METHODOLOGY ABOUT CULTURE

Introduction

The purpose of this descriptive correlational study was to generate data that would

address the impact of the cultural encounter on the cultural competence of baccalaureate

nursing students. The specific aims of this study were: 1) to determine the frequencies of

the demographic and cultural competence measures of baccalaureate nursing students, 2)

to determine if there were significant differences in the cultural competence of first

semester baccalaureate nursing students and final semester baccalaureate nursing students,

and 3) to investigate the association of self-reported cultural awareness, cultural skill,

cultural knowledge, cultural encounter, cultural desire, total cultural competence, year in

school, and academic program credits of baccalaureate nursing students.

Chapter three will be a discussion of the methodologies used for this study. It will

be divided into sections that include (a) research design, (b) sample and setting, (c)

instrumentation, (d) data collection procedures, (e) data analysis, and (f) limitations.

Research Design

The purpose of a research design is to achieve “greater control and thus improve

the validity of the study in examining the research problem” (Burns & Grove, 2005, p.

231). Correlational research is focused on determining the differences in groups, and

identifying the relationship between two or more sets of data (Polit & Beck, 2012).

This descriptive correlational study was designed: 1) to determine the frequencies

of the demographic and cultural competence measures of baccalaureate nursing students,

2) to determine if there were significant differences in the cultural competence of first

semester baccalaureate nursing students and final semester baccalaureate nursing students,

and 3) to investigate the association of self-reported cultural awareness, cultural skill,

cultural knowledge, cultural encounter, cultural desire, total cultural competence, year in

school, and academic program credits of baccalaureate nursing students.

Sample and Population

Setting

The study was conducted at three private, faith-based liberal arts

colleges/universities in an upper Midwest state. The number of potential students for this

proposed study was 482 undergraduate, nursing students from the three schools of nursing.

Cultural encounter opportunities were introduced during the first semester of each of the

three nursing programs and were a part of the requisite clinical hours or course

requirements for each successive semester.

A 48 Hour Program. The first setting, 48 Hour Program, is an evangelical,

Christian institution. Of the approximate 3,300 undergraduate students, there were

approximately 86% Caucasian, 6% Black, 4% Asian, 2% Hispanic, 2% multiracial, and

<1% American Indian/Alaskan Native students. Nursing is one of the five majors chosen

most often by students (Minnesota’s Private Colleges, 2013). Cultural encounters, through

community engagement, were introduced in the curriculum during the first semester of the

program and were a designated part of the total clinical hours for each successive semester:

sophomores had five clinical hours, and juniors had eight clinical hours in the fall and ten

clinical hours in the spring for community engagement. Community engagement is a

teaching and learning strategy that integrates meaningful service with instruction and

reflection to enrich learning experiences, teach civic responsibility, and strengthen

communities. Community engagement focuses on the needs, expectations, and desires of

a community’s members (Schaffer & Hargate, 2015). The cultural encounter experiences

through community engagement occurred in inner city churches, Head Start and Early

Childhood and Family Education programs, innercity housing communities, domestic

violence shelters, and substance abuse treatment centers. During the fall of senior year the

students had 25 clinical hours incorporated into the course NUR425GZ Population-

Focused Nursing Care. Additionally, throughout the nursing program students had clinical

experiences with the opportunity to care for diverse patients. (Minnesota’s Private

Colleges, 2013).

A 45 Hour Program. The second setting, 45 Hour Program, is a private,

faithbased, liberal arts college, founded on the Catholic, Benedictine heritage. Of the

approximate 2,900 undergraduate students, there were 88% Caucasian, 4% Black, 3%

Asian, 2% Hispanic, 2% American Indian/Alaska Native, 2% multiracial, and <1% Native

Hawaiian/Pacific Islander students. Nursing was one of the top five majors chosen by

students (Minnesota’s Private Colleges, 2013).

Each semester, beginning in the spring of the sophomore year, the nursing students

participated in a “community day”, doing service with an agency of their choice such as

homeless shelters, schools, or community agencies; each student interacted with cultures

different from their own during these experiences. Throughout the nursing program

students had clinical experiences with the opportunity to care for diverse patients. During

the fall of the senior year, students had 45 hours of clinical experiences in a community

setting with diverse populations during the course Community as Client. The different

settings included a homeless shelter, public health agencies and their populations, and

assisted living for the homeless and those recovering from addictions (Minnesota Private

Colleges, 2013).

A 30 Hour Program. The third setting, 30 Hour Program, is a private, faithbased,

liberal arts college, founded on the Catholic, Benedictine heritage. Of the approximate

2,050 undergraduate students, there were 85% Caucasian, 6% Asian, 6% Hispanic, 2%

Black, <1% American Indian/Alaskan Native, <1% Native

Hawaiian/Pacific Islander, and 1% multiracial students (Minnesota’s Private Colleges,

2013). Nursing students were admitted in the fall of sophomore year, and completed six

semesters in the program. The sophomore students took a required two credit intercultural

course and then participated in a cultural immersion public health clinical in the fall of

senior year. The immersion experience could be international (South Africa, Belize, or

Dominican Republic) or local (boys and girls clubs, or Somali population). In between the

sophomore and senior years, the curriculum was integrated with cultural case studies,

simulation, clinical experiences caring for diverse patients in settings that included schools,

senior centers, acute and chronic care, domestic violence shelters, homeless shelters, a

prison, and county public health agencies, and other culturally focused methodologies

(Minnesota’s Private Colleges, 2013).

Sampling

Convenience sampling was used to recruit the baccalaureate-nursing students from

the three schools of nursing. Each of the deans at the three schools of nursing received a

letter from the principal investigator describing the study and requesting their participation.

The deans at each school consented, and then contacted the faculty leading the sophomore

and senior nursing courses, connecting them with the principal investigator. The students

were informed of the study by their faculty, and the principal investigator presented the

study in person to each group of students at each of the three schools of nursing. The study

began in September of 2014 and ended in May of 2015.

The colleges and universities in the study admit their students as follows: 48 Hour

Program admits 90 students to the nursing program beginning the spring of the sophomore

year; 45 Hour Program admits 112 students to the nursing program during the spring of the

sophomore year; and 30 Hour Program admits 45-54 students to the nursing program in the

fall of sophomore year.

Statistical Power

The potential subjects for the study sample came from a voluntary pool of

approximately 252 pre-licensure baccalaureate degree sophomore nursing students and 230

pre-licensure senior nursing students enrolled in the three private, liberal arts nursing

programs. From this larger group, all students were given the opportunity to participate,

and all completed surveys were included in the study. Using G*Power 3.1, a minimum

sample size of 134 sophomores and 134 seniors were needed to detect a small to medium

effect size of 0.1, using an alpha of 0.05, and assuming a power of 0.80 with five predictors

(Faul, Erdfelder, Lang, & Buchner, 2007). In fact this sample size exceeds the required

sample of 90 participants according to Tabachnick and Fidells’formula (2012) of 8m + 0,

whereby m equals the expected numbers of predictors in the model. Therefore, based on

the comparison of the two formulas, the sample size of 134 sophomores and 134 seniors

was sought for this study with the final sample size of 245 sophomores nursing students

and 208 senior nursing students.

Inclusion and Exclusion Criteria

Inclusion criteria included sophomore students in the first semester of the program,

and senior nursing students within a few weeks of graduating from the program. The

rationale for choosing those students was because the sophomores did not have any cultural

encounter experiences in the nursing program at the time of the survey, and the seniors had

completed all of their cultural encounter experiences in the nursing program at the time of

the survey. The students from both groups had to be enrolled in one of the three schools of

nursing, they had to be students in good standing, had experienced or would be

experiencing cultural encounters at some point during the nursing program, otherwise they

would be excluded. The students could be women or men of any ethnic or cultural group.

Specific target for non-white nurses was not set. An effort was made to obtain multi-ethnic

and multi-racial representation in the sample but was limited to the composition of the

current student group. The majority of nurses in the United States are women, therefore it

was anticipated the inclusion of women in this study would not be problematic. Recruiting

male nursing students proved to be more difficult related to their small numbers in the

nursing profession. Subjects had to be willing to take the survey.

Participation was completely voluntary. All subjects were advised of the benefits

of participation, their right to withdraw, and the measures used to ensure confidentiality.

The principal investigator shared inclusion/exclusion criteria and explained the study

procedures and requirements to those who were eligible. Based upon the University of

Grand Forks IRB, completion of the demographic questionnaire and inventory

constituted consent. The principal investigator did not share the identity of the participants

with faculty or staff of the university, and participation in the study did not impact the grade

received in the course. The potential benefits of participating in the study included

allowing subjects to examine their own cultural knowledge and how their experience with

other cultures may impact patient outcomes, as well as benefit to the patients as the

recipients of culturally competent care.

Instrumentation

The study utilized the Inventory for Assessing the Process of Cultural Competence

in Healthcare Professionals-Student Version, to measure the relationship between cultural

encounters and cultural competence, as well as a demographic survey (Appendix A). The

IAPCC-SV is a self-assessment instrument consisting of twenty questions with a four-point

Likert scale from strongly agrees to strongly disagree (Figure 2). Each of the five constructs

of Campinha-Bacote’s model is represented: cultural awareness, cultural skill, cultural

knowledge, cultural encounter, and cultural desire.

1. I believe that there is a relationship between culture and health (cultural awareness)

Strongly Agree

Agree

Disagree

Strongly Disagree

2. I am comfortable asking questions that relate to the clients cultural/ethnic background (cultural

skill)

Strongly Agree Agree Disagree Strongly Disagree

3. I am knowledgeable of at least 2 institutional barriers that prevent cultural/ethnic groups from seeking

healthcare services (cultural knowledge)

Strongly Agree

Agree

Disagree

Strongly Disagree

4. I am involved with cultural/ethnic groups outside of my healthcare setting role (cultural

encounter)

Strongly Agree

Agree

Disagree

Strongly Disagree

5. I have a personal commitment to care for clients from culturally/ethnically diverse backgrounds

(cultural desire)

Strongly Agree

Agree

Disagree

Strongly Disagree

Figure 2: Sample questions, related construct, and Likert scale measurement from the Inventory for

Assessing the Process of Cultural Competence in Healthcare Professionals-Student Version

(Campinha-Bacote, 2007).

Scores from the inventory range from 20-80 points, with higher scores indicating a

higher level of competence: cultural incompetence (scores of 20 to 40), cultural awareness

(scores 41 to 59), cultural competence (scores of 60 to 74) and cultural proficiency (score

of 75 to 80). Administration of the inventory is a paper-pencil survey and took

approximately 10-15 minutes to complete (Campinha-Bacote, 2007; Campinha-

Bacote, 2010a; Palombaro & Lattanzi, 2012).

Instrument Analysis

Reliability

One of the most common methods for checking instrument reliability is the

Cronbach’s alpha coefficient (Cronk, 2014; Pallant, 2013). The Inventory for Assessing

the Process of Cultural Competence in Healthcare Professionals-Student Version (IAPCC-

SV) has been found to be a reliable instrument in measuring cultural competence, with a

Cronbach’s alpha range of 0.74-0.856 (Campinha-Bacote, 2010a; Hsiu-Chin et al., 2012;

Palombaro & Lattanzi, 2012; Wilson, 2011). The instrument has also been found to have

construct and content validity. In 2009, Fitzgerald, Cronin, and Campinha-Bacote

conducted a study, and within it addressed the construct validity and content validity of the

inventory. The IAPCC-SV was administered to 91 participants in a baccalaureate nursing

program, and the researchers found it reflected the available cultural competence literature

that identified awareness/attitudes, skill and knowledge as important areas of cultural

competence (Fitzgerald, Cronin, & Campinha-Bacote, 2009). Additionally, it was

important to check the reliability of the IAPCC-SV constructs, or subscales: cultural

awareness (CA), cultural skill (CS), cultural knowledge (CK), cultural encounter (CE), and

cultural desire (CD). The Cronbach’s alpha ranged from .25-.76 for the five

constructs/subscales of the inventory (Table 2). This is similar to a study by Hsiu-Chin et

al.(2012) who found the range of the constructs to be -.32 to .66 and a study by Fitzgerald,

Cronin and Campinha-Bacote (2009) who found the constructs to range from .19-.68. The

lower reliability could be a direct result of the small number of items for each of the

constructs (Cronk, 2014; Hsiu-Chin et al., 2012; Pallant, 2013). When the overall

inventory was tested using Cronbach’s alpha, the itemtotal statistics output provided a

Cronbach’s alpha if a specific item was deleted from the scale. If deleted, two of the items

(14 and 15) would have raised the overall alpha by a small amount (.002 and .004

respectively), so it appears that all the items were worthy of retaining (Field, 2013).

Table 2

Instrument Construct Reliability

Construct

N/Items

N/Cases

Cultural Awareness

.25

453

Cultural Skill

.68

453

Cultural Knowledge

.49

453

Cultural Encounter

.46

453

Cultural Desire

.76

453

Internal consistency of the five constructs was investigated using Pearson product-

moment correlation coefficient.

Table 3

Correlation Matrix Between Constructs of Cultural Competence

CE CD

.27*

.22*

.59*

.35*

.49*

.46*

.41*

.30*

.28*

.55* 1

Note: significance *p = < .001

Table 3 illustrates the findings and shows there were medium to large correlations

between the five constructs, suggesting internal consistency of the inventory, and a fairly

strong relationship between each of the constructs (Pallant, 2013).

Validity, Reliability, and Internal Consistency Analysis from the Literature

Research studies on the psychometric properties of the IAPCC-SV were listed on the

Transcultural C.A.R.E Associates website by Campinha-Bacote. The inventory based upon

the five constructs of Campinha-Bacote’s cultural competence model established construct

validity (Fitzgerald, et al., 2008). Capell, et al. (2008) identified construct validity of the

IAPCC-SV through the inverse relationship with the ethnocentrism scale. The IAPCC-SV

demonstrated content validity because the items of the inventory reflected the cultural

competence in healthcare literature. Review of the IAPCC-SV by national transcultural

experts established face and content validity (Fitzgerald, et al., 2008). A study by Okere et

al (2011) found test-retest reliability of .87. Therefore this tool was selected for the study.

Demographics

Demographic data was created by the primary investigator alongside two

consultants Dr. Yurkovich and Dr. Zoucha, and was designed to obtain information on the

samples’ age, gender, race and ethnicity, religion, marital statues, previous courses on

culture, previous college degree, previously traveled outside the United States, and

previously lived outside of the United States. Additionally there was a question for the

senior students related to international immersion experiences within the nursing program.

The data was used to study the relationship of the demographics to the overall cultural

competence score.

Data Collection Procedures

The IAPCC-SV was administered to all sophomore nursing students from the three

schools of nursing within two weeks of beginning the nursing program, and was

administered to all senior nursing students at the three schools of nursing at end of their

program, two weeks before their graduation day (Campinha-Bacote, 1999, 2002). Because

of time constraints for completing the data gathering, the sophomore students were not the

same as the senior students. Additionally, all subjects were given a demographic

questionnaire. Data was gathered in the following manner:

1. Paper/pencil demographic questionnaire

2. Paper/pencil inventory on cultural competence

All students were given an envelope with the demographic questionnaire and

IAPCC-SV instrument inside; code numbers were specific to each packet, identified the

school represented by the data, and was assigned to each individual subject. Students were

instructed that completion of the demographic inventory and the IAPCC-SV constituted

consent, with the exception of 48 Hour Program; their IRB required students to sign an

informed consent. It took approximately twenty minutes to complete the questionnaire and

inventory. Upon completion, the students returned the sealed envelope containing the

questionnaire to the principal investigator. The principal investigator gathered the packets

from each individual school, separated out the completed from not completed packets, and

entered the data from all completed demographic questionnaires and IAPCC-SV.

The demographic questionnaire and the IAPCC-SV by individual school were kept

in a locked file accessible only to the principal investigator. Confidentiality of the

individual subjects was maintained, with no names or other identifying information

gathered or used in any publication or shared with university faculty or staff.

Protection of Human Subjects

Participants were nursing students enrolled in a pre-licensure baccalaureate nursing

program. Because participants may have worried their grade would be affected by non-

participation, complete anonymity of the participants was ensured. The principal

investigator kept the data and the course instructor assigning grades did not have access to

who was participating or to the participant’s survey results. No invasive procedures were

implemented in the study.

Participants were recruited from three private, faith-based, liberal arts Midwest

schools of nursing. Potential participants were recruited from a sophomore and senior year

nursing class and participation was completely voluntary. All participants were told that

their completion of the questionnaire and inventory constituted consent, and that they were

free to refuse to participate. 48 Hour Program nursing students signed an informed consent,

a requirement of their Institutional Review Board (Appendix C). The principal investigator

provided explanation of the study, which included the study purpose, time commitment for

the study, the nature of the study, and advised the students of the benefits of participation,

their right to withdraw, and the measures to ensure confidentiality. The principal

investigator shared inclusion/exclusion criteria and explained the study procedures and

requirements. Participants remained anonymous to the principal investigator, the faculty,

and the staff of the university.

Human subjects education was completed by the principal investigator, which was

required by the University of North Dakota. Protection from potential risks were included

as part of the study design. Research data was kept in a locked file in the principal

investigator’s office. No names were gathered, and no identifying data were used in any

report shared with university faculty or staff. Electronic files were protected by passwords

to ensure confidentiality and privacy. No adverse event occurred as a part of the study. Had

there been an adverse event it would have been reported to the University of North Dakota

and the Midwest universities’ IRB, and procedures would have been followed as necessary.

The study protocol was submitted for approval to the IRB at both the University of

North Dakota and each of the Midwest universities from which the participants were

recruited. Full IRB approval was obtained before any aspect of the study was initiated

(Appendix B). The principal investigator on this project acknowledged that stringent

safeguards were needed to ensure that the rights, well-being, and confidentiality of enrolled

participants were protected. The principal investigator continuously monitored the study

implementation.

Data Analysis

Descriptive statistics were calculated for each continuous demographic variable,

including mean, range, standard deviation, and frequency distribution. All data were

assessed for normal distribution. Pearson product-moment correlation coefficient was

calculated to determine to the association of the self-reported cultural awareness, cultural

skill, cultural knowledge, cultural encounter, cultural desire, total cultural competence, year

in school, and academic program credits of baccalaureate nursing students. The effects of

age, gender and ethnicity on the overall IAPCC-SV scores were analyzed using

independent t-tests, and chi square tests. One-way analysis of variance was used to

determine if there is statistical significance in the variance of the mean scores of cultural

competence between the three schools of nursing, as well as mean cultural competence

scores of the sophomores and seniors (Pallant, 2013). Data was entered into a Statistical

Package for the Social Sciences (SPSS) software package for analysis and statistical

comparisons. The data was analyzed with a significance level of alpha = 0.05.

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