Design and participants
We adopted a quasi-experimental research design to examine nurses working at a medical center in Taiwan. The nurses were randomly allocated into an experimental group (N = 47), which participated in the Cultural Competence Cultivation Program, and a control group (N = 50), which did not partake in an educational program. For inclusion, participants needed to be licensed nurses (1) who graduated from an approved nursing program and (2) who have served as a clinical nurse for at least one year. Nurses diagnosed with cancer or depression were excluded from this study. G*Power 3.1 software was used to calculate the required sample size. Two statistical tests were performed using an analysis of variance (repeated measures, between factors) with parameters α = .05 and power = 0.8. We adopted Cohen's rule of thumb for an effect size of 0.25 and a moderate autocorrelation value of 0.5 at 50% time interaction. The minimum sample size was 82 samples. This value was adjusted to 100 to allow for a 23% loss rate (N = 23). A total of 97 respondents completed the formal intervention and the two-month post-intervention OSCE (47 respondents in the experimental group, and 50 respondents in the control group). The loss rate was 3%.
Basic attributes: These attributes include age, gender, marital status, highest level of education, nursing experience, nursing competence and rank, place of work, experience caring for foreigners, participation in multicultural programs, experience studying abroad, experience interacting with foreigners, and language proficiency.
Cultural Competence Cultivation Program
The Cultural Competence Cultivation Program for nurses is based on social learning theory and focuses on cultural awareness, cultural knowledge, cultural willingness, cultural skills, and cultural circumstances [24, 25]. The program consisted of four units. A new unit was taught each week and each unit lasted three hours, for a total intervention time of 12 hours. Three experts in the cultivation of cultural competence were invited to review and provide feedback on the cultural aspects of the program. The program was also adjusted based on feedback provided by the participants. The program was delivered by two lecturers with postgraduate degrees in nursing practice and trained in multicultural education.
Objective Structured Clinical Examination (OSCE)
Previous studies have reported that an education and assessment tool that combines SPS and OSCE can effectively evaluate the clinical performance of learners . The OSCE was designed based on Khattab and Rawlins .The OSCE comprised the Multicultural Objective Structured Examination (MOSE) to assess nurses and the Standardized Patient Survey (SPS) to assess standardized patients.
MOSE: The evaluation criteria of the nurses include (1) doctor/patient communication, problem assessment, and problem-solving; and (2) nursing instruction for medications (communication ability and skill). The test comprises ten items. The items are scored on a three-point scoring system, where 2 denotes “accomplished,” 1 denotes “partially accomplished,” and 0 denotes “unaccomplished.” The scores of the ten items are summed. A high score represents a high cultural competence in clinical care. The Cronbach’s α coefficient of the test is .70.
SPS: The contents of this survey include empathy and verbal/nonverbal communication skills. A score is allocated based on the perceived interactions between the SP and the respondent. Specifically, 2 is allocated when the “correct” field in the right column is checked, 1 for “partially correct,” and 0 for “not performed.” The fields represent the respondents’ perceived performance. The survey comprises five items and the total score therefore ranges between 0 and 10. A high score represents a high nurse-patient communication performance and cultural competence. The Cronbach’s α coefficient of the survey is .62.
All SPs who participated in the OSCE completed a general SP program and a performance and teacher training program (eight hours) and an OSCE rehearsal (three hours). Before the lesson, the researcher and three SPs discussed their roles. Before commencement, the examiner and the SPs discussed the script and rehearsed the scenario. The OSCE was administered two months after the completion of the education program. The two groups of respondents were told by telephone that they could take the test at the Clinical Competence Center. The respondents entered the examination hall in order of registration, regardless of group. The examiner and SPs were unable to identify the respondent groups, which ensured that the research results remained unbiased.
The validity of the OSCE has been assessed by experts with over ten years of medical and clinical education experience based on the content validity index (CVI). A four-point scoring system was adopted as the assessment standard. Expert opinions were consolidated and applied and referenced to adjust the research tools . The item-CVI and scale-CVI coefficients were 1.00 for the MOSE and SPS.
The study was conducted from August 2017 to July 2018. The procedures of the OSCE were based on Boursicot and Roberts .
Designing and editing lesson plans: Several meaningful real-world examples were used to design the scripts for the program. Lessons were divided into the following parts: (1) student guidelines, which included patient background data, clear instructions, and test time; (2) examiner guidelines, which included case descriptions, patient summaries, health education tools and models, and scoring standards; (3) SP (Standardized Patient) guidelines, which included basic SP information, script summaries, and dialogues; and (4) score sheet, which included the assessment items, content, and scoring standards.
Examiner consensus: A teaching video was produced and jointly evaluated by the examiners. The Cronbach’s α coefficient was 0.85, indicating a fair internal consistency.
OSCE operating procedures: The OSCE was administered in the Clinical Competence Center of the research hospital. The examination was conducted in a simulated clinical environment that could be unidirectionally monitored and recorded. The script and notes were adhered to the door. The scenario involved a 23-year-old Vietnamese caregiver who has worked in Taiwan for two months. Her job was to care for a 75-year old male stroke patient with a urinary infection. The patient was scheduled for discharge that day. Student guidelines included background information, test topics, and test time. The scene involves a nurse issuing post-discharge instructions for the medication given to the Vietnamese caregiver for the patient. During the examination, the examiner completed the MOSE based on the examiner guidelines. After the examination, the SPs completed the SPS based on their perceived subject performance.
SPSS 22.0 for Windows was used for data processing and analysis. A descriptive statistics approach was used to analyze the demographics. The outcomes were presented as percentages, mean values, and standard deviation values. Inter-group differences were compared using independent t-tests. A Spearman’s correlation analysis was conducted to determine the correlations between the assessment tools in the OSCE. P < .05 was adopted as the measure of statistical significance.
This study was approved by the Institutional Review Board of the research hospital (Approval No. XXX). Before commencing this study, the participants were fully informed of the research objectives and data collection methods. They were also informed that they could withdraw from the study at any time if they felt uncomfortable, or they no longer wanted to participate in this study. The collected data were archived anonymously. The research only commenced once the participants agreed to participate in this study and signed an informed consent form.