brief report

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:

Received Date: 15 September, 2018; Accepted Date: 12 October, 2018; Published Date: 18 October, 2018
Citation: 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. 

 Cultural Compeence; Premed Students; Transcultural Nursing; Transculturall Self-Efficacy Tool

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





The Cognitive Scale





The Practical Scale

26 - 53




The Affective Scale

54 - 83




The Advocacy

82 - 83




Pre-Med Students





The Cognitive Scale





The Practical Scale

26 - 53




The Affective Scale

54 - 83




The Advocacy

82 - 83




Table 1: Results regarding survey.

1.         Jeffrreys MR (2010) Teaching Cultural Competence in Nursing and Health Care (2nd Edition). New York: Springer Publishing 2010.

2.         Jeffrreys MR (2010) Teaching Cultural Competence in Nursing and Health Care (2nd Edition). New York: Springer Publishing 2010.

3.         Leiininger M McFarland (2006) Culture Care Diversity and Universality: A Worldwide Nursing Theory (2nd Edition) Boston: Jones & Bartlett Publishers 2006.

4.         Purnell LD (2014) Guide to Culturally Competent Health Care (3rd Edition) Philadelphia: F.A. Davis Co 2014.

5.         Spector R (2017) Cultural Diversity in Health and Illness (9th Edition) New York: Pearson 2017.

6.         Busher Baetancourt D (2015) Madeleine Leininger and the transcultural theory of Nursing. The Downtown Review 2.

7.         Burrell P (2010) Perceived cultural competency of Nursing students. In: Teaching Cultural Competence in Nursing and Health Care 2nd Ed. Jeffreys MR. New York: Springer Publishing Co 2010.

8.         Burrell P (2018) Cultural competence in Nursing: Transcultural Nursing Self-Efficacy. Proceedings of the 7th Global Healthcare Conference GHC 2018: 93-95.

9.         Giger JN, Davidhizar RE (2004) Transcultural Nursing: assessment & Intervention (4th Edition) St. Louis: Mosby 2004.

© by the Authors & Gavin Publishers. This is an Open Access Journal Article Published Under Attribution-Share Alike CC BY-SA: Creative Commons Attribution-Share Alike 4.0 International License. With this license, readers can share, distribute, download, even commercially, as long as the original source is properly cited. Read More.

International Journal of Nursing and Health Care Research