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Improving the Cultural Competence of Nursing Students: Results of Integrating Cultural Content in the Curriculum and an International Immersion ExperienceRosalie A. Caffrey, PhD; Wendy Neander, MN; Donna Markle, MS; and Barbara Stewart, PhD

ABSTRACTThe purposes of this study were to evaluate the effect

of integrating cultural content (ICC) in an undergraduate nursing curriculum on students’ self-perceived cultural competence, and to determine whether a 5-week clinical immersion in international nursing (ICC Plus) had any additional effect on students’ self-perceived cultural com-petence. Cultural competence was measured using a 28-item scale regarding students’ self-perceived knowledge, self-awareness, and comfort with skills of cultural com-petence. Pretest scores from admission into the program were matched with posttest scores obtained just prior to graduation for 32 students, 7 of whom also participated in a 5-week immersion experience in Guatemala. Results, expressed in effect sizes, showed small to moderate gains for the 25 students in the ICC group, and very large gains for the 7 students in the ICC Plus group, related to per-ceived cultural competence. These results are consistent with the two-phase (cognitive and affective) development of cultural competence proposed by Wells.

Integration of cultural content into nursing education-al programs has been a goal advocated by a number of nursing education organizations. The National League

for Nursing has required that cultural content be included in nursing curricula since 1977, and accreditation criteria refl ect this requirement (Poss, 1999). The American Acad-emy of Nursing (1995), the American Association of Col-leges of Nursing (1998), and the Pew Health Professions Commission (1995) have all published vision statements and recommendations for the inclusion of cultural content in nursing and other health care provider educational pro-grams.

However, cultural competence as an educational out-come has been diffi cult to assess. As the U.S. population continues to grow and become more culturally diverse, cultural competence has emerged as a critical element of professional nursing practice. A concern, then, is whether nursing education is meeting the need for preparing cul-turally competent nurses.

How does one become culturally competent? Wells (2000) proposed a model that incorporates two phases—the cognitive (acquisition of knowledge) and the affective (attitudinal and behavioral changes)—in the development of cultural competence. The cognitive phase is character-ized by transitioning from cultural incompetence (lack of knowledge) to cultural knowledge, and then cultural awareness. The affective phase builds on the cognitive phase and includes the development of cultural sensitiv-ity, cultural competence, and fi nally cultural profi ciency. The affective phase “requires actual experience working with diverse groups” (Wells, 2000, p. 193).

Cultural competence, then, is an ongoing process requir-ing more than formal knowledge. Values and attitudes are the foundation for a commitment to providing culturally competent care, and their development requires experi-ences with culturally diverse individuals and communities. St. Clair and McKenry (1999) do not believe cultural com-petence can be achieved without living in another culture, even if only for a short period of time. Students have lim-ited ability to grasp and overcome their own ethnocentrism

Received: August 26, 2003Accepted: July 14, 2004Dr. Caffrey is Professor Emerita, Ms. Neander is Assistant Pro-

fessor, and Ms. Markle is Associate Professor, Oregon Health & Science University, School of Nursing, Ashland, and Dr. Stewart is Professor Emerita, Oregon Health & Science University, School of Nursing, Portland, Oregon.

Address correspondence to Rosalie A. Caffrey, PhD, Professor Emerita, Oregon Health & Science University, School of Nursing, 1250 Siskiyou Boulevard, Ashland, OR 97520; e-mail: [email protected].

234 Journal of Nursing Education

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CAFFREY ET AL.

without an opportunity to actually live in another culture. Since this is not always feasible for all students, how can cultural competence be included in the educational experi-ence? What level of cultural competence should be expected of new nursing graduates? What is the added value of an immersion experience in international nursing?

Evaluation of the effectiveness of the educational pro-cess on the development of cultural competence in new graduates is needed to provide guidance in curriculum de-velopment. Students’ self-perceived knowledge, attitudes, and skills can provide a measure of their comfort with their learning related to cultural competence and can pro-vide a proxy measure of their commitment to the ongoing process of becoming culturally competent practitioners.

This study was designed to accomplish two objectives: ● Evaluate the effect of integrating cultural content

(ICC) in an undergraduate nursing curriculum on stu-dents’ self-perceived cultural competence.

● Determine whether a 5-week clinical immersion in international nursing (ICC Plus) had any additional effect on students’ self-perceived cultural competence.

METHOD

DesignWe used a two-group, pretest-posttest, quasi-experi-

mental design to compare students in the ICC group (n = 25) and students in the ICC Plus group (n = 7) on per-ceived cultural competence.

SampleThe sample consisted of 32 nursing students in a bacca-

laureate nursing program at a university in southern Ore-gon. These students were admitted as juniors in 2000 and graduated in 2002. Five students identifi ed themselves as at least partially from a different ethnic group than Eu-ropean American. The group contained no male students. Of the 10 students who applied to travel to Guatemala for a 5-week clinical immersion the last term of their se-nior year (ICC Plus), 7 were selected. Selection criteria included the student’s interest, the faculty’s assessment of the student’s ability to work in groups, an acceptable aca-demic standing, and acceptable clinical performance eval-uations. The 25 students in the ICC group continued with traditional senior-year clinical assignments. The students ranged in age from 20 to 44. The mean age of the students in the ICC Plus group (mean age = 25.3, SD = 8.7) was not statistically different from that of the students in the ICC group (mean age = 25.6, SD = 6.5).

Independent VariableThe independent variable included two components:

the integration of cultural content into the undergraduate nursing curriculum (ICC), and a 5-week clinical immer-sion in international nursing (ICC Plus).

ICC. Southern Oregon is limited in culturally diverse populations, thus limiting students’ exposure to culturally diverse clients within this region. Therefore, the faculty

made a concerted effort to incorporate cultural concepts into course materials. This included obtaining a Fund for the Improvement of Higher Education (FIPSE) 3-year North American Mobility Grant for an international ex-change program involving two schools each in Canada, Mexico, and the United States. In addition, new faculty members with experiences in international and cross-cul-tural nursing were hired. Student learning experiences with Hispanic populations were expanded. More content in the form of multicultural case studies was introduced into the ongoing courses.

ICC Plus. This experience was a partnership with Pueb-lo Partisans, a Canadian and U.S. nongovernmental orga-nization, recognized by the Guatemalan government as providing international assistance in the areas of health, agriculture, literacy, and economic development. The goal of the 5-week, 200-hour experience was the preparation of nursing professionals who were capable of collaborating with and supporting a culture to promote its own health. The 7 students participating in ICC Plus during the last term of their senior year worked with community-directed initiatives for health promotion and illness prevention across the lifespan and with general medical clinics.

Students worked in teams of 2 or 3. The clinics were large, with 40 to 60 clients on average. Some clients walked for up to 3 hours to reach the clinic and waited all day just to see a nurse or other health care provider. Experienced health professionals, including Guatemalan health professionals, worked with students in the clinics. Students were also exposed to and, in certain clinical set-tings, worked with traditional healers.

InstrumentThe Caffrey Cultural Competence in Healthcare Scale

(CCCHS) was developed based on the cultural competencies we expected from our students on completion of our bac-calaureate nursing program. It was initially developed to evaluate the outcomes of the FIPSE grant. The model used in constructing the items was a rating scale of respondents’ self-perceived knowledge, self-awareness, and comfort with skills of cultural competence. The statements were generic in that they did not test knowledge, skills, or attitudes re-lated to any specifi c cultural group. A sample item is, “In general, how would you evaluate your comfort level in car-ing for clients from a culture other than your own?”

The scale contained 28 items requesting a self-rating on a Likert scale, with 1 = not comfortable (or not knowl-edgeable or not aware) and 5 = very comfortable (or very knowledgeable or very aware) in relation to concepts ap-propriate to cultural competence. An overall CCCHS score was computed by averaging the 28 items. Items included the following categories:

● Knowledge about health care beliefs and practices of a cultural group other than their own.

● Knowledge of and comfort with the cultural assess-ment process.

● Comfort with their ability to work with a translator, clients’ family members, or folk healers.

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IMPROVING CULTURAL COMPETENCE

● Knowledge of another cultural group’s practices around death and dying, organ donation, and pregnancy and childbirth.

● Awareness of one’s own limitations related to cul-tural competence.

● Willingness and ability to work as a team member with or supervise diverse staff.

● Awareness of national policies affecting culturally diverse populations and perceived ability to advocate on their behalf.

The scale was reviewed by a consultant who is an ex-pert in the culture and nursing arena, and preliminary psychometric evaluation was performed with a student

group of our FIPSE project partner in West Virginia. The university Institution-al Review Board approved the research.

Preliminary testing of the CCCHS' reliability and validity for detecting change was obtained from students involved in the FIPSE grant. Fourteen total matched scores were analyzed by the paired samples t test. Twenty-two of the 28 items showed sig-nifi cant improvement be-tween pretest and posttest, based on a .05 level of sig-nifi cance. Cronbach’s al-pha was .94 on the pretest (N = 14) and .90 on the posttest (N = 14). Based on these preliminary re-sults, it appeared that the CCCHS was reliable and sensitive in detecting improvement in students’

self-assessment of their culturally competent attitudes, knowledge, and skills following the international experi-ences they had during their nursing program. Therefore, we used the CCCHS in this study to evaluate the overall effectiveness of our nursing education program on stu-dents’ development of perceived cultural competence and to further evaluate the outcomes of the Guatemala immer-sion experience.

In this study, Cronbach’s alpha was .93 on the pretest (N = 44) and .97 on the posttest (N = 32). Using an inde-pendent samples t test, pretest mean scores on the overall CCCHS of the 7 students in the ICC Plus group (mean = 3.19, SD = .41) and the 25 students in the ICC group (mean = 3.41, SD = .58) were not signifi cantly different (p = .28). Similarly, the pretest mean scores of the two groups did not differ on any of the CCCHS items.

ProcedureThe pretest CCCHS was administered to 44 new juniors

upon entry to the program. Students were asked to identify a number they would recognize at the end of the program, so each student’s pretest and posttest could be matched. The researchers had no access to student-identifying infor-mation. By the end of the senior year, 32 of the original 44 students could be matched with their pretest scores.

RESULTS

At the posttest, just before graduation, the mean CCCHS of the ICC group was 3.60 (SD = .59) and the mean for the ICC Plus group was 4.42 (SD = .48). An F test for

Figure 1. Comparison of changes in mean cultural competence scores of students in the ICC group (coursework only) and students in the ICC Plus group (coursework plus immersion experience in Guatemala). Values plotted are mean ± standard error of the mean.

TABLE 1

Number of Items Falling into Each Effect Size Category for the ICC and ICC Plus Groups

Number of Items

Effect Size Category ICC GroupICC Plus

Group

Very large effect (� 1.00) 0 21

Large effect (.66 to .99) 1 2

Moderate effect (.36 to .65) 8 3

Small effect (.10 to .35) 12 2

No effect (–.09 to .09) 1 0

Negative effect (� –.10) 6 0

Total number of items 28 28



CAFFREY ET AL.

the groups � time interaction from a 2 � 2 repeated mea-sures analysis of variance (ANOVA) was used to compare the ICC and ICC Plus groups in terms of their change in overall CCCHS scores from pretest to posttest. Improve-ment in cultural competence on the overall CCCHS score, while demonstrated by students in both the ICC and ICC Plus groups, was signifi cantly greater for students in the ICC Plus group (F[1, 30] = 21.2, p < .001) (Figure 1).

Effect SizesEffect sizes were then computed for each group by di-

viding the mean change score (posttest minus pretest) by the standard deviation of the change scores (Lipsey, 1990). The advantage of an effect size is that it presents mean change in standard deviation or z-score units. We drew on guidelines from Cohen (1988), who considered effect size values of .20, .50, and .80 as small, medium, and large, respectively, and we categorized effect size values into six categories as shown in Table 1.

Effect Sizes for Overall CCCHS Scores. Simply inte-grating cultural content in the curriculum (ICC group, n = 25) improved students’ cultural competence by .19 raw score points (on a scale of 1 to 5; SD of change = .46). This raw score change corresponded to an effect size of .41 SD,

which is considered a small-to-moderate effect size. How-ever, adding the international immersion experience (ICC Plus group, n = 7) improved students’ perceived cultural competence by 1.23 raw score points (on a scale of 1 to 5; SD of change = .59). This corresponded to an effect size of 2.07 SD, which is very large. Using these actual changes between the ICC and ICC Plus groups to estimate the ef-fect size for the difference between change scores for the two groups (effect size = 2.13) and using an alpha of .01 for a one-tailed test to compare the two groups with n = 25 (ICC group) and n = 7 (ICC Plus group), the power is 89%. Conventionally, an 80% level of power is considered adequate.

Effect Sizes for Item-Level Change. Because of the study’s exploratory nature, we also analyzed data at the item lev-el to show more clearly where change on the CCCHS was occurring and not occurring. As shown in Table 1, for the ICC group, no item had a very large effect size value, and only 1 item had a large effect size value (.84). Nearly three fourths of the items showed either moderate or small ef-fect sizes, with a negative effect size (� –.10) for 6 items, indicating lower posttest than pretest scores. In stark con-trast to the ICC group, the ICC Plus group had very large effect size values (1.00 to 3.46) for 21, or three fourths,

TABLE 2

Comparison of Pretest and Posttest Cultural Competence Means and Effect Sizes for Selected CCCHS Items

ICC Group (n = 25) ICC Plus Group (n = 7)

CCCHS ItemPretest

Mean (SD)Posttest

Mean (SD)Pretest-to-Posttest r

Effect Size

Pretest Mean (SD)

Posttest Mean (SD)

Pretest-to-Posttest r

Effect Size

Two items with largest effect size for the ICC Plus group

22. Ability to provide culturally competent care.

3.52 (.82) 3.64 (.76) .31 .13 2.86 (.69) 4.86 (.38) .55 3.46**

24. Comfort supervising diverse staff.

3.52 (1.19) 3.80 (.87) .47 .25 2.57 (1.27) 4.43 (.79) .88 2.69**

Two items with largest effect size for the ICC group

19. Awareness of own cultural competence limitations.

3.24 (.93) 4.04 (.84) .42 .84** 3.43 (.79) 4.57 (.79) .08 1.07*

4. Knowledge regarding risk factors of another cultural group.

2.64 (.95) 3.28 (.84) .39 .64** 2.43 (.79) 4.71 (.49) –.50 2.05**

Two items with largest negative effect size for the ICC group

25. Interest in working with diverse staff.

4.52 (.51) 4.04 (.79) .36 –.62** 4.43 (.79) 4.86 (.34) .80 .80

10. Comfort working with a translator.

4.48 (.59) 4.08 (.86) .17 –.42* 4.43 (.53) 4.86 (.38) –.47 .54

* p < .05; ** p < .01. Signifi cance of paired t test for pretest-to-posttest change in mean scores.Note: Bolded values indicate reversed scores from junior to senior year. Complete table of information for all items is available from the fi rst author upon request.CCCHS = Caffrey Cultural Competence in Healthcare Scale.

May 2005, Vol. 44, No. 5 237



of the items; all of these improvements in perceived cul-tural competence were statistically signifi cant at p < .05. Of the effect size values for the remaining 7 items, two were large, three were moderate, and two were small; no item had a negative effect size value for this group. For illustration purposes, we have listed selected individual CCCHS items in Table 2 to show the 2 items with the larg-est effect size for the ICC Plus group, the 2 items with the largest effect size for the ICC group, and the 2 items with the largest negative effect size (i.e., items where perceived cultural competence worsened) for the ICC group.

Pretest to Posttest Change for Individual StudentsBecause change at the individual student level is im-

portant for educators, we also inspected change scores on the overall CCCHS to determine what percentage of students improved, worsened, or showed no change. Un-less the change exceeded two standard errors of measure-ment, the pretest to posttest difference was considered “no change.” The standard error of measurement was .15 on the scale of 1 to 5, and was estimated by multiplying the SD of the pretest (.55) by the square root of 1 minus the reliability of the pretest [�1 – .93)]. Thus, we considered a pretest-to-posttest change of at least 2 � .15 (.30) as more than simply measurement error.

As shown in Figure 2, a scatterplot of pretest and posttest CCCHS scores of all 32 students, 17 total stu-

dents improved, 11 showed no change, and 4 worsened on perceived cultural com-petence. For the 25 stu-dents in the ICC group, 11 improved, 10 showed no change, and 4 worsened. For the 7 students in the ICC Plus group, 6 im-proved, and 1 showed no change.

DISCUSSION

Overall, students in the ICC group demonstrated moderate improvement in perceived culturally com-petent attitudes, knowl-edge, and skills over the 2 years in the nursing pro-gram. However, students in the ICC Plus group gained much more than their classmates in their perceived cultural compe-tence as a result of the im-mersion program.

The item showing the greatest improvement for students in the ICC Plus

group was, “Overall, how would you evaluate your abilities to provide culturally competent care in the clinical setting to clients from a culture other than your own?” The effect size value for this item was 3.46 for students in the ICC Plus group, whereas the improvement of students in the ICC group on this item was negligible (effect size = .13). In contrast, the item with the largest effect size value for stu-dents in the ICC group was, “How aware do you think you are regarding your own limitations in providing cultur-ally competent care to a member of a cultural group other than your own?” (effect size = .84). For students in the ICC Plus group, this item had an effect size value of 1.07. Perceived knowledge regarding risk factors of another cul-tural group ranked second for students in the ICC group. It would appear that the experiences gained by students in the ICC Plus group enhanced their perceived abilities to provide culturally competent care along with diverse staff, while students in the ICC group became more aware of their limitations and reliance on knowledge gained from classroom content.

The 2 items with the largest negative effect size for stu-dents in the ICC group (Table 2) are representative of the 6 items for which students’ scores reversed from pretest to posttest. These items all had received high pretest values (4.08 to 4.52 on a scale of 1 to 5). These reversals indicate a high self-evaluation at the beginning of the program, but perhaps refl ect a more realistic view of students’ level of

Figure 2. Scatterplot of overall Caffrey Cultural Competence in Healthcare Scale (CCCHS) pretest and posttest scores for students in the ICC and ICC Plus groups. The solid line ± 2 standard errors of measurement indicates no change.



CAFFREY ET AL.

comfort with these items as they progressed in the nurs-ing program. It may also refl ect students’ lack of experi-ence with culturally diverse clients, staff, and translators as, for students in the ICC Plus group, these items showed small to large gains.

LIMITATIONS

Some concerns need to be addressed in examining the results of this study. First is whether self-perceived cultural competence has any relationship to actual prac-tice. This is an ongoing concern of researchers who are attempting to study this phenomenon. This study does not answer the question but only examines students’ perceived knowledge, self-awareness, and comfort with the skills of cultural competence. How these translate into practice is unknown.

Second are concerns about the small sample. However, the very large effect size values obtained indicate the scale was sensitive enough to give valid results with this small sample.

A third concern is whether the self-selection, and then fi nal selection by faculty, of students in the ICC Plus group biased the results. As noted previously, no differences ex-isted in the pretest scores of the two groups. In fact, stu-dents in the ICC Plus group scored somewhat lower on the pretest. The ages of students in the two groups were also comparable.

One factor that may well have infl uenced the study re-sults was recognition by students in the ICC group of what experiences they had missed, when students in the ICC Plus group returned from abroad and shared their expe-riences. This may have made students in the ICC group less confi dent in their perceived knowledge and skills re-garding their own cultural competence. Administering the posttest to students in the ICC group prior to the return of the students in the ICC Plus group would help decrease this contamination, although not completely, because the students in the ICC Plus group were still communicating with their classmates through e-mail.

In addition, although we were not aware of any other, unmeasured factors that could have resulted in the im-provement in posttest scores for students in the ICC Plus group, this is always a possibility.

CONCLUSIONS

The following communication from one of the students in the ICC Plus group provides insight into the personal and professional implications of the Guatemala immer-sion experience (L. Rushton, personal communication, No-vember 19, 2002):

It was in Guatemala that I fi nally felt like I was apply-ing my nursing knowledge. This was my refl ective practice clinical experience, the time that I needed to more fully embrace the responsibilities and knowledge of nursing. We were practicing nursing on a basic level without the modern equipment that makes life easier in this country

[United States]. Testing supplies were a luxury in Guate-mala, so a clear picture of the patient’s signs and symptoms was necessary for treatment. My senses were heightened: I listened, looked, touched, smelled, and intuited. Nursing knowledge gained in the classroom was being applied in a clinical setting full of families with various ailments. My confi dence grew as I recognized patient symptoms related to certain illnesses. Using the knowledge of other nursing students was equally as exciting. We were peers sharing information in an attempt to uncover the unknown. The experience was invaluable in building confi dence. It is clear in the above statement that the experience

played a critical role in the students developing confi dence in nursing skills. More important, the results of this study are consistent with those of St Clair and McKenry (1999) regarding the importance of an international experience in the development of cultural competence. Although cul-tural awareness may develop when students interact with culturally diverse groups in the clinical practice setting, St. Clair and McKenry (1999) found there was no change in students’ ethnocentrism if the experience did not in-clude immersion into the cultural groups’ daily reality. Ms. Rushton described the effect of this experience on her current practice as an RN:

In many ways, not speaking the language highlighted important issues regarding cultural differences and com-munication problems that can exist between nurse and patient. Even though there were cultural brokers [indi-viduals who are both bilingual and knowledgeable about the culture] assisting with translation in Guatemala, we were forced to fi nd new ways of reaching the patient. It was critical that we explain our hands-on nursing assess-ment in an effort to [show] respect and avoid violating social norms.

At the same time, we were learning how to create a trusting relationship with a people [who] we did not fully understand culturally and [who] appeared fearful of us at times. This task may have been as simple as making eye contact with a mother and smiling. However, more often, it entailed an array of tactics to reveal the real problem that brought the patient to the clinic.

I speak of this because it has been very useful to me in my practice today. Patients are aware of how busy nurses are. It is impossible not to notice the pace of a nurse, or hear the beepers and phones ringing when the nurse is at the patient’s bedside. Additionally, being hospitalized is traumatic, and fear is common. I have the gift of words in this country to assist in making a human connection with my patients. I learned in the clinical setting in Guatemala that a few extra seconds or minutes focused on the patient produces a relationship of mutual respect and trust. There is an art to providing undivided attention to a patient in the midst of a busy nursing environment. Ms. Rushton described the “art” of nursing. According

to Bernal (1998), “Delivering culturally competent care is no more and no less than delivering quality holistic care to anyone regardless of ethnic or racial background, place of birth or national origin” (p. 7). Bernal went on to say, “An-

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other way to look at this issue is, if we, as nurses, become more sensitive to these differences, we will deliver more holistic, relevant care to everyone” (p. 7).

CONCLUSION

Questions remain regarding the level of cultural com-petence that should be expected from students at gradua-tion. The Wells (2000) model can be useful in helping edu-cators make this decision. For those students who do not participate in an immersion experience with another cul-ture, perhaps the cognitive level of cultural competence is the best that can be expected. This would include baseline knowledge about cultural health care needs and practices of diverse populations and an awareness of their own limi-tations in providing culturally competent care.

However, cultural competence is an ongoing process requiring more than formal knowledge. Values and at-titudes are the foundation for a commitment to provid-ing culturally competent care, and their development requires experiences with culturally diverse individuals and communities. For those nursing education programs that are committed to promoting cultural competence in their students, support for an immersion clinical experi-ence in another country can result in dramatic affective

changes in students’ values and attitudes, which affect their cultural competence, as evidenced by the results of this study.

REFERENCESAmerican Academy of Nursing. (1995). Diversity, marginalization

and culturally competent health care: Issues in knowledge de-velopment. Washington, DC: Author.

American Association of Colleges of Nursing. (1998). The essen-tials of baccalaureate education for professional nursing prac-tice. Washington, DC: Author.

Bernal, H. (1998). Delivering culturally competent care. Connect-icut Nursing News, 71(3), 7-8.

Cohen, J. (1988). Statistical power analysis for the behavioral sci-ences (2nd ed.). Hillsdale, NJ: Erlbaum.

Lipsey, M.W. (1990). Design sensitivity: Statistical power for ex-perimental research. Newbury Park, CA: Sage.

Pew Health Professions Commission. (1998). Recreating health professional practice for a new century. The fourth report of the Pew Health Professions Commission. Retrieved November 12, 2002, from http://futurehealth.ucsf.edu/pdf_fi les/rept4.pdf

Poss, J.E. (1999). Providing culturally competent care: Is there a role for health promoters? Nursing Outlook, 47(1), 30-36.

St. Clair, A., & McKenry, L.(1999). Preparing culturally competent practitioners. Journal of Nursing Education, 38, 228-234.

Wells, M.I. (2000). Beyond cultural competence: A model for in-dividual and institutional cultural development. Journal of Community Health Nursing, 17, 189-199.


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