extremely liberal, liberal, somewhat liberal, moderate, somewhat conservative, conservative, or extremely conservative. The postadministration of the surveys included a checklist of transcultural nursing experience interventions that were provided throughout the academic year. The students were asked to respond whether they had participated in these activities.
Data Collection Faculty in the College of Nursing were asked to provide time for data collection through written correspondence and in a faculty meeting. For consistency in data collection, one faculty member took the lead in data collection and administered the TSET at the beginning and at the end of the academic year to all students. The paper-and-pencil tool was administered in person in the classroom setting for most of the students. Students enrolled in the online RN to BSN program completed the instrument electronically. Students were provided with informed consent either verbally or electronically depending on the setting. They were assured of confidentiality and that participation was voluntary and would not affect their grade. For those students who chose to participate, the completion time was about 20 minutes.
Results Data Analysis Procedures The data were analyzed using IBM’s Statistical Package for the Social Sciences (SPSS Version 19). All missing value percentages were acceptable, with two exceptions. In the spring semester there were two surveys with a large missing value percentage; these responses were not included in the
Journal of Transcultural Nursing 26(3) analyses. Given the low percentage of missing values for the remaining respondents, an imputation method was not necessary for the missing TSET survey responses. Univariate analysis was repeated for the fall and spring semester where the means and standard deviations were compared. For all the statistical inferential tests, the significance level was set at p < .05. The standard parametric two-sample t test was completed to determine if there was any statistical difference between two population means. To determine if the sampled populations are normally distributed, graphical procedures were observed to view shapes and the presence of outliers. Statistical power for the independent t tests exceeded .90. Contingency tables were employed to analyze categorical data with more than one variable. A classification and regression tree (CART) was used as an exploratory analytical technique to observe how a categorical response variable changes given a series of explanatory variables. Breiman, Friedman, Olshen, and Stone (1984) originally proposed the CART algorithm. This decision tree partitions the data into statistically significant subgroups that are mutually exclusive and exhaustive. This nonparametric classification procedure produces a visual tree image with easily understood results.
Sample Characteristics In the fall semester, 260 students out of 285 (91%) agreed to participate and submitted useable surveys; in the spring semester, 236 students out of 286 (83%) agreed to participate and submitted useable surveys. For both semesters, most (95%) of the sample was female and non-Hispanic White. About 75% were younger than 25. A majority (87%) of the sample was enrolled in the traditional undergraduate program. Nearly half of the students had family income levels of less than $49,999, and nearly half had previous health care experience. Most of the students considered their social orientation to be either moderate (46% fall semester, 43% spring semester) or conservative (32% fall semester, 40% spring semester).
Demographic Variables and Self-Efficacy Perceptions The first research question was “What is the influence of select demographic variables on TSE perceptions in baccalaureate nursing students?” There were no significant differences found for the variables of gender, age, income, race/ ethnicity, or social orientation in relationship to TSE. During the fall semester, there were significant differences found for the cognitive subscale by class rank. Freshmen and seniors scored significantly higher than sophomores (p < .012). Using a two-sample t test for the variable of previous health care experience, significance was demonstrated for the cognitive subscale in the first semester. Students with
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Figure 1. Overall SEL CART algorithm for fall semester 2011.
Note: SEL = self-efficacy level; CART = classification and regression tree. Nonconservative: extremely liberal, liberal, somewhat liberal, moderate; Conservative: somewhat conservative, conservative, extremely conservative.
previous health care experience had a cognitive mean score of 6.82 (SD = 1.55) compared to students without health care experience who had a mean score 6.25 (SD = 2.11). The relationship between demographic variables and SEL classification was also explored using a CART decision tree algorithm. This exploratory technique determines what combinations of demographic variables are most predictive of the SEL classification variable. The algorithm traces each path from the root (top) of the tree to each of the terminal
nodes (bottom of a branch). The benefit of this nonparametric classification procedure is that it can visually depict the relationship between the SEL classification dependent variable and the explanatory variables in a tree image. Figure 1 displays the four-level CART tree derived in SPSS for the fall semester only. The root node (Node 0) reveals that of the 260 nursing students who participated in the fall 2011 administration of the TSET, 25% were classified as low, 50% were classified as medium, and 25% were
332 classified as high. The first variable that was strongly associated with the students’ SEL classification was social orientation (see the first level of tree). As the tree splits individuals by social orientation and moves on to other variables, additional factors arise as predictive for scores. As seen in the second level of the tree, previous health care experience and family income proved to be the next best predicting variable for SEL classification. Without previous health care experience, 34% of liberal-moderate (nonconservative) students fell into the low classification; with previous health care experience 18% fell into the low group. At this level, the variable that affects conservative students’ classification is family income. Conservative students who had a family income less than $50,000 had a higher percentage of the low classification (46.4%) compared to students with a family income greater than $50,000 (23.6%). As seen in the third level of the tree, family income and social orientation were considered to be the most predictive of SEL classification among students on the nonconservative side of the decision tree. It should be noted that gender was the only variable expressed in the fourth level of the tree.
Journal of Transcultural Nursing 26(3) Table 2. Fall Semester 2011 and Spring Semester 2012 Mean Self-Efficacy Strength Scores.
Overall Fall Spring Cognitive Fall Spring Practical Fall Spring Affective Fall Spring
M
SD
7.24 7.97
1.35 1.14 t = 6.51 (p = .000) 1.90 1.48
6.51 7.54 t = 6.716 (p = .000)
1.95 1.58
6.61 7.47 t = 5.393 (p = .000)
1.17 1.0
8.44 8.80 t = 3.693 (p = .000)
Transcultural Self-Efficacy Perceptions Self-efficacy strength refers to the average strength of selfefficacy perceptions within a particular subscale (i.e., cognitive, practical, and affective; Jeffreys, 2000). There is also an overall SEST score that refers to the average strength of selfefficacy perceptions aggregated across all dimensions. The second research question, “What are the changes in TSE perceptions following formalized educational and other learning experiences integrated throughout the curriculum?” is addressed in Table 2. It shows the overall and subscale mean scores for both the fall semester and spring semester SEST scores after an academic year of transcultural interventions. The results indicate that the spring semester scores were significantly affected on all three subscales (cognitive, practical, and affective). Figure 2 represents the shape of the TSET outcomes by semester with a smooth density curve. Whereas the overall TSET mean outcomes were both symmetrical, the center location of the spring semester results was shifted to the right with less variability. This locational shift and reduced variability indicate that the overall SEST scores improved after a year of transcultural interventions. TSET scores for nursing students from the fall and spring semesters showed an overall difference among the group means (t = 6.51, p < .001) based on t test scores. The change in the cognitive subscale between the fall and spring semester was statistically significant (t = 6.72, p < .001). The practical subscale also demonstrated a statistically significant difference between fall and the spring semester (t = 5.39, p < .001). Finally, the change in the affective subscale was also statistically significant (t = 3.69, p < .001).
Figure 2. Overall TSET outcomes for fall semester 2011 and spring semester 2012. Note: TSET = Transcultural Self-Efficacy Tool.
Chi-square analysis revealed that the distribution of percentages from the fall semester SEL classification was significantly different in the spring semester (p < .001; Table 3). Specifically, the spring semester had fewer students classified in the “low” group compared to the fall semester for the overall SEL classification and for each subscale. There was a positive correlation (p = .046) between the total number of cultural experiences in which students engaged and total TSET scores. There were few significant correlations between specific cultural experiences and TSET scores. For seniors, the Assessment Technology Institute Real Life Scenarios for seniors was associated with improved cognitive scores (p = .001) and improved affective scores (p = .034). Cultural immersion experiences in the Navajo
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Halter et al. Table 3. Self-Efficacy Level (SEL) Results for Fall and Spring Semester Students. Fall semester, % Overall Low SEL Medium SEL High SEL Cognitive Low SEL Medium SEL High SEL Practical Low SEL Medium SEL High SEL Affective Low SEL Medium SEL High SEL
25 50 25 χ2 = 33.1 (p < .001)
Spring semester, % 7 52 41
25 50 25 χ2 = 33.3 (p < .001)
8 48 44
25 50 25 χ2 = 24.9 (p < .001)
8 60 32
25 50 25 χ2 = 11.8 (p < .001)
14 52 34
reservation, Nicaragua, and South Africa were associated with improved affective scores (p = .057).
Discussion The current study evaluated two research questions, one involving the relationship of demographic variables to perceived TSE and the other the impact of transcultural experience interventions over the course of the academic year. Although there was no significant relationship found between most demographic variables and perceived TSE, there were significant findings by academic level and prior health care experience. As in other studies (Lim, Downie, & Nathan, 2004; Jeffreys & Dogan, 2012), class rank was generally associated with increasing scores on the TSET, suggesting that new information and experiences support self-efficacy. For this study, there were significant differences found by academic level in both fall and spring. In the fall, freshmen and senior cognitive scores were significantly different from sophomores, with freshmen and senior scores significantly higher than sophomore scores. Freshmen students scored high on the subscales and the SEST despite having little formal cultural education and no practical (clinical) experience at the baccalaureate level. Prior studies explained this type of highly efficacious selfappraisal among lower level students (Jeffreys & Smodlaka, 1999). Jeffreys and Smodlaka determined that the early identification of highly efficacious individuals allows for more appropriate interventions aimed at preparing them with transcultural nursing skills. Other researchers, in the
field of education, suggested that such optimism is a mechanism that helps the novice survive difficult situations (Minniti, 2013). This is an area for further exploration. A qualitative study with individuals who identify early in the nursing program as supremely efficacious would provide greater understanding regarding effective strategies for their development of transcultural nursing skills as they progress through the program. Students with previous health care experience scored higher on the cognitive subscale in the fall semester. This might be expected as students who work in health care likely have some level of exposure to the cultural care needs of patients. This finding is similar to Jeffreys and Dogan (2012), who found that the strongest statistically significant predictors of cognitive TSE were semester (level) and previous health care experience. A unique aspect of this study relates to the use of the CART algorithm. This decision tree allowed the researchers to identify personal attributes that were associated with more or less accepting attitudes toward culturally informed care. One example of a demographic variable worthy of further examination is that of social orientation, an oftenoverlooked, yet essential dynamic in determining attitudes and behaviors related to cultural issues. The analysis found that liberal to moderate socially oriented students reported lower TSE levels than conservative students. Variables in combination that influenced perceived SEL were previous health care experience, family income, and gender. Based on this research, educational interventions can be developed and tested in future research to target demographicbased variables that predispose students to decreased cultural sensitivity. The second research question examined whether transcultural educational interventions were associated with change in TSE. Three types of analyses were used that resulted in significant findings. Analysis included whether there was statistical significance in the overall scores and three subscales following interventions, whether there was significance in the TSE level following interventions, and whether overall and specific interventions led to statistically significant findings. Scores in the cognitive, affective, and practical domains were significantly improved over the course of the academic year. This finding supports that cultural competence education in the curriculum leads to improved TSE perceptions. As in other studies (Amerson, 2012; Jeffreys & Dogan, 2012), students felt most confident in the affective/attitude domain. Overall, SEST scores improved from the fall to the spring semester. The SEL of students was significantly different for the overall score and the three subscales, affective, practical, and cognitive. Over the course of the academic year, following interventions, there were fewer students who fell within the “low” SEL. This finding demonstrates the aggregate effectiveness of the targeted interventions to improve TSE.
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The impact of the overall interventions and individual interventions was examined to determine if there were significant differences found in the students’ scores. A positive correlation was found between the total number of cultural experiences the students participated in and student’s overall TSE. Also, two specific interventions led to significant findings; they were the Assessment Technology Institute’s Real Life Scenarios and cultural immersion experiences. The simulated patient scenarios are relatively new and no studies in the literature address Assessment Technology Institute’s Real Life Scenarios and cultural competence. However, this study found significance in increasing both cognitive and affective TSE based on the numbers of the scenarios completed by senior-level students. This is important to educators as seek new ways of improving students’ cultural competence in the provision of care. Cultural immersion experience opportunities were made available to students in three locations: a Navajo reservation, Nicaragua, and South Africa. Students who participated in one or more of these experiences had higher mean affective scores. This is consistent with Amerson’s (2010) findings that immersion experiences improve cultural competency. The intensity of living, interacting, and providing care for people from another culture is likely to induce profound emotional responses.
program have limited exposure to the nursing curriculum until the junior year and may not have understood some of the questions. One question, “How confident are you that you recognize the need for cultural care repatterning/restructuring?” may have been problematic for novice nursing students.
Limitations
Implications
Aggregate data are helpful in understanding that student scores on the TSET were influenced by the cultural interventions that were provided. However, it explains little about which specific interventions may have provided the greatest impact. Also, aggregate data do not account for students who left the institution from one semester to the next and those who enrolled only for spring semester. The modified pool of students may have affected results. Presumably, students who stayed versus those who left were more committed to their education and more confident in their overall abilities. Coded identifiers will be added in future studies. This longitudinal data analysis approach is similar to one used by Jeffreys and Dogan (2012) and will allow for more powerful tests by tracking individual changes. The absence of a control group was another limitation in this study; other forces such as the influence of the normal college experience or maturation may account for changes in SEST scores and SEL. The addition of a comparison group, perhaps from another school, would increase the ability to measure change based on the interventions. Students were asked to complete the 83-item TSET twice in an academic year. After the first year of the study, the design was altered to administer the TSET only in the spring semester in order to decrease the exposure effect (familiarity principle) that could potentially influence results. Some of the TSET items are complex and more reflective of upperclassmen knowledge and ability. Students in this
Nurse educators can make a difference by thoroughly integrating transcultural nursing content and experiences into the curriculum. Models such as the CCC provide the framework for developing educational design, implementation strategies, and evaluation of nursing curricula. Tools such as the TSET have been tested extensively and provide useful evaluative information regarding the effectiveness of specific transcultural interventions. Understanding demographic variables that affect cultural competence, such as social orientation, should continue to be explored. Based on this study, computer-assisted learning experiences and immersion experiences are two positive methods to enhance and support culture competence.
Conclusion The American Association of Colleges of Nursing (2008) asserts that organizational commitment to enhancing the cultural competence of faculty and students is vital. The intentional and systematic inclusion of cultural content and experiences in nursing education across the United States is overdue and necessary in a health care environment that is no longer isolated by geographic boundaries. This study did not find significant relationships between TSE and most demographic variables examined; the results did support that student perceptions of TSE can be modified by formalized educational and other culturally relevant learning experiences. Immersion experiences and the use of computer-assisted scenarios are two valuable methods for improving TSE. As this study is continued over the next 2 academic years, additional knowledge will be gained regarding how student TSE is affected when educators intentionally integrate transcultural care concepts throughout the curriculum.
Acknowledgment This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by a Health Resources and Service
Halter et al. Administration Grant #D11HP22187-01-00, I CARE: Increasing Baccalaureate Nursing Enrollment, Nurse Education, Practice, Quality and Retention (NEPQR), provided to Ashland University.
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