Cultural Competence: Transcultural Self-Efficacy in Nursing and Pre-Med Students
Patricia M. Burrell1*, Allison Bachlet2
1College of Health and Society, Hawaii Pacific
University, Kaneohe, Hawaii, USA
2College of Natural and Computational Sciences,
Hawaii Pacific University, Kaneohe, Hawaii, USA
*Corresponding author: Patricia
M. Burrell, College of Health and Society, Hawaii Pacific University, Kaneohe,
Hawaii, USA. Tel: +1-808-236-5813; Fax: +1-808-236-3524; Email: pburrell@hpu.edu
Received
Date: 15 September, 2018; Accepted Date: 12 October,
2018; Published Date: 18 October, 2018Citation: Burrell PM, Bachlet A (2018)
Cultural Competence: Transcultural Self-Efficacy in Nursing and Pre-Med
Students. Int J Nurs Res Health Care: IJNHR-148. DOI: 10.29011/
IJNHR-148. 100048
Cultural
competence and Transcultural Nursing focuses on acknowledging, knowing about,
learning more about and using the culture of our clients in their health care.
Cultural competence, a lifelong evolving skill, is defined as a set of cultural
behaviors and attitudes integrated into the practice methods of a system,
agency, or its professionals, that enables them to work effectively in cross
cultural situations. A research agenda, examining the effectiveness of
Transcultural threads throughout the nursing curriculum was established in 2006
utilizing Jeffreys’ Transcultural Self-Efficacy Tool. We examined a small
sample of our graduating senior BSN students in 2016/17 along with a small
group of pre-med students. We looked at the self-efficacy of the students in
their utilization of transcultural skills. The TSET is based on perceived
self-efficacy in cognitive, practical and affective skills [1]. Results: On the cognitive scale, 35.43% of
the nursing students and 16.5% of the pre-med students perceived themselves as
high, while 63.43% of the nursing students and 51% of the pre-med students
perceived themselves as medium. On the practical scale, 24.66% of the nursing
students and 40.63% of the pre-med students scored high, with 71.93% of the
nursing students and 57.14% of the pre-med students scoring medium. On the
affective scale, 64.12% of the nursing students and 56.25% of the pre-med
students scored high, 35.71% of the nursing students and 24.17% of the pre-med
students scored medium. Recommendations: Nursing and the Pre-Med instructors
will enter into a discussion about the desired Transcultural efficacy of our
students.
1. Introduction
Transcultural
Care is about acknowledging the culture of our clients, knowing about the culture
of our clients, learning about the culture of our clients and using the culture
of our clients in their care. Madeleine Leininger, the founder of Transcultural
Nursing Theory noted that nurses need to be able to understand the cultural
care ways of the people for which they’re caring [2,3]. Leininger had noted in
her early days in pediatric nursing that nurses missed opportunities when some
of their patients and parents were from differing cultures. Leininger and
others have noted that these lost opportunities of understanding the culture,
beliefs and practices of the patients results in lost opportunities for healing
and positive health care outcomes and ultimately leads to higher health care
costs [3-5]. Busher Betancourt noted that since nurses are the largest group of
health care providers, they have a tremendous opportunity to deliver quality
care through the transcultural nursing model. The ultimate edge in the
transcultural nursing model is the openness and willingness to investigate the
ways of their clients which intensifies the caring aspect that is considered to
be the ultimate foundation for nursing [6].
While
Leininger most definitely established Transcultural Theory as highly pertinent
in Nursing, Spector and Purnell expanded Transcultural Theory to the overall
Health Professions [4,5]. Purnell noted that all profession involved with
health care utilized the same type of paradigms as Leininger’s Model. So going
beyond nursing and looking at pre-med students is also important in the ultimate
needs of clients of healthcare [4].
2.
The TSET
Jeffreys
addressed ways to teach transcultural nursing and healthcare in ways that would
assist developing the appropriate skills to address the cultural ways of
clients in nursing and health care. She focused on perceived self-efficacy in
three arenas that are important in health care, cognitive, practical and
affective skills. She perceived transcultural self-efficacy as a “…perceived
confidence for performing or learning general transcultural skills among
culturally different clients.” Jeffreys posited cultural competence as “…a
multidimensional learning process…integrating transcultural skills in three
dimensions (cognitive, practical, and affective), and involves transcultural
self-efficacy (confidence) as a major influencing factor…” [1]. Jeffreys
Transcultural Self-Efficacy Tool (TSET) addresses confidence in transcultural
nursing and health care in the cognitive sphere by addressing questions
pertaining to knowing and understanding cultural factors that influence care.
The practical arena addresses questions pertaining to their capacity to conduct
a cultural assessment of clients. And the affective arena addresses questions
pertaining to their knowledge of themselves and their own culture as well as their
willingness to advocate for those from other cultures. The cognitive domain of
the TSET has 25 questions, the practical domain has 28 questions and the
affective domain has 30 questions. In summary, the TSET is an 83-item tool
addressing perceptions of Transcultural Self-Efficacy.
3.
TSET Utilization
In the early
2000s, our Nursing School received a 3-year U.S. Department of Health and Human
Services Administration (HRSA) grant focused on the development of culturally
competent practitioners. We examined the effectiveness of the transcultural
nursing threads throughout our nursing curriculum. We had transcultural nursing
threads throughout our curriculum at all levels. For example, our Gerontology
course not only focused on the healthy elder but also spotlighted the varying
cultures of the elders in our community. The case studies focused on cultural
understanding about some of the many cultural misunderstandings that have
happened in health care and that our practitioners may still come across in
their clinical experiences and ultimately in their clinical practices.
We surveyed
the nursing students when they first entered the program and again right before
they graduated. Our sample size in one of our first cohorts was 248 students.
The Chronbach’s alpha on the total TSET was 0.810. The cognitive scale was
0.987, the practical scale was 0.991, and the affective scale was 0.397. The
post-test scores on the TSET were as follows: Cognitive, High - 13.89%, Medium
- 15.47%, and Low - 73.54%.: Practical, High - 50.51%, Medium - 47.60%, and Low
- 1.89%: and Affective, High - 96.75%, Medium - 3.25%, and Low - 0.02%.
Advocacy, which is items 82 and 83 post-test scores, High - 72.72%, Medium -
24.9%, and Low - 2.38%. Our biggest concern on the posttest was the low Cognitive
scale score. In our discussion with others, we realized that the timing of the
posttest, right after we presented information and material about taking the
National Exam for Nursing (NCLEX) may have contributed to the low score in the
cognitive domain [7].
4.
TSET Utilization in 2017
ze have, as
have many schools, gone through many curriculum changes over the years. The
need for culturally competent care has not waned over the years. In fact, the
need for culturally competent care has increased. It was time to look at the
Transcultural Self-Efficacy of our students. We got IRB approval for the study
and we obtained the copyright for the TSET. Since Hawaii Pacific University
prides itself in our highly diverse student body, we expanded beyond the
Nursing Department and surveyed other departments that were preparing students
in caring. Although we tested many of our students, this report will address a
portion of our graduating senior BSN students and the pre-med students.
4.1.
Sample: We obtained a small sample of convenience of
21 graduating senior BSN students and an even smaller sample of 8pre-med
students.
4.2.
Our Research Question: What is the
self-efficacy of our graduating senior BSN students and the junior level
pre-med students.
4.3.
Methods: We usually requested that the students fill
out the survey at the start of a class. We had a consent form attached to the
Survey, which we asked the students to sign and pass back to us. Then they took
the 83-item survey. The surveys were collected and then the class continued.
The surveys were delivered back to the lead investigator after the end of the
class.
4.4.
Results: The results regarding the survey was
mentioned below (Table 1).
5.
Discussion
The cognitive
scale findings were higher than our first group’s scoring in nursing, so we’re making
headway in this arena. The cognitive arena covers their awareness of possible
cultural differences and their effect in their providing quality nursing care.
The practical scale was stronger in scoring medium level perceived proficiency
than high proficiency. This scale covers their proficiency in doing a cultural
assessment of their clients. There is a need to work on this issue in our
curriculum. The affective scale was weaker in their awareness of their own
culture and cultural biases. However, the advocacy scale was higher than our
first TSET nursing student group [8].
The cognitive
scale in the pre-med students indicated that 67.5% were medium to high in
understanding differing cultures of possible clients. While 32% indicated a
need to increase knowledge. The pre-med students indicated a 97.77% confidence
in the area of conducting a cultural assessment of clients. Only 2.23% felt
shaky about this undertaking. Although, the pre-med students scored 78.42% of
medium to high in cultural self-knowledge, 19.58% scored low. However, the
telling piece was that 100%; 75% high and 25% medium felt that they could
advocate for their clients. None felt that they could not advocate.
Although we’re
moving ahead in the awareness of the influence of culture on the effect of
nursing care is improving, we still have a way to go. Nursing has decreased in
the perception of the students’ capacity to do adequate cultural assessment.
Although we have a strong medium perceived effectiveness, we can improve. The
pre-med students demonstrate a fair amount of confidence, their low score of
32% indicates a needed increase in their confidence about follow up on cultural
issues and their future clients. Nursing’s awareness of own culture and
cultural biases has decreased somewhat. Nursing can always improve on our
awareness of cultural bias. As can the pre-med students with their low score of
19.58%. One must take into consideration that the pre-med students are at the
junior level while the BSN students were at senior level, so maturation in
science might prove to be a changing factor in their progression. Advocacy has
increased somewhat in nursing and the pre-med students also indicated high
sense of advocacy. It’s nice that there was 0% Low perception of advocacy,
across both groups.
6.
Strengths and Weaknesses
First of all,
the sample size is very small. Both groups had small numbers. These numbers
were far smaller than our original sampling in the early 2000s.
7. Recommendations
It would be helpful to survey the pre-med students at
the start of their program and at finish to see if there are any changes. It
would really be helpful to follow up in the community with the nurses who have
graduated and are working to see what they look like in transcultural
self-efficacy to see if they carry through on their perceptions of
self-efficacy. In the meantime, it will be helpful to sit down and discuss the
findings with our respective departments as well as bring these findings to our
curriculum committees and examine our current stance and threading of cultural
competence in our curriculums.
Nursing Students |
Items |
High |
Medium |
Low |
The Cognitive Scale |
1-25 |
35.43% |
63.43% |
0.18% |
The Practical Scale |
26 - 53 |
24.66% |
71.93% |
3.06% |
The Affective Scale |
54 - 83 |
64.12% |
35.71% |
0.16% |
The Advocacy |
82 - 83 |
80.95% |
19.05% |
0% |
Pre-Med Students |
Items |
High |
Medium |
Low |
The Cognitive Scale |
1-25 |
16.50% |
51% |
32% |
The Practical Scale |
26 - 53 |
40.63% |
57.14% |
2.23% |
The Affective Scale |
54 - 83 |
56.25% |
24.17% |
19.58% |
The Advocacy |
82 - 83 |
75% |
25% |
0% |
Table 1: Results regarding survey.