Scholarly Peer Reviewed Nursing Journal Articles on Diversity and Patient Care

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Research Article

Developing and validating the Nursing Cultural Competence Calibration in Taiwan

• Mei Hsiang Lin,
• Te Hsin Chang,
• Yu Hsia Lee,
• Pao Yu Wang,
• Li Hui Lin,
• Hsiu Chin Hsu

ten

• Published: August xiii, 2019
• https://doi.org/10.1371/journal.pone.0220944

Figures

Abstract

Groundwork

Civilization influences personal health habits and behavior, and healthcare personnel possess different views of cultural perspectives. Currently, an appropriate musical instrument to assess cultural competence in clinical practice is limited. The present study aimed to develop and examine the psychometric properties of the Nursing Cultural Competence Calibration (NCCS) for clinical nurses.

Methods

Developing and assessing the scale was carried out in two phases: Phase I involved a qualitative research to explore the themes of nurses' cultural competence and instrument evolution; Phase II established construct validity of the scale using a sample of 246 nurses in Taiwan. Data from the questionnaire were analyzed using exploratory factor analysis, confirmatory cistron analysis, internal consistency and test-retest reliability. Analysis results were used to decide the reliability and validity of the developed scale.

Results

The results showed iv factors including cultural awareness power, cultural action power, cultural resources application ability, and self-learning cultural ability were generated by exploratory factor analysis, and these factors explained 62.0% of total variance. Cronbach's α of the Nursing Cultural Competence Scale was .88, and test-retest reliability correlation was .70.

Conclusions

The establishment of the tool will facilitate accurate monitoring of the cultural competence among nurses and nursing managers, which can inform the construction of nursing policies aimed at pledge cultural competence expansion.

Commendation: Lin MH, Chang Th, Lee YH, Wang PY, Lin LH, Hsu HC (2019) Developing and validating the Nursing Cultural Competence Scale in Taiwan. PLoS ONE 14(8): e0220944. https://doi.org/10.1371/periodical.pone.0220944

Editor: Meng-Cheng Wang, Guangzhou Academy, CHINA

Received: February vii, 2019; Accepted: July 27, 2019; Published: August 13, 2019

Copyright: © 2019 Lin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted apply, distribution, and reproduction in any medium, provided the original writer and source are credited.

Information Availability: All relevant data are within the paper and its Supporting Data files.

Funding: The authors would like to thank the Ministry of Science and Engineering science of Taiwan for funding [grant numbers: MOST 105-2511-Southward-227 -002 -MY2] this study. The funders had no role in study pattern, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors take declared that no competing interests be.

Introduction

Today, international migration is a global and complex miracle. The culturally competent healthcare structure may exist augmented [1–2]. Cultural competence consists of two subconcepts, civilization and competence [iii]. Culture is a collection of shared characteristics that encompasses learned patterns of thought, communications, beliefs, institutions of racial, religious as well as social groups and beliefs, including language, activity, and ethnic or religious institutions [four– 6]. Competence implies an ongoing process that involves accepting and respecting differences and non letting one's personal cultural beliefs have an undue influence on those whose worldview is different from one's own [v]. Nursing cultural competence has generally been understood in a nursing chapters to promote the health and wellness of clients whose cultural backgrounds are different from that of the nurses [7].

Many researchers accept reported that nursing cultural competencies tin ensure that nurses would provide culturally specific information, equally well as certain explicit services to clients with different cultural conflicts [3, viii]. Notably, cultural competence is considered to exist a cadre competency as evident in the professional codes and standards of practice internationally [nine]. There are more than than 45 types of self-administered tools for cultural competence amid the wellness professionals that are used in both a clinical and curricular content [10]. To the best of our knowledge, no scale has been developed with uniqueness and specificity to discover the localized experience of nursing cultural competence in Taiwan. Therefore, an urgent need for localized tools of cultural competence for nurses has emerged to assess their abilities of diversity from a cultural perspective.

A number of researchers take reported that civilisation could affect personal health habits and beliefs, along with the noesis of, and seeking a response to healthy behavior [11–xiii]. Accordingly, Nielsen et al. [14], conducted a qualitative study which showed that the issue of death is often considered a taboo when discussed in public for the Chinese. From this signal of view, because nurses are the gimmicky healthcare providers, and identify a significant function in performing cultural assessments, they must be sensitive to the delivery of culturally appropriate care [13, 15]. Immature and Guo [six] stated that communication styles, cultural differences, explanatory styles, and interpreter services are several perspectives that require when in providing care for diversified populations. Additionally, as part of a cultural assessment, determining the specific values, behavior, attitudes, and health needs of each patient are crucial [15]. For this reason, the cultural competence measurement tool requires to be recognized and transcend this different exposure to cultural diverseness [16–17]. Also, the challenges of cultural multifariousness revolve around linguistic differences, verbal/nonverbal communication, and multigenerational differences [6]. However, the current measuring cultural competence tools focus on the personal attributes of medical care providers, without because the cultural diverseness of cases or their health outcomes [xviii]. Indigenous/ethnic wellness differences have been well described in numerous literature. Betancourt [19] pointed out that minority members are particularly afflicted by specific illnesses such every bit cardiovascular disease, diabetes, asthma, and cancer. Hence, in determining the relevance of cultural competence to health and well-existence, information technology is noted that cultural competence in healthcare merged, in part, as a means of addressing racial and ethnic inequalities that may lead to wellness disparities [20].

The measurement of cultural competence includes both the general and specific cultural data, and serves as an assessment reference for health intendance providers [five]. Culture-specific tools assess the ability of the healthcare professionals to care for the patients' needs from a particular cultural groundwork [18], such as in the Cultural Self-Efficacy Scale (CSES) [21]. Whereas culture-full general tools do not distinguish between cultural groups, every bit in the Inventory for Assessing the Procedure of Cultural Competence amongst Healthcare Professional-revised (IAPCC-R) [2]. However, since few related instruments have demonstrated an acceptable reliability and/or validity, these assessment tools nevertheless exhibit limitations [22]. Lin et al. [23] conducted a systematical review which reviewed the English language-linguistic communication articles published from 1983 to 2013, as the findings showed that the psychometric properties of several instruments are regularly used to appraise the cultural competence of the healthcare providers, and discovered that virtually of the Chinese versions of the cultural competence instruments are by and large based on previous literature or direct translated from the Western instruments. At this signal, Cai et al. [22] indicated that it was necessary to develop a psychometrically sound instrument with a reasonable format and diction to present a complete moving-picture show of cultural competence in the Chinese nursing context that is distinct from those of Western countries. Along with this line, the 'Nurses' Multicultural Caring Competence Scale (NMCCS)' is mostly accepted as a valid measurement to investigate the cultural competence of the nursing staffs in Taiwan [24], however, it was still translated from the Western instrument. Moreover, the 'Cultural Competence Inventory for Nurses in Red china (CCINC)' [22] which contains five dimensions with 29 items has been developed for the perception of the Chinese nurses regarding cultural competence. The psychometric properties of the CCINC had showed good reliability and validity by examining Cronbach's alpha and exploratory factor analysis. It is worth noting that as globalization continues to diversify populations, while current views of cultural competence for nurses in Taiwan have been chiefly adopted from Western cultures. The various ethnic groups have diverse medical care needs, for case, immigrant patients who are waiting for an performance would like to bring a temple amulet with them, or request caregivers to perform religious rites in their wards because of their illnesses.

Civilization is highly specific and individual, as nurses cannot pattern treatment plans on the basis of uniform standards when facing culturally-various patients. Therefore, a more suitable cultural competencies scale is needed to assess the nurses' cultural competence and their interaction with the culturally and/or ethnically diverse patients. The aims of this study were to develop and examine the psychometric properties of the Nursing Cultural Competence Scale (NCCS) among nurses in Taiwan.

Methods

Pattern

Two phases were conducted to develop the NCCS for assessing the cultural competence of the clinical nurses. In-depth interviews were employed in Stage I to establish a large pool of potential items which were constructed as the preliminary calibration, and and so tested the instrument using the item analysis before defining the concluding relevant items of the scale. A cross-sectional with a descriptive study design was used for evaluating the psychometric properties of the final calibration in Phase II.

Setting and sample

Convenience sampling was employed to recruit participants from a variety of infirmary units, including internal medicine, surgical, pediatric, intensive care units, and gynecology units. Likewise that, in Taiwan, the clinical ladder arrangement is one with a hierarchical structure that tin can be classified in four clinical ladder levels associated with an private'southward clinical abilities and proficiency growth. The four levels were N0/ N1 (responsible for bones nursing), N2 (critical care nursing), N3 (in charge of education and holistic nursing), and N4 (responsible for research and specialized nursing) [25]. The inclusion criteria were those registered nurses who have been employed for more than one yr and are willing to share cultural experience during clinical care.

Nurses who were diagnosed with astringent depression or other major illnesses (i.e., malignancies) were excluded from this report. There were 250 participants who met the inclusion criteria. Four participants who did non complete the questionnaire were excluded from this study. Therefore, a total of 246 participants completed this study (Phase 2), and the response rate was 98.four%.

Procedures

Initial item pool and item analysis (Phase I).

The NCCS items were derived mainly from information elicited during the 30 in-depth interviews. The years of nursing experiences in clinics varied from two to 20 years. The numbers of participants working in the general wards, emergency room, intensive care unit, and as example managers were v(17%), nine (xxx%), six (20%), 7 (23%) and three (10%), respectively. A semi-structured interview guide was adult to explore the interviewees' opinions on their cultural competence experiences among the clinical nurses. The average time for interviewing ranged from xxx to 70 minutes. There were 4 interview guidance contents including: 'What are the differences between the diverse health/sickness cultures?', 'What is your understanding of Taiwan'south health/sickness culture?', 'Please describe the content of some of the multicultural intendance your current workplace provides.', and 'In your opinion, how does one demonstrate the ability to provide multicultural intendance?' (S1 and S2 Files). Interview data were continuously collected until the information saturation was reached, and and then no new data was recorded. Initially, 23 items were generated and categorized nether five subheadings including (a) 7 items addressing 'embarrassment when encountering unlike cultures'; (b) seven items addressing 'sensation of value differences'; (c) three items addressing 'difficulty implementing nursing piece of work'; (d) 3 items addressing 'seeking resource' and (eastward) iii items addressing 'encompassing and acceptances'.

A seven-member panel of experts, including iv nursing professors with expertise in spirituality, cultural and research, and three nurses that had more than ten years of experiences caring for foreign patients, were invited to verify the content validity of the NCCS. Content experts were asked to rate the clarity and relevance of each detail using a iv-point rating scale. A score of '1' indicated not adequate, while a score of '4' represented very adequate. Finally, the item-level content validity index (CVI) was .99, and the scale-level CVI was .91, indicating that the scale had a very good validity. Nevertheless, based on the experts' suggestions, four items were removed because of irrelevancy, redundancy and some wording ambiguities. This final musical instrument independent 19 item with a v-point Likert response calibration (i.e. 1 = 'Rarely', 2 = 'occasionally', 3 = 'neutrally', 4 = 'often', and v = 'e'er'). Item analysis including maximizing the internal consistency and evaluating how well the items fit together to correspond the potential construct of interest was conducted [26]. The corrected item- full correlation coefficients between the items ranged from .50–.71 and the correlation matrix was above .65 among the resultant nineteen-item console-modified version of the NCCS. These results indicated that the items were consistent with the connotations that the overall scale was intended to measure. No items were removed, and the psychometric properties of the refined calibration were so evaluated, later on which a further analysis was then conducted.

Psychometric properties evaluation (Phase II).

A total of 246 participants completed the new NCCS (S3 File) and the Chinese version of the Nurses' Multicultural Caring Competence Scale (NMCCS) (S4 File) in Phase 2. The psychometric properties were performed on all the psychological constructs to assess their validity and reliability. The sample size for validating a scale should exist based on the field of study to item ratio of five–10:one [27–28]. All of the enrolled nurses were asked to complete the questionnaires and and then place it into a box that was located outside their ward within seven days. See S5 File for the NCCS-minimal underlying information prepare.

Upstanding considerations

An blessing was obtained from the Upstanding Commission of the study hospital (approval No. 17MMHIS031e). The study purpose was fully explained to all the participants and written consent was acquired from them all, and they were also bodacious that the data nerveless was on an anonymous footing. Additionally, the participants were informed that they were not obliged to participate in the written report and could withdraw at any fourth dimension. The data were collected between August 2015 and July 2016.

Musical instrument

The Chinese version of the NMCCS was devised by Liang et al. [24], with a widespread usage among Taiwan'south healthcare workers. The 29 item NMCCS scale with a 5-point Likert-blazon scoring arrangement rated the responses from 0, representing 'strongly disagree' to four, representing 'strongly agree'. A higher score indicated a higher degree of cultural competence. This scale divided the cultural competence into four aspects, with a total of 29 items to measure out the 'cultural awareness power' (seven items), 'cultural knowledge' (eight items), 'cultural sensitivity' (iii items), and 'cultural skills' (11 items). The Cronbach'south alpha was .91, showing the comprehensive psychometric backdrop [24]. In this study, a Cronbach's blastoff of the NMCCSC was .94 indicating a satisfactory internal consistency. The NMCCS was adopted in the present study as criteria for determining the concurrent validity of the NCCS.

Statistical assay

Information was analyzed using the IBM SPSS software statistical version 20.0 and the IBM SPSS Amos version 22.0 for Windows (IBM Corp., Armonk, New York, The states). The characteristics of the participants in this study were analyzed using descriptive statistics. An exploratory cistron assay (EFA) was performed to determine the construct validity of NCCS. Hair et al. [29] postulated that the factor extraction criteria used were (a) a gene loading of .50 or above, (b) an eigenvalue greater than one for each component, and (c) a minimum of three items for each factor. After the factors were rotated, the criteria of factor interpretability and cistron usefulness were used to decide the number of factors [30]. The chief components assay and varimax rotation were conducted to extracted common factor. In point of fact, the criterion-related validity of the NCCS was analyzed past using Pearson's correlation to compute between the NCCS and the NMCCS to examine the concurrent validity of the NCCS. A confirmatory cistron analysis (CFA) was performed to validate the factor structure that was constructed in the EFA. The Goodness of fit the model was evaluated using a diversity of indices that were required to meet the following criteria: a χⁱⁱ/ df ratio of lower than 3; a goodness-of-fit index (GFI), non-normed fit index (NNFI), and comparative fit alphabetize (CFI) that were all higher than .90; a root mean square error of approximation (RMSEA) and standardized root mean squared residual (SRMR) that were less than .08 [31–32]. Moreover, internal consistency was assessed using Cronbach's blastoff coefficients. Test-retest reliability was estimated using Pearson'due south correlation coefficient.

Results

There were 246 participants that completed the required questionnaire and cess scales. Table 1 shows the participants' demographic data. Most were female person (north = 243, 98.8%) with a mean age of 32.30 ± 9.63 years (range, xx–58 years). The participants had been working every bit nurses for an average of ix.96 ± 9.52 years (range, 1–35 years). A total of 222 participants (90.2%) had experienced caring for strange nationals, and 121 participants (49.2%) possessed a clinical ladder system that was N1.

Construct validity

The internal construction of the 19-item NCCS was offset tested using the EFA with a varimax rotation. The Kaiser-Meyer-Olkin (KMO) measure out of sampling sufficiently produced a coefficient of .85, and the Bartlett's test of sphericity reached the statistical significance (chi-square = 2147.88, p < .001) that were significant without violation in both the cistron assay and sampling requirements. 4 factors emerged from the gene analysis that deemed for 62.0% of the explained variance of the NCCS. Factor 1 was loaded by the seven items, and named every bit the 'cultural awareness ability'. Factor ii consisted of six items, and named as the 'cultural action power'. Gene 3 represented the 'cultural resource application ability' and included 3 items. Factor four consisted of iii items, and named as 'self-learning cultural ability'. The four factors explained the variances ranging from 12.6 to nineteen.i% (Table 2).

The CFA was used to validate the gene construction that was constructed in the EFA. The model fit indices for the initial CFA were generally adequate (i.e., χ² /df = 2.50, CFI = .89, SRMR = .06, and RMSEA = .07). Convergent validity is illustrated in Table 3 and Fig 1, all standardized factor loadings exceeded the threshold of .l, and the average variance extracted (AVE) for each construct ranged from .43 to .69. Furthermore, the construct reliability (CR) for all of the constructs was greater than .82, which provided evidence for the convergent reliability of this instrument. Table four shows the discriminate validity of the CCNS. All of the foursquare roots of the AVE for each construct (values in the diagonal elements) were greater than the corresponding inter-construct correlations (values below the diagonal). This suggested that the results supported the discriminate validity of the current musical instrument.

In Table v, the results showed that the 'cultural awareness ability', 'cultural action ability', 'cultural resource application ability' and the 'self-learning cultural ability' correlated significantly and positively with the NMCCS (r = .22, .39, .33, and .44, respectively; p < .001).

Reliability

The results of this report revealed that at that place were good internal consistency reliability for the NCCS and information technology subscales. The Cronbach'south alpha coefficients for the global NCCS were .88, and the Cronbach's alpha coefficients for the subscales were as follows: .84 for the 'cultural awareness ability', .83 for the 'cultural action power', .86 for the 'cultural resources awarding ability' and .82 for the 'self-learning cultural ability', indicating a good internal consistency among the items. The stability of the NCCS was verified by fulfilling test-retest. The correlation coefficients from .53 to .61 were institute in the four subscales (Table 2).

Discussion

This newly adult scale is a culturally specific musical instrument designed to measure out the nurses' ability for providing various aspects of the cultural contexts of clients in Taiwan. As aforementioned at that place must be at least three items in 1 factor since besides few questions would not be able to test the characteristics of the factor [thirty]. The newly developed NCCS has more than than three items in each factor. Additionally, the four factors indicated that the total variance of the scale was 62%, which explains that the ratio is higher than the error ratio. This consequence shows that all four factors are representative, and hence, the newly designed cultural competence calibration has a expert construct validity, indicating that the NCCS can be used to evaluate the nurses' cultural competence.

Unremarkably, the EFA is the first footstep in building a scale or a new metric system [33]. The measure of sampling adequacy value was .85 using the Kaiser-Meyer-Olkin mensurate for the EFA, which is considered "meritorious" by Kaiser [34]. In addition, the Bartlett's test of sphericity reached a statistical significance of (p < .001). In the final scale, all 19 items with factor loading > .50. According to Pilus et al. [29], the factor loading of more than .50 should be canonical past the criterion of selection for the scale items in order to construct a scale to analyze the results. Therefore, the NCCS met the assumptions for the factor assay. The NCCS could be considered as a new measuring tool for Taiwan'southward clinical nurses to assess their cultural competences. Furthermore, the results showed a Cronbach's blastoff was .84 for cistron one, .83 for factor two, .86 for factor 3, .82 for factor 4 and .88 for the overall calibration. DeVellis [35] pointed out that a proficient reliability of the calibration should be in a higher place .eighty, and the new NCCS possessed the reliability betwixt .82 and .86, which is thought to be more than than acceptable in consequent reliability.

Four factors have emerged from the cistron analysis. The first, which entitled the 'Cultural sensation ability', has a total of seven items and implies that the nurses' cocky-cultural perspective allows them to care for the patients from unlike cultures, as well as understanding when the patients will not accept handling due to traditional taboos, such equally death, which is a subject field that cannot be discussed. Traditional taboos have brought challenges to the health care system in Taiwan, and thus reduce constructive communication with culturally diverse clients. The finding was congruent with previous studies which showed that taboos and other daily rituals, which restrict certain activities or mandate certain behaviors, could either harm or benefit homo health and/or livelihoods [36]. From a Chinese medical perspective, the Chinese culture puts a tremendous influence on the perceptions of Taiwan's nurses nigh their role equally healthcare providers. Chew et al. [xiii] studied the bear on of Chinese cultural health beliefs among 50 Malaysian Chinese from the general public of a suburban population. Those authors found that healthcare providers needed to exist aware of existing beliefs and practices among the Chinese patients regarding traditional Chinese medicine. Simply stated cultural sensation signifies the ability to realize in a meaningful style that ane's own cultural viewpoints are different from those of others, assuasive one to know more than well-nigh any personal understanding and bias towards foreign cultures [24].

The 2d factor, which entitled the 'Cultural action power', consists of vi items and points out that nurses are able to provide nursing services according to the needs of the patients' cultural background. Nursing care involves emphasizing the practical aspects of communication and problem solving. After evaluating the information related to the cultural background for each patient, the nurses are able to deal with any misunderstandings with the patients due to the language bulwark, and and so provide different degrees of nursing care owing to the differences in religious rituals or lifestyles. The finding of this written report was consistent with those of previous studies that addressed the health professionals abandoning their personal biases, thereby making them more than able to carry out the cultural assessments and utilize [37–38].

The third cistron, which entitled the 'Cultural resource application ability', has a full of three items and indicates that nurses are able to search different resources to satisfy the cultural background needs of unlike patients. This includes existence able to find assistance from different professional person personnel, such as religious personnel, careers, or strange workers, and Net resources. This finding was similar to a report that claimed nurses were reported to arm-twist the assistance of colleagues, patients' caregivers, or fifty-fifty help from another client when dealing with various cultural aspects in clinical settings [39].

The fourth gene entitled the 'Self-learning cultural ability' has a total of three items, which indicate that nurses are able to utilise unlike methods, including reading books or taking part in cultural or language teaching classes, in order to enrich their agreement of different cultural data. The finding was like to a survey conducted by Cicolini et al. [40], which showed that nurses acquired a certain level of cultural sensation and sensitivity through the feel of cross-cultural nursing in service education. However, findings of the present study were contradictory with a written report by Almutairi et al. [41], which reported that some nursing staff tended to be reluctant to larn about the patients' culture and presenting passive learning well-nigh cultural competence.

The strength of this written report is that the initial items were adult using in-depth interviews with nurses in Taiwan. The qualitative inquiry method of this study highlights the differences in the clinical cultural backgrounds between these nurses and those in the Due west. Cultural diversity can besides refer to having different cultures respect each other's differences [42]. In Taiwan, various groups have diverse medical intendance needs, including new immigrants, elderly individuals accompanied by foreign caregivers, and preoperative patients who wish to bring a temple amulet with them or wish caregivers to perform religious rites in the patients' infirmary rooms because of their illnesses. Situations such as these in which members of different groups require culturally various health care are extremely common in clinical settings. Therefore, results from the current study indicated that the NCCS possessed a substantial reliability and validity for assessing the cultural competence of the clinical nurses.

Another strength of this study is that multiple methods were used to establish the validity of the NCCS, including using the EFA and CFA to construct validity, and criterion-related validity. CFA is a statistical technique that is used to verify the factor structure of a set of observed variables [43]. The present study used CFA to cheque equally to whether this new construction was acceptable with our sample. The findings showed that the model fit of the NCCS, as evaluated using GFIs, SRMR, and RMSEA was adequate, and the CFA yielded four factors. The NCCS and its subscales were found to take practiced internal consistency. On the other mitt, Cai et al. [22] conducted a study in which the groundwork was familiar with this electric current report, Cai did not perform the CFA to validate the factor structure of the new scale.

There are several limitations of the study. Firstly, since convenience samplings and homogenous groups were employed in the present study, the generalization to the total population of clinical nurses cannot be causeless. Therefore, farther testing of the NCCS is needed to cross validation on other Taiwanese clinical nurses. Secondly, 38% of the variance value was unable to be explained due to the NCCS being a new instrument with only preliminary testing, and there is nevertheless a demand of ensuring boosted tests to corroborate the findings of the present study.

Conclusion

The developed NCCS has an acceptable reliability and validity when measuring the nurses' cultural competence. Hence, this calibration not only provides the nurses with an constructive analysis of their clinical care cultural competence ability, but can also be used every bit a reference for their clinical in-service educational activity design and planning. Furthermore, using the NCCS for assessment may provide the clinical nurses, nursing managers, and nursing educators with information about the aspects of cultural competences to guide the interventions, thereby supporting their continuous professional evolution.

Supporting information

Acknowledgments

"The authors would like to thank the Ministry of Science and Technology of Taiwan for funding [grant numbers: Most 105-2511-Due south-227–002 -MY2] this written report. The funders had no role in study blueprint, data collection and analysis, decision to publish, or preparation of the manuscript." this written report and the nurses who participated in this study.

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Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0220944

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