This study evaluated whether the cultural competence of nurses was strengthened through the Cultural Competence Cultivation Programme.
Design and participants
We adopted a quasi-experimental research design to examine nurses working at a medical centre in Taiwan. The nurses were randomly allocated into an experimental group (n = 47), which participated in the Cultural Competence Cultivation Programme, or a control group (n = 50), which did not participate in an educational programme. For inclusion, participants had to be licensed nurses who graduated from an approved nursing programme and have served as a clinical nurse for at least 1 year. Nurses diagnosed as having cancer or depression were excluded from this study. G*Power (version 3.1) 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. Cohen’s rule of thumb predicted an effect size of 0.25 and a moderate autocorrelation value of 0.5 at 50% time interaction. The minimum sample size was 82 participants. This value was adjusted to 100 to allow for a 23% loss rate (n = 23). In total, 97 respondents completed the formal intervention and the 2-month post-intervention OSCE (47 respondents in the experimental group and 50 respondents in the control group). The loss rate was 3%.
The basic attributes included age, gender, educational attainment, nursing seniority, professional rank, department of work, experience of caring for foreigners, experience of attending cultural courses, experience of studying or living abroad and language proficiency.
Cultural Competence Cultivation Programme
The Cultural Competence Cultivation Programme for nurses is based on social learning theory and focuses on cultural awareness, cultural knowledge, cultural willingness, cultural skills, and cultural circumstances [29, 30]. The programme consisted of four units. In Unit 1, the authors introduced information on the cultural competence of clinical nurses and explained the procedures of the cultural competence education intervention programme. In Unit 2, experts with ample experience interacting with new immigrant families from diverse cultural backgrounds were invited. In Unit 3, the participants watched a movie on the racial war between two countries to encourage them to reflect on their ideas about culture. In Unit 4, the authors used structured role play activities to enable the participants to experience inequality in designed scenarios.
A new unit was taught each week and each unit lasted for 3 h, for a total intervention time of 12 h. Cultural competence courses with diverse teaching strategies, such as discussion, film appreciation, and roleplaying, and continual adjusting can enhance the cultural competence of clinical nurses. Three experts in the cultivation of cultural competence were invited to review and provide feedback on the cultural aspects of the programme. The programme was also adjusted based on feedback provided by the participants. The programme was delivered by two lecturers with postgraduate degrees in nursing practice and trained in multicultural education.
Studies have reported that an education and assessment tool that combines Standardised Patient Survey (SPS) and OSCE can effectively evaluate the clinical performance of learners . The OSCE was designed based on Khattab and Rawlins’s  recommendations. The OSCE comprised the Multicultural Objective Structured Examination (MOSE) to assess nurses and the SPS to assess standardised patients. The OSCE measurement was conducted a week after the intervention was completed.
The evaluation criteria of the nurses involve the following: (1) doctor–patient communication, problem assessment and problem-solving; and (2) nursing instruction for medications (communication ability and skill). The test comprises 10 items. The items are scored on a 3-point scoring system, in which 2 denotes ‘accomplished’, 1 denotes ‘partially accomplished’ and 0 denotes ‘unaccomplished’. The scores of the 10 items are summed. A high score represents a high cultural competence in clinical care. The Cronbach’s α coefficient of the test is .70.
The contents of this survey include empathy and verbal and nonverbal communication skills. A score is allocated based on the perceived interactions between the SP and the respondent. In particular, 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, with the total score ranging from 0 to 10. A high score represents a high nurse-to-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 programme and a performance and teacher training programme (8 hours) and an OSCE rehearsal (3 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 2 months after the completion of the education programme. The two groups of respondents were telephonically informed that they could take the test at the Clinical Competence Centre. The respondents entered the examination hall in order of registration, regardless of the group. The examiner and SPs could not identify the respondent groups, which ensured the research results remained unbiased.
The validity of the OSCE has been assessed by experts with over 10 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 standard procedures of the OSCE were based on those recommended by Boursicot and Roberts .
Designing and editing lesson plans
Several meaningful real-world examples were used to design the programme scripts. Lessons were classified into the following segments: (1) student guidelines, involving patient background data, clear instructions, and test time; (2) examiner guidelines, involving case descriptions, patient summaries, health education tools and models, and scoring standards; (3) SP guidelines, involving basic SP information, script summaries, and dialogues; and (4) score sheet, involving the assessment items, content, and scoring standards.
A teaching video was developed and evaluated collaboratively by the examiners. The Cronbach’s α coefficient was 0.85, indicating a fair internal consistency.
OSCE operating procedures
The Clinical Competence Centre of the research hospital served as the OSCE administration centre. The examination was conducted in a simulated clinical environment that could be unidirectionally monitored and recorded. The script and notes were stuck to the door. The scenario involved a 23-year-old Vietnamese caregiver who has worked in Taiwan for 2 months. Her role was to provide care for a 75-year-old man with stroke experiencing a urinary infection. The patient is scheduled for discharge that day. Student guidelines included background information, test topics, and test time. The scene involves a nurse delivering post-discharge instructions to the Vietnamese caregiver regarding medications prescribed to 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.
The data were processed and analysed using SPSS for Windows (version 22.0). Demographics were analysed using a descriptive statistics approach. The results are presented as percentages, mean values, and standard deviation values. Independent t test was used to compare intergroup differences. The correlations between the assessment tools in the OSCE were determined using a Spearman’s correlation analysis. A p value of <.05 was adopted as the measure of statistical significance.
This study was approved by the McKay Memorial Hospital Institutional Review Board of the research hospital (Approval No. 17MMHIS096e). Before the study initiation, the participants were fully informed of the research objectives and data collection methods. They could withdraw from the study at any time for any reason. The data collected were archived anonymously. The study was initiation once the participants provided their consent and signed the consent form.