Is the research study relevant to the study of nursing, (be specific and include examples from the article)?   2.  Is the method/design appropriate in terms of the research question/hyp

469The Journal of Continuing Education in Nursing · Vol 50, No 10, 2019

Predictors of Hospital Nurses’ Cultural Competence: The Value of Diversity Training Susan M. McLennon, PhD, ARNP, ANP-BC; Tara L. Rogers, BSN, RN, CCRN; and Altheria Davis, BSN

The United States is rapidly becoming a culturally and ethnically diverse country, with projections in- dicating that 56% of the total U.S. population will

be composed of various minority groups by 2060 (U.S. Census Bureau, 2015). Health care providers will need

to become increasingly culturally competent to provide high-quality care for more patients from diverse groups as they enter the health care system. In the past decade, there has been an increase in cultural competence training in health care related academic curricula and hospital orga- nizations to address the needs of diverse groups (Darnell & Hickson, 2015; Purnell, 2016). This may be attributed primarily to guidelines from national organizations and accrediting bodies that recommend that health care insti- tutions deliver culturally appropriate services (The Joint Commission, 2014; National Quality Forum, 2009; U.S. Department of Health and Human Services, 2015). At the organizational level, quality initiatives to promote cul- tural competence and address institutional barriers have resulted in improvements in diversity competency (Og- bolu, Scrandis, & Fitzpatrick, 2017; Weech-Maldonado et al., 2018). At the individual provider level, progress has been made in the quality of culturally appropriate pro- vider–patient communication, tailored care, and patient satisfaction (Crawford, Candlin, & Roger, 2017; Powell, 2016).

RNs are largely responsible for most of the direct care provided for patients and their families. Nurses should ex- hibit culturally congruent behaviors, eliminate bias, and cultivate cultural awareness (Darnell & Hickson, 2015). The American Association of Colleges of Nursing (AACN,

abstract Background: RNs must be culturally competent to

facilitate optimal health outcomes for diverse patients and families. The purpose of this study was to identify factors associated with cultural competence in hospi- tal nurses. Method: In this cross-sectional, descriptive study, the Cultural Competence Assessment Tool was administered to RNs (N = 74) from a 500-bed urban medical center in the southeastern United States. The mean age of participants averaged 40.6 (SD = 11.0) years, and most participants were White (63%) and had encountered more than five (66%) different cul- tures in their work environment in the prior 12 months. Forty-two percent had received two or more different types of diversity training (M = 1.6, SD = 1.1). Results: Mean score for overall cultural competence was 7.3 (SD = 0.8) on a scale of 0 to 10 (10 = highest pos- sible). Years of education was positively associated with diversity training (r = 0.31, p < .01) and cultural competence (r = 0.25, p < .05). Only diversity training predicted greater cultural competence (b = 0.40, p = .001). Conclusion: Results suggest that diversity train- ing is associated with greater cultural competence. Further research is needed to identify optimal types, dose, and frequency of diversity training to enhance overall cultural competence. [J Contin Educ Nurs. 2019;50(10):469-474.]

Dr. McLennon is Associate Professor, Ms. Rogers is MSN Student– Nurse Anesthesia, Ms. Davis is Registered Nurse, College of Nursing, Uni- versity of Tennessee–Knoxville, Knoxville, Tennessee.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Susan M. McLennon, PhD, ARNP, ANP- BC, Associate Professor, College of Nursing, University of Tennessee– Knoxville, 1200 Volunteer Blvd., 331, Knoxville, TN 37996; e-mail: [email protected].

Received: November 3, 2018; Accepted: June 10, 2019 doi:10.3928/00220124-20190917-09

470 Copyright © SLACK Incorporated

2019) statement on diversity in the nursing workplace em- phasized the need for nurses to be culturally competent for the purpose of providing quality care. Recent research sug- gests that nurses desire greater knowledge about providing culturally competent care (Eche & Aronowitz, 2017) but lack access to culturally specific resources (Ogbolu et al., 2017). In addition, 77% of the three million nurses com- prising the current workforce are White (Bureau of La- bor Statistics, 2018). Despite efforts to increase diversity among newly enrolled nursing students, only 32% of the students enrolled in baccalaureate nursing programs were from minority backgrounds (AACN, 2018).

A variety of factors have been reported to influence nurse cultural competence such as age, years of experience, educa- tional level, and frequency of diversity experiences (Cicolini et al., 2015; Lin, Mastel-Smith, Alfred, & Lin, 2015; Schim, Doorenbos, Benkett, & Miller, 2007; Young & Guo, 2016). Diversity training has been recommended, but optimal peda- gogical methods remain unclear and influenced by resource constraints (McElroy, Smith-Miller, Madigan, & Li, 2016; Ogbolu et al., 2017). Academic educators have espoused threading diversity training through the curriculum, simula- tion activities, and the use of linguistic frameworks (Bahre- man & Swoboda, 2016; Crawford et al., 2017). Clinical educators in hospitals have used training videos, group dis- cussions, journaling, and case-based scenarios (McElroy et al., 2016; Warren, Baptiste, Foronda, & Mark, 2017). Targeting cultural competence at the hospital organizational level has also been successful (McElroy et al., 2016).

In a recent systematic review of 51 qualitative studies that examined the experiences of hospitalized minority patients, Degrie et al. (2017) identified four main themes. The themes depicted the encounter between two different cultural contexts (provider and patient); the dynamics of ongoing relationships with different providers; efforts by the patient to achieve a balance between the two contexts to maintain their own individual traditions and values within the limitations and realities of the hospital care environment; and mediators of family, communication, organizational culture, and humanness. This description highlights the complexity of interactions between people from different cultures and potentially modifiable organi- zational and human factors. Clearly, nurse cultural com- petence is highly desirable to optimize care for minority patients, and improvements have been made in recent years. However, a greater understanding of the factors in- fluencing cultural competence among RNs is needed to strategically develop efficient methods to target improve- ments in nurse cultural competence. The purpose of this study was to identify factors associated with cultural com- petence among nurses working in hospital settings. This study addressed the following question: Is there a relation-

ship between cultural competence and nurses’ age, years of education, diversity experience, and diversity training?

THE MODEL OF CULTURALLY CONGRUENT CARE The theoretical model of culturally congruent care

guided the current study (Schim et al., 2007). The model was envisioned using the metaphor of a puzzle, with each piece representing parts of the final picture—culturally congruent care (Schim et al., 2007). Key concepts (i.e., puzzle pieces) in the model included cultural diversity, awareness, sensitivity, and culturally competent behav- iors (Schim et al., 2007). Cultural diversity was described as the quality and quantity of cross-cultural experiences. Cultural awareness was described as knowledge about cul- tural contexts (i.e., history and background) and influence on health care. Cultural sensitivity encompassed attitudes toward self and others and a willingness to appreciate dif- ferent cultures. Culturally competent behaviors reflected actions as responses to cultural diversity, awareness, and sensitivity and demonstrated in practice.

METHOD Procedure

In this descriptive, cross-sectional study, a paper survey was distributed to RNs on two different medical–surgical units at one southeastern urban medical center. Nursing unit directors on the respective units were contacted and approval was received to distribute the surveys in nurse’s mailboxes. Surveys contained an information sheet explain- ing the purpose, risks, benefits, anonymity, and contact in- formation. No identifiers or protected health information were collected. Nurses were given 2 weeks to complete the survey. Participation was voluntary, and a $5.00 gift card was awarded upon completion. Nurses returned completed surveys to a designated box located on each nursing unit.

Sample After receiving approval from the institutional review

board and following ethical procedures for the protection of human subjects, the one-time survey was completed by the convenience sample of 76 RNs. Approximately 110 sur- veys total were distributed to the RNs (55 per unit), which equated to an acceptable 69% response rate (Nulty, 2008). Two surveys were not included due to more than 50% miss- ing data. The final sample (n = 74) consisted primarily of White nurses (63%), with a mean age of 40.6 years and a bachelor’s degree or higher in nursing (60%).

Measures The survey consisted of 33 items, including the Cultur-

al Competence Assessment (CCA) (25 items), Diversity Training (two items), Diversity Experience (two items),

471The Journal of Continuing Education in Nursing · Vol 50, No 10, 2019

Self-Assessed Cultural Competence (one item), and de- mographic information (three items) (Schim, Doorenbos, & Borse, 2005). The CCA consisted of two subscales that assess cultural awareness and sensitivity (CAS) and cul- turally competent behaviors (CCB). The CAS subscale contained 11 items, with 5-point Likert scale response op- tions from strongly agree to strongly disagree. An example of a question from the CAS subscale is “I understand that people from different cultures may define the concept of ‘health care’ in different ways.” The CCB subscale con- tained 14 items, with 5-point Likert scale options from al- ways to never. Items for each subscale were summed (some items reverse scored) and divided by the number of items, with higher scores (range = 1 to 5) indicating greater cul- tural awareness and sensitivity or culturally competent be- haviors. An example of a question from the CCB subscale is “I find ways to adapt my services to individuals and group cultural preferences.” Overall cultural competence (CCA) was calculated by summing the two subscale (CAS + CCB) scores. In this study, overall (total score) CCA was used as the dependent variable.

Cultural diversity training was measured with two questions that asked whether the nurse had ever received cultural diversity training (yes or no) and, if so, to identify the different types of training received from a list of eight options. A total score for diversity training was calculated by a count of the options selected, with higher numbers indicating greater diversity training. Cultural diversity experience was measured with two items that asked par- ticipants to identify the number of individuals from other cultural groups they had worked with or cared for (respec- tively) in the past 12 months, with up to eight options to select. The questions were scored with a count of the number of groups indicated, with higher numbers mean- ing greater diversity experience. The Self-Assessed Cultural Competence question asked participants to rate their own perceived cultural competence on a 5-point Likert scale, with options from very incompetent to very competent, with higher scores indicating greater cultural competence.

Demographic items included questions about age, self- identified race and ethnicity, and level of educational at- tainment (high school, associate, bachelor’s, or graduate de- gree). Gender was not included on the survey because of the possibility that participants could be identified if combined with other demographics. The survey took approximately 10 minutes to complete. The CCA has been tested in a variety of health care settings and has demonstrated good internal consistency reliability (a = .88, .76, .89) (Benkert, Templin, Schim, Doorenbos, & Bell, 2011; Cicolini et al., 2015; Doorenbos, Schim, Benkert, & Borse, 2005), rep- resented respectively. In the current study, overall internal consistency reliability for the CCA was .78.

Analyses Data were analyzed using SPSS® version 24.0. The level

of significance was set at .05. Missing data (random) were addressed by listwise deletion (Acock, 2005). Descriptive analyses were used to calculate frequencies, percentages, means, and standard deviations (n = 74). After recod- ing the type of education (degree) to a continuous vari- able indicating years of education, Pearson’s correlation analyses were used to determine associations among the variables. Rule of thumb estimates for sample size in lin- ear regression analyses were used to determine that 10 to 15 participants per variable would be adequate (Austin & Steyerberg, 2015; Green, 1991; Schmidt, 1971). For four predictor variables and 15 participants per variable, a sample size of 60 would be required. Predictors of cultural competence were determined with multiple linear regres- sion analyses, regressing cultural competence total scores (CCA) on age, years of education, diversity experience, and diversity training, after testing for assumptions.

RESULTS All but one of the participants reported having received

some form of diversity training (yes or no). Eighty-one per- cent received one or two types of diversity training, where- as 19% received three or more different types. Employer- sponsored programs (n = 59) and those that were part of a college course (n = 29) were the most frequently reported, followed by continuing education programs (n = 10), Web-based training modules (n = 9), professional devel- opment conferences (9), separate college courses (n = 8), and other types (n = 7) (Figure 1). Most of the nurses (66%) encountered five or more different racial or ethnic groups in their work environment (M = 4.8, SD = 1.1) with African American (100%), Hispanic (97%), Asian

Figure 1. Number (frequency) and types of diversity training.

472 Copyright © SLACK Incorporated

(87%), and Arab American (62%) cited most frequently. Most nurses (64%) perceived themselves to be culturally competent (M = 4.5, SD = .76) (Table 1).

Results of the Pearson correlation analyses indicated there were significant positive associations between years of education and amount of diversity training with overall

cultural competence (r = .24, p < .05; r = .46, p < .01). Years of education were also positively correlated with amount of diversity training (r = .31, p < .01). A multiple linear regression analysis was calculated to predict over- all cultural competence based on age, years of education, diversity training, and diversity experience. A significant regression equation was found [F(4, 65) = 4.78, p = .002], with an R2 of .23. Only amount of diversity training (b = .4, p = .001) predicted overall cultural competence, ex- plaining 23% of the variance (Table 2).

DISCUSSION Most of the nurses in this sample cared for a wide vari-

ety of racially and ethnically diverse people and perceived themselves as culturally competent, congruent with the high score of measured cultural competence. Although educational level and diversity training were associated with cultural competence, only diversity training emerged as significant in the final model. This study contributes unique findings about the value of relationship between cultural diversity training and overall cultural competence among RNs employed in hospitals.

Prior studies have linked cultural diversity training (yes or no) with greater overall cultural competence; however, this study contributes new information about the num- ber and types of diversity training (Doorenbos & Schim, 2004; Schim et al., 2005). Many of the respondents had completed two or more different types of training with the most frequently endorsed method being an employer- sponsored program followed by college courses. A mul- tisite survey credited employer-based diversity training for the variation in cultural competence for oncology surgeons (n = 253) but did not include a list of different types of training (Doorenbos, Morris, Haozous, Harris, & Flum, 2016).

Almost all of the nurses in this study had completed diversity training, compared with 50% and 87%, respec- tively, as reported by Cicolini et al. (2015) and Benkert et al. (2011). This suggests that nurses experiencing more and different types of training is an important component of improving cultural competence. These findings high- light the importance of diversity training offered by hospi- tals as contributing to nurse cultural competence. Future research to identify optimal types and dose of training that are most effective are needed. Investigating interprofes- sional training and team-based care delivery models in the context of improving cultural competence may be worth- while initiatives (Easter & DeWalt, 2017). As the United States becomes more racially and ethnically diverse and health care systems are increasingly challenged to deliver cost-effective and high-quality care, it is of critical impor- tance that health care providers are culturally competent.

TABLE 1

CHARACTERISTICS OF THE SAMPLE (N = 74)

Variablea Frequency

n (%) M (SD)

Age (years)a 40.6 (11)

Education (nursing degree)

Associate’s 18 (25)

Pursuing bachelor’s 6 (8)

Bachelor’s 32 (45)

Pursuing graduate 5 (7)

Graduate 11 (15)

Ethnicity/race

White/Caucasian 45 (63)

Asian 13 (18)

Black/African American 6 (8)

Hispanic 2 (3)

Arab American 1 (1)

Other 5 (7)

Diversity experiencea 4.8 (1.1)

Seven groups 4 (5)

Six groups 12 (16)

Five groups 33 (45)

Four groups 18 (24)

Three groups 6 (8)

Two groups 1 (1)

Diversity training 1.7 (1.1)

Six types 1 (1)

Four types 5 (7)

Three types 7 (10)

Two types 17 (24)

One type 41 (57)

Zero types 1 (1)

Cultural competence, self- rated

4.5 (0.8)

Cultural competence assess- ment (a = .78)

7.3 (0.8)

a Not all participants responded.

473The Journal of Continuing Education in Nursing · Vol 50, No 10, 2019

Nurse education levels vary considerably across hos- pitals in the United States, with reports for proportions of nurses with baccalaureate degrees or higher, ranging from 0% to 77%, and 61% in teaching hospitals (Aik- en, Clarke, Cheung, Sloane, & Silber, 2003). Nationally, across all types of hospitals, an overall average of 55% of nurses have baccalaureate degrees (Health Resources & Services Administration, 2013), with higher educational levels in Magnet® hospitals (Kelly, McHugh, & Aiken, 2012). The educational level of the nurses in the sample was slightly higher than national averages, with 63% hav- ing a bachelor’s degree or higher; these findings may have contributed to the nurses in this sample reporting “in col- lege” as the second largest source of diversity training.

LIMITATIONS Results from this study should be considered in the con-

text of the following limitations. The study was conducted in one major medical center in the southeast, therefore restricting generalizability to other settings. Geographic variations in cultural diversity, as well as differences in or- ganizational culture and type of hospital (size, urban versus rural, community hospital versus large urban medical cen- ter), may have affected the findings. It is also possible that more nurses who were culturally aware and sensitive self- selected to participate in the study or that their responses were biased because of concerns about social norms. In addition, this sample was highly educated, with 15% pur- suing a baccalaureate or graduate degree and 15% having already attained a graduate degree—both factors that may have influenced the findings. Because this was a self-report instrument, there may have been some internal bias on the part of the participants. In this convenience sample, par- ticipants were predominantly White and female, limiting generalizability to other groups. Statistical reporting us- ing regression analyses does not imply causality. Therefore,

the direction of the relationship between diversity training and overall cultural competence cannot be distinguished.

CONCLUSION Because the U.S. population is expected to be largely

composed of minorities in the next few decades, many health care providers will be caring for people from other cultures and ethnicities. Improvements in cultural compe- tence have been made at the provider level, with education and training programs, and at the health care institutional level partly because of recommendations from national or- ganizations and accrediting bodies. Cultural competence training programs that address both cultural awareness and sensitivity and culturally competent behaviors are needed to ensure that health care providers will be able to attend to the needs of these vulnerable groups. The re- sults from this study suggest that more and different types of diversity training were important predictors of cultural competence; however, more research is needed to further elucidate optimal methods and amounts of training.

REFERENCES Acock, A.C. (2005). Working with missing values. Journal of Marriage

and Family, 67, 1012-1028. Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H.

(2003). Educational levels of hospital nurses and surgical patient mor- tality. Journal of the American Medical Association, 290, 1617-1623.

American Association of Colleges of Nursing. (2018). Race/ethnicity of graduates from generic (entry-level) baccalaureate, master’s, and doc- toral (research-focused) programs in nursing, 2008-2017. Retrieved from https://www.aacnnursing.org/Portals/42/News/Surveys-Data/ EthnicityTbl.pdf

American Association of Colleges of Nursing. (2019). Enhancing diversity in the workforce. Retrieved from https://www.aacnnursing.org/News- Information/Fact-Sheets/Enhancing-Diversity

Austin, P.C., & Steyerberg, E.W. (2015). The number of subjects per vari- able required in linear regression analyses. Journal of Clinical Epidemi- ology, 68, 627-636.

Bahreman, N.T., & Swoboda, S.M. (2016). Honoring diversity: Devel-

TABLE 2

CORRELATIONS AND LINEAR REGRESSION FOR PREDICTORS OF NURSE CULTURAL COMPETENCE

Variable 1 2 3 4 B SE B b

1. Age (years) – .00 .01 .01

2. Education (years) .06 – .05 .07 .09

3. Diversity experience .03 .08 – .09 .08 .13

4. Diversity training .06 .31** .13 – .28 .08 .40***

5. Cultural competence .04 .24* .17 .46**

R2 .23

F 4.78**

*** p < .001. ** p < .01. *** p < .05.