- Email: [email protected]
Nursing students' self-efficacy in providing transcultural care
Nurse Education Today (2004) 24, 428–434
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nursing students’ self-efficacy in providing transcultural care Janet Lim, Jill Downie*, Pauline Nathan School of Nursing and Midwifery, Curtin University of Technology, GPO Box U1987, Perth 6845, Australia Accepted 21 April 2004
KEYWORDS
Summary The aim of any health care service is to provide optimal quality care to clients and families regardless of their ethnic group. As today’s Australian society comprises a multicultural population that encompasses clients with different cultural norms and values, this study examined undergraduate nursing students’ self-efficacy in providing transcultural nursing care. A sample of 196 nursing students enrolled in the first and fourth year of a pre-registration nursing program in a Western Australian University were invited to participate in a survey incorporating a transcultural self-efficacy tool (TSET) designed by Jeffery [Unpublished instrument copyrighted by author, 1994]. The findings revealed that fourth year students, exposed to increased theoretical information and clinical experience, had a more positive perception of their self-efficacy in providing transcultural nursing skills than the first year students. In addition, the study found that age, gender, country of birth, languages spoken at home and previous work experience did not influence the nursing students’ perception of self-efficacy in performing transcultural care. The study supports the notion that educational preparation and relevant clinical experience is important in providing nursing students with the opportunity to develop self-efficacy in performing effective and efficient transcultural nursing in today’s multicultural health care system. It is for this reason that educators need to focus on providing students with relevant theoretical information and ensure sufficient clinical exposure to support student learning in the undergraduate program. c 2004 Elsevier Ltd. All rights reserved.
Multicultural; Self-efficacy; Transcultural care; Nursing education
Background and literature review The changing demographic trends in the Australian population reflect a multicultural society with expressed variations and differences of each cultural *
Corresponding author. Tel.: +61-8-9266-3024; fax: +61-89266-2959. E-mail address: [email protected] (J. Downie).
group in relation to individual beliefs and values regarding health and illness. An individual’s social attitudes toward health and illness, participation in early detection and screening programs, client’s compliance with treatment and their coping strategies are all known to be profoundly affected by cultural values, beliefs and norms (Jeffery and Smodlaka, 1999a,b). Nurses, who are considered to be the largest group of professional health care
0260-6917/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2004.04.007
Nursing students’ self-efficacy in providing transcultural care providers face the challenge of maintaining, promoting and providing quality nursing care that is culturally congruent to the clients they serve. Hence, these factors support the need for nursing students to be competent in providing quality nursing care and to prepare them to function confidently so that they can understand, communicate and work effectively with culturally diverse groups (Lynch, 1992). Several studies have reported that nurses have difficulties in providing quality care to culturally diverse groups. The ethnocentric perspective of many nurses has been demonstrated by negative attitudes towards clients with different cultures (Gorman, 1995; Leininger, 1990; Taylor, 1998). Language barriers and discrimination have been given as some of explanations for the failure of nurses to meet the needs of different cultural groups (Gorman, 1995; Murphy and MacleodClark, 1993; Scammell, 1990). Leininger (1991) stated that it was not easy for nurses to demonstrate confidence in acquiring skills that would enable them to provide culturally congruent care. Furthermore, it was difficult for nurses who were not well educated in transcultural nursing to function effectively with culturally diverse groups. Data collected from 517 registered nurses and 250 baccalaureate-nursing students showed that neither group expressed confidence in their ability to care for minority ethic clients. The study also revealed that both the registered nurses and student nurses reported the need for transcultural nursing knowledge and the need to modify existing nursing curriculum to increase knowledge and clinical confidence in transcultural nursing. These findings maybe related to factors such as nurses’ resistance to learn about other cultures or perhaps their lack of awareness of the extent to which they require knowledge and skills to work with diverse clients (Kavanaugh and Kennedy, 1992; Pope-Davis et al., 1994). However, according to Suzanne (1999), knowledge by itself was not sufficient to enable nurses to provide effective transcultural nursing care. She reported that nurses must be able to translate transcultural concepts and skills into practical strategies that were linguistically and culturally appropriate for each patient. She suggested that by doing this they would be more proficient in assessing, planning, implementing and evaluating cultural specific nursing care. This supports the notion that nurses not only need to gain sufficient knowledge in regard to transcultural nursing care but they must be efficacious in delivering care to culturally diverse client groups.
429
Jeffery and Smodlaka (1999a,b) conducted a longitudinal descriptive study of 51 nursing students during their first clinical semester and then during their fourth semester. They evaluated their self-efficacy in performing transcultural nursing skills and evaluated changes in perception following a two-year educational experience. The results showed that there were statistically significant differences between first and fourth semester nursing students in their perception of self-efficacy in performing transcultural nursing skills. Thus, they concluded that self-efficacy is a dynamic construct that changes over time in response to new experiences and information such as education and clinical experiences. Bandura (1977) defined the term self-efficacy as a person’s belief about his or her ability to cope in specific situations. According to Bandura (1977) individuals with adequate belief in their selfefficacy were better able to cope with the demands of a particular situation. Whereas, individuals who perceived a lack of self-efficacy might face difficulties in performing specific activities presented to them. In relation to the application of Bandura’s (1977) self-efficacy theory, nurses who have an opportunity to work with clients from culturally diverse groups might develop an increased sense of confidence in performing transcultural care. Hence, it is vital for nurses, who work in a multicultural society, to portray a sense of self-efficacy as it allows them to think critically and make confident decisions (Andrew and Boyle, 1995). The provision of transcultural nursing skills is seen to be a very important aspect of nursing practice in today’s multicultural health care environment due to the ever-increasing cultural diversity of the Australian population. To date, a review of the literature has shown that there is a paucity of Australian studies that have investigated the issue of self-efficacy and transcultural nursing, The purpose of this study was to enhance the understanding of undergraduate nursing students’ selfefficacy in relation to transcultural nursing with an interest in recommendations for nurse educators.
Method The aim of the quantitative study was to examine undergraduate nursing students’ perception of self-efficacy in performing transcultural nursing skills for clients from culturally diverse backgrounds. The study was considered important given Australia’s rapidly growing multicultural population and the dearth of literature that has examined
430 this issue in an Australian context. Specifically, the study objectives were to: • Identify first year (semester two) and fourth year (semester seven) undergraduate nursing students’ perception of self-efficacy in performing transcultural nursing skills. • Determine if there was a difference between the first and fourth year students’ perception of self-efficacy in performing transcultural nursing. • Examine demographic variables in relation to undergraduate nursing students’ perception of self-efficacy and the provision of transcultural nursing skills.
Study sample, context and process The study recruited a convenience sample of first year (semester two) and fourth year (semester seven) undergraduate nursing students of a preregistration nursing program in a Western Australian University. The reason for choosing these groups was the potential to demonstrate differences in the perception of nursing students’ selfefficacy from first year to fourth year. One hundred and nine (109) first year nursing students completed a questionnaire at the commencement of their second semester of study, while 90 fourth year nursing students completed the questionnaire at the commencement of their seventh semester of study. The first year students had experienced limited nursing theory and undertaken one observational clinical experience before completing the questionnaire. By contrast, the fourth year students had engaged in extensive theory in relation to holistic care, including transcultural nursing, with many clinical experiences in a variety of nursing contexts. Permission to conduct the study was granted by the University Human Research Ethics Committee and consent to access the sample given by the Head of School and Unit Coordinators responsible for the students’ learning. Prior to a nursing lecture, students were given a copy of the questionnaire together with an explanatory cover sheet and consent form. Participants took approximately 20 min to complete the questionnaire that was supervised by the researcher and lecturer.
Instrument The questionnaire included various demographic variables and the transcultural self-efficacy tool (TSET) designed by Jeffery (1994) to measure stu-
J. Lim et al. dent’s self-efficacy in performing transcultural nursing skills. Permission to use the TSET was granted by Jeffery, and consists of 83 items, with a 10-point rating scale anchored from (1) ‘not confident’ to (10) ‘totally confident’. There are three subscales in the TSET; the cognitive, practical and affective subscales. The first subscale (cognitive) consists of 25-items that rate the respondents’ self-efficacy in regards to their knowledge of cultural factors that influence nursing care among culturally diverse groups. The items examined various cultural issues such as race, ethnicity, gender, socio-economics and religious backgrounds. An example of the cognitive subscale is ‘how knowledgeable are you about the ways cultural factors may influence nursing care’? Other items such as health prevention, aging, death and dying, grieving, and loss are also included in this subscale. The second subscale (practical) consists of 28-items which measure the respondents’ self-efficacy about interviewing culturally diverse clients in regards to their beliefs and values. Interview topics included items such as language preferences, religion, discrimination and attitudes about health and illness. The third subscale (affective) contains 30-items where the respondent is asked to rate their self-efficacy in respect to values, attitudes and beliefs concerning cultural awareness, acceptance, appreciation, recognition and advocacy. An example of one of these items is ‘do you accept differences between cultural groups’? Jeffery and Smodlaka conducted four studies to examine the validity and reliability of the TSET (Jeffery and Smodlaka, 1996, 1998, 1999a,b; Jeffery, 2000). A factor analysis approach was used to analyze the factorial composition of the TSET in relation to 1260 culturally diverse undergraduate nursing students’ perception of self-efficacy in transcultural nursing skills. The results showed that the 83 items were correlated between 0.30 and 0.70, suggesting that all items contributed satisfactorily and uniquely to the measurement of the transcultural self-efficacy construct. Intercorrelations between subscales were statistically significant at p < 001 (Jeffery, 2000). Internal consistency was also examined using two approaches, split-half reliability and Cronbach’s a (coefficient a). Split-half reliability resulted in coefficients ranging from 0.76 to 0.92 for the three subscales (cognitive, practical and affective) and total instrument. Cronbach’s a yielded a high level of internal consistency, ranging from 0.92 to 0.98 for the three subscales (cognitive, practical and affective) and total instrument. These findings suggest that the TSET assesses the multidimen-
Nursing students’ self-efficacy in providing transcultural care sional nature of transcultural self-efficacy (Jeffery and Smodlaka, 1996, 1998, 1999a,b).
Analysis Analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS Version 10). Descriptive statistics were calculated to summarize the demographic data. Self-efficacy strength was calculated using the mean score of each subscale (cognitive, practical and affective) and the Self-efficacy level of each subscale was divided into three categories: low, medium and high. A low level of self-efficacy was rated for participants who selected a ‘1’ or ‘2’ response on the likert scale for more than 80% of the subscale items. A medium level of self-efficacy was rated for participants who responded with anchors ‘3’ to ‘8’ for more than 80% of the subscale items and a high level of self-efficacy was rated for participants who selected a ‘9’ or ‘10’ response for more than 80% of the subscale items. Independent t-tests were used to explore the differences of the three TSET subscales (Knapp, 1990).
Results Of the sample of 196, the majority of the nursing students were female. In first year, 94% were females (n ¼ 100) and 6% were males (n ¼ 6). In fourth year, 84% were females (n ¼ 76) and 16% were males (n ¼ 14). The participants’ demographic data are summarized below. In first year, 67% of participants were aged 17–21 years, 14% aged 22–26 years, 6% aged 27–31 years, 7% aged 32–36 years, and 6% aged 37 years and older. Fourth year participants comprised 44% aged 17–21 years, 29% aged 22–26 years, 8% aged 27–31 years, 4% aged 32–36 years and 15% aged 37 years older. The results revealed that the majority of first year participants were born in Australia (81%, n ¼ 86), and 11% (n ¼ 20) were born in Asia, Europe and South America. By contrast, 74% (n ¼ 67) of the fourth year participants were born in Australia and 26% (n ¼ 23) born in Europe and Asia. The majority of the participants from both groups reported English as the main language spoken at home (94%, n ¼ 100; 94%, n ¼ 85). Twenty four percent of the first year participants (n ¼ 25) had previously worked in a health care setting, with only 22% (n ¼ 23) currently working in health care. Of the fourth year participants, 64% (n ¼ 58) had previously worked in a
431
health care setting and 53% (n ¼ 48) were currently working in health care. Most of the participants in the study reported having some social contact with people from other cultural groups (76%, n ¼ 81; 81%, n ¼ 73). The TSET was used to measure and explore nursing students’ perception of self-efficacy in performing transcultural nursing skills. In the current study the 83-items of the TSET demonstrated an a coefficient of 0.93, thus demonstrating highly satisfactory reliability. The three subscales (cognitive, practical and affective) of the TSET demonstrated reliability with an a coefficient of 0.91 for the cognitive subscale, 0.91 for the practical subscales and 0.92 for the affective subscale. Hence, these overall results suggest that the TSET was a reliable tool to measure students’ selfefficacy in providing transcultural care to diverse cultural groups. Table 1 shows the mean scores for both first year and fourth year participants in each TSET subscale. For first year participants, the mean score for the cognitive subscale was 6.04 (SD ¼ 1:57), the practical subscale was 6.05 (SD ¼ 1:63) and 7.82 (SD ¼ 1:23) for the affective subscale. For fourth year participants, the mean score for the cognitive subscale was 6.71 (SD ¼ 1:31), 6.63 (SD ¼ 1:36) for the practical subscale and 8.16 (SD ¼ 1:06) for the affective subscale. The results showed that both first year and fourth year participants reported higher mean scores on the affective subscale. When the results of all three subscales (cognitive, practical and affective) were compared, the mean scores for the three subscales (cognitive, practical and affective) were higher for fourth year participants than for first year participants (Table 1). From these findings it can be said that fourth year students’ perception of self-efficacy in performing transcultural nursing skills was higher then first year students’ perception.
Table 1 scores Subscales
First year and fourth year students mean n
Mean
SD
Cognitive First year (semester 2) 106 Fourth year (semester 7) 90
6.04 6.71
1.57 1.31
Practical First year (semester 2) 196 Fourth year (semester 7) 90
6.05 6.63
1.63 1.36
Affective First year (semester 2) 106 Fourth year (semester 7) 90
7.82 8.16
1.23 1.06
432
J. Lim et al.
An independent t-test was used to explore the differences of the three TSET subscales (Table 2) (Knapp, 1990). Results showed that the cognitive subscale revealed a statistically significant difference between first year and fourth year participants’ self-efficacy in regard to their knowledge about the cultural factors that may influence nursing care (t ¼ 3:2, df ¼ 194, p < 0:001). Results for the practical subscale showed a statistically significant difference between the first year and fourth year participants (t ¼ 2:7, df ¼ 194, p < 0:008). Similarly, the affective subscale also showed that there was a statistically significant difference between the first year and fourth year participants (t ¼ 2:1, df ¼ 194, p < 0:04). These findings suggest that there is a difference in the self-efficacy of first year and fourth year students in relation to transcultural nursing skills with fourth year students more confident. This is possibly related to theory and the clinical experiences of fourth year students during their six semesters of previous study in the nursing program, however, these findings may also be due to attrition before year four, personal growth or maturational effects. Table 3 shows the level of self-efficacy for both first year and fourth year participants. In all three subscales; cognitive (89%, n ¼ 94; 94%, n ¼ 85),
practical (92%, n ¼ 98; 94%, n ¼ 85) and affective (70%, n ¼ 74; 70%, n ¼ 63) a medium level of selfefficacy for both first year and fourth year participants was reported. v2 Tests were used to further analyze the relationship between the two year groups of participants and their level of self-efficacy in all three subscales (cognitive, practical and affective). There were no statistically significant differences between any of the subscales; cognitive subscale (p ¼ 0:30), practical subscale (p ¼ 0:84) and affective subscale (p ¼ 0:98). However, due to the small sample size of this study the results need to be interpreted cautiously. When comparing first year and fourth year participants’ demographic data with their perception of self-efficacy in transcultural nursing, the findings showed that first year and fourth year participants’ perception of self-efficacy was not related to their age, gender, country of birth, current work experience, or language spoken at home. However, there was a trend evident that suggested personal experiences with another culture may affect the participants’ perception of self-efficacy in performing effective and efficient transcultural nursing skills.
Discussion Table 2 Significant differences on TSET of first year and fourth year students Subscales
T
df
p
Mean difference
Cognitive Practical Affective
)3.2 )2.7 )2.1
194 194 194
0.001 0.008 0.04
)0.68 )0.58 )0.34
Table 3 Subscales
The findings showed that fourth year nursing students portrayed a higher perception of self-efficacy than first year nursing students in performing transcultural nursing skills. Both groups of students demonstrated higher perception of self-efficacy in the affective domain, such as their awareness, acceptance, appreciation and recognition of the importance of one’s cultural values and beliefs.
Comparison self-efficacy levels between first year and fourth year students First year
Fourth year
Total cases
n
%
n
%
n
Cognitive High Medium Low
5 94 7
5 89 6
3 85 2
3 94 3
8 179 9
Practical High Medium Low
6 98 2
6 92 2
4 85 1
4 94 2
10 183 3
Affective High Medium Low
32 74 0
30 70 0
27 63 0
30 70 0
5 137 0
Nursing students’ self-efficacy in providing transcultural care Both participant groups also demonstrated the lowest perception of self-efficacy in the cognitive domain, including knowledge of cultural factors such as race, ethnicity and gender that may influence nursing care. This suggests that the students were more effective in the practical and affective domain and least effective in relation to their knowledge of cultural aspects. The results showed that first year nursing students lack certain knowledge in regards to the importance of cultural factors when compared to fourth year students. In relation to items such as interviewing culturally diverse groups and learning about individual’s values and beliefs in association with health and illness the first year group did not perceive themselves as effective. The reason for this could be related to maturational factors, personal attributes or perhaps that at this stage of their education the first year students had only been exposed to foundational information such as; different models of health, sociocultural perspectives on health and individual perception and adaptation to health challenges. Also, first year education had only included one observational clinical exposure before completing the questionnaire. In comparison, the fourth year nursing students had been informed about the theory related to holistic care, including transcultural nursing care. Furthermore, fourth year students had experienced several clinical care settings. The findings of the current study support the findings of Bell et al. (1998) who found that frequent clinical exposure did affect the students’ confidence in their ability to communicate effectively with clients. Jeffery and Smodlaka (1999a,b) also showed that students in their fourth semester of clinical experience reported more confidence in recognising and accepting the fact that cultural values and beliefs does affect one’s perception of health care. In the current study, despite the fact that students in their fourth year had received more information and theory and been exposed to several clinical experiences, they reported having less confidence in interviewing clients from diverse cultural groups. This suggests that further studies are required to investigate the impact of theory on practice in regard to nursing students’ level of selfefficacy in interviewing culturally diverse groups. Jeffery’s (2000) assumption that “self-efficacy is a dynamic construct that changes over time in response to new experience and information” (p. 128) is supported by the current study. The results showed that there was a statistically significant difference in the strength of self-efficacy between first year and fourth year nursing students in the areas of transcultural nursing skills; cognitive,
433
practical and affective. As it appears that nursing student’s self-efficacy in performing transcultural nursing skills increases with theory and clinical experiences there is a need for nurse educators to ensure that students are well prepared to integrate theory and practice to provide effective transcultural nursing. Findings from the current study are also consistent with several other studies that have demonstrated that clinical experience and appropriate education is an important determinant in creating clinical confidence in nurses (Felder, 1990; Rooda, 1993; Jeffery and Smodlaka, 1999a,b; Sandra, 2000). Felder’s (1990) findings suggest that inclusion of cultural diversity in education increases nursing students’ knowledge of culturally diverse clients. The idea of students being culturally sensitive is important as previous studies of registered nurses’ caring for culturally divergent clients showed that they lacked knowledge of the client’s culture and reported having difficulty in providing holistic care (Sandra, 2000). This also supports an earlier study that reported that the nurses were only familiar with their own culture and health care practices leading to a negative attitude toward the culture and health practices of different ethnic groups (Rooda, 1993). Both Rooda (1993) and Sandra (2000) support the concept that knowledge of cultural issues is directly related to the students’ level of educational preparation. It is clear that nursing students not only need to understand nursing theory but they require clinical experience in order for them to continue to develop a sense of efficacy in performing transcultural nursing skills. In addition, the findings highlight the need for nurses in today’s multicultural society to have more knowledge, skills and personal encounters with clients from different cultural groups so that they can acquire the optimal skills and knowledge to deliver effective culturally congruent care.
Conclusion In conclusion, this study indicates the importance of relating theoretical education and clinical experience to transcultural nursing care in order to increase students’ self-efficacy with their clients. The implication of the findings to nurse education, emphasize the necessity to ensure that students are exposed to diverse cultural groups early in their clinical experience in pre-registration programs. This may provide the best opportunity for students to experience transcultural nursing and develop
434 through learning, maturation and personal growth. As student’s knowledge was found to be deficient compared to the practical and affective domains it is recommended that curriculum developers include adequate content related to transcultural care, given the changing multicultural population requiring health care. It is critical for nurse educators to focus on transcultural nursing care to ensure that future generations of nurses are better able to provide effective and efficient care to meet the health care demands of a multicultural society. However, further research is needed to demonstrate this. Graduate nurses need to develop a strong sense of efficacy in providing transcultural nursing care because only then will they have reached their potential and be prepared to provide optimal health care to diverse multicultural groups.
References Andrew, M., Boyle, J., 1995. Transcultural Concepts in Nursing Care, second ed. Lippincott, Philadelphia. Bandura, A., 1977. Self-efficacy and competence and independent living among oldest old persons. Psychological Review 84 (2), 191–215. Bell, A., Horsfall, J., Goodin, W., 1998. The mental health nursing clinical confidence scale: a tool for measuring undergraduate learning on mental health clinical placement. Australian and New Zealand Journal of Mental Health Nursing 7, 184–190. Felder, E., 1990. Baccalaureate and associate degree student nurses’ cultural knowledge of and attitudes toward Black American clients. Journal of Nursing Education 29 (6), 282. Gorman, D., 1995. Multiculturalism and transcultural nursing in Australia. Journal of Transcultural Nursing 6 (2), 27–33. Jeffery, M., 1994. Transcultural self-efficacy tool (TSET). Unpublished instrument copyrighted by author. Jeffery, M., Smodlaka, I., 1996. Steps of the instrument design process: an illustrative self-efficacy tool. International Journal of Nursing Studies 35, 217–225.
J. Lim et al. Jeffery, M., Smodlaka, I., 1998. Exploring the composite of the Transcultural Self-Efficacy Tools. International Journal of Nursing Studies 35 (4), 217–225. Jeffery, M., Smodlaka, I., 1999a. Changes in students’ transcultural self-efficacy perceptions following an integrated approach to cultural care. The Journal of Multicultural Nursing and Health 5 (2), 12. Jeffery, M., Smodlaka, I., 1999b. Construct validation of the transcultural self-efficacy tool. Journal of Nursing Educator 38 (5), 222–227. Jeffery, M., 2000. Development and psychometric evaluation of the transcultural self-efficacy tool: a synthesis of finding. Journal of Transcultural Nursing 11 (2), 127–136. Kavanaugh, K., Kennedy, P., 1992. Promoting Cultural Diversity: Strategies for Health Care Professional. Sage, CA. Knapp, T.R., 1990. Treating ordinal scales as interval scales: an attempt to resolve the controversy. Nursing Research 39, 121–123. Leininger, M., 1990. Ethnomethods: the philosophic and epistemic basis to explicate transcultural nursing knowledge. Journal of Transcultural Nursing 2 (1), 254–257. Leininger, M., 1991. Culture Care Diversity and Universality: A Theory of Nursing. National League for Nursing Press, New York. Lynch, E., 1992. The importance of cross-cultural effectiveness. Caring 11 (10), 14–19. Murphy, K., Macleod-Clark, J., 1993. Nurses’ experiences of caring for ethnic minority clients. Journal of Advanced Nursing 18, 442–450. Pope-Davis, D., Eliason, M., Ottavi, T., 1994. Are nursing students multiculturally competent: an exploratory investigation. Journal of Nursing Education 33, 31–33. Rooda, L., 1993. Knowledge and attitudes of nurses culturally different patients: implication for nursing education. Journal of Nursing Education 32 (5), 209–217. Sandra, B., 2000. Nurses’ experiences in caring for patients from different cultural backgrounds. Transcultural Nursing 5 (5), 382–388. Scammell, B., 1990. Communication Skills: Essentials of Nursing Management Series. Macmillan, London. Suzanne, S., 1999. Cultural competence: a priority for performance improvement action. Journal of Nursing Care Quality 13 (3), 23–35. Taylor, R., 1998. Check your cultural competence. Nursing Management, 30–32.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nursing students’ self-efficacy in providing transcultural care Janet Lim, Jill Downie*, Pauline Nathan School of Nursing and Midwifery, Curtin University of Technology, GPO Box U1987, Perth 6845, Australia Accepted 21 April 2004
KEYWORDS
Summary The aim of any health care service is to provide optimal quality care to clients and families regardless of their ethnic group. As today’s Australian society comprises a multicultural population that encompasses clients with different cultural norms and values, this study examined undergraduate nursing students’ self-efficacy in providing transcultural nursing care. A sample of 196 nursing students enrolled in the first and fourth year of a pre-registration nursing program in a Western Australian University were invited to participate in a survey incorporating a transcultural self-efficacy tool (TSET) designed by Jeffery [Unpublished instrument copyrighted by author, 1994]. The findings revealed that fourth year students, exposed to increased theoretical information and clinical experience, had a more positive perception of their self-efficacy in providing transcultural nursing skills than the first year students. In addition, the study found that age, gender, country of birth, languages spoken at home and previous work experience did not influence the nursing students’ perception of self-efficacy in performing transcultural care. The study supports the notion that educational preparation and relevant clinical experience is important in providing nursing students with the opportunity to develop self-efficacy in performing effective and efficient transcultural nursing in today’s multicultural health care system. It is for this reason that educators need to focus on providing students with relevant theoretical information and ensure sufficient clinical exposure to support student learning in the undergraduate program. c 2004 Elsevier Ltd. All rights reserved.
Multicultural; Self-efficacy; Transcultural care; Nursing education
Background and literature review The changing demographic trends in the Australian population reflect a multicultural society with expressed variations and differences of each cultural *
Corresponding author. Tel.: +61-8-9266-3024; fax: +61-89266-2959. E-mail address: [email protected] (J. Downie).
group in relation to individual beliefs and values regarding health and illness. An individual’s social attitudes toward health and illness, participation in early detection and screening programs, client’s compliance with treatment and their coping strategies are all known to be profoundly affected by cultural values, beliefs and norms (Jeffery and Smodlaka, 1999a,b). Nurses, who are considered to be the largest group of professional health care
0260-6917/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2004.04.007
Nursing students’ self-efficacy in providing transcultural care providers face the challenge of maintaining, promoting and providing quality nursing care that is culturally congruent to the clients they serve. Hence, these factors support the need for nursing students to be competent in providing quality nursing care and to prepare them to function confidently so that they can understand, communicate and work effectively with culturally diverse groups (Lynch, 1992). Several studies have reported that nurses have difficulties in providing quality care to culturally diverse groups. The ethnocentric perspective of many nurses has been demonstrated by negative attitudes towards clients with different cultures (Gorman, 1995; Leininger, 1990; Taylor, 1998). Language barriers and discrimination have been given as some of explanations for the failure of nurses to meet the needs of different cultural groups (Gorman, 1995; Murphy and MacleodClark, 1993; Scammell, 1990). Leininger (1991) stated that it was not easy for nurses to demonstrate confidence in acquiring skills that would enable them to provide culturally congruent care. Furthermore, it was difficult for nurses who were not well educated in transcultural nursing to function effectively with culturally diverse groups. Data collected from 517 registered nurses and 250 baccalaureate-nursing students showed that neither group expressed confidence in their ability to care for minority ethic clients. The study also revealed that both the registered nurses and student nurses reported the need for transcultural nursing knowledge and the need to modify existing nursing curriculum to increase knowledge and clinical confidence in transcultural nursing. These findings maybe related to factors such as nurses’ resistance to learn about other cultures or perhaps their lack of awareness of the extent to which they require knowledge and skills to work with diverse clients (Kavanaugh and Kennedy, 1992; Pope-Davis et al., 1994). However, according to Suzanne (1999), knowledge by itself was not sufficient to enable nurses to provide effective transcultural nursing care. She reported that nurses must be able to translate transcultural concepts and skills into practical strategies that were linguistically and culturally appropriate for each patient. She suggested that by doing this they would be more proficient in assessing, planning, implementing and evaluating cultural specific nursing care. This supports the notion that nurses not only need to gain sufficient knowledge in regard to transcultural nursing care but they must be efficacious in delivering care to culturally diverse client groups.
429
Jeffery and Smodlaka (1999a,b) conducted a longitudinal descriptive study of 51 nursing students during their first clinical semester and then during their fourth semester. They evaluated their self-efficacy in performing transcultural nursing skills and evaluated changes in perception following a two-year educational experience. The results showed that there were statistically significant differences between first and fourth semester nursing students in their perception of self-efficacy in performing transcultural nursing skills. Thus, they concluded that self-efficacy is a dynamic construct that changes over time in response to new experiences and information such as education and clinical experiences. Bandura (1977) defined the term self-efficacy as a person’s belief about his or her ability to cope in specific situations. According to Bandura (1977) individuals with adequate belief in their selfefficacy were better able to cope with the demands of a particular situation. Whereas, individuals who perceived a lack of self-efficacy might face difficulties in performing specific activities presented to them. In relation to the application of Bandura’s (1977) self-efficacy theory, nurses who have an opportunity to work with clients from culturally diverse groups might develop an increased sense of confidence in performing transcultural care. Hence, it is vital for nurses, who work in a multicultural society, to portray a sense of self-efficacy as it allows them to think critically and make confident decisions (Andrew and Boyle, 1995). The provision of transcultural nursing skills is seen to be a very important aspect of nursing practice in today’s multicultural health care environment due to the ever-increasing cultural diversity of the Australian population. To date, a review of the literature has shown that there is a paucity of Australian studies that have investigated the issue of self-efficacy and transcultural nursing, The purpose of this study was to enhance the understanding of undergraduate nursing students’ selfefficacy in relation to transcultural nursing with an interest in recommendations for nurse educators.
Method The aim of the quantitative study was to examine undergraduate nursing students’ perception of self-efficacy in performing transcultural nursing skills for clients from culturally diverse backgrounds. The study was considered important given Australia’s rapidly growing multicultural population and the dearth of literature that has examined
430 this issue in an Australian context. Specifically, the study objectives were to: • Identify first year (semester two) and fourth year (semester seven) undergraduate nursing students’ perception of self-efficacy in performing transcultural nursing skills. • Determine if there was a difference between the first and fourth year students’ perception of self-efficacy in performing transcultural nursing. • Examine demographic variables in relation to undergraduate nursing students’ perception of self-efficacy and the provision of transcultural nursing skills.
Study sample, context and process The study recruited a convenience sample of first year (semester two) and fourth year (semester seven) undergraduate nursing students of a preregistration nursing program in a Western Australian University. The reason for choosing these groups was the potential to demonstrate differences in the perception of nursing students’ selfefficacy from first year to fourth year. One hundred and nine (109) first year nursing students completed a questionnaire at the commencement of their second semester of study, while 90 fourth year nursing students completed the questionnaire at the commencement of their seventh semester of study. The first year students had experienced limited nursing theory and undertaken one observational clinical experience before completing the questionnaire. By contrast, the fourth year students had engaged in extensive theory in relation to holistic care, including transcultural nursing, with many clinical experiences in a variety of nursing contexts. Permission to conduct the study was granted by the University Human Research Ethics Committee and consent to access the sample given by the Head of School and Unit Coordinators responsible for the students’ learning. Prior to a nursing lecture, students were given a copy of the questionnaire together with an explanatory cover sheet and consent form. Participants took approximately 20 min to complete the questionnaire that was supervised by the researcher and lecturer.
Instrument The questionnaire included various demographic variables and the transcultural self-efficacy tool (TSET) designed by Jeffery (1994) to measure stu-
J. Lim et al. dent’s self-efficacy in performing transcultural nursing skills. Permission to use the TSET was granted by Jeffery, and consists of 83 items, with a 10-point rating scale anchored from (1) ‘not confident’ to (10) ‘totally confident’. There are three subscales in the TSET; the cognitive, practical and affective subscales. The first subscale (cognitive) consists of 25-items that rate the respondents’ self-efficacy in regards to their knowledge of cultural factors that influence nursing care among culturally diverse groups. The items examined various cultural issues such as race, ethnicity, gender, socio-economics and religious backgrounds. An example of the cognitive subscale is ‘how knowledgeable are you about the ways cultural factors may influence nursing care’? Other items such as health prevention, aging, death and dying, grieving, and loss are also included in this subscale. The second subscale (practical) consists of 28-items which measure the respondents’ self-efficacy about interviewing culturally diverse clients in regards to their beliefs and values. Interview topics included items such as language preferences, religion, discrimination and attitudes about health and illness. The third subscale (affective) contains 30-items where the respondent is asked to rate their self-efficacy in respect to values, attitudes and beliefs concerning cultural awareness, acceptance, appreciation, recognition and advocacy. An example of one of these items is ‘do you accept differences between cultural groups’? Jeffery and Smodlaka conducted four studies to examine the validity and reliability of the TSET (Jeffery and Smodlaka, 1996, 1998, 1999a,b; Jeffery, 2000). A factor analysis approach was used to analyze the factorial composition of the TSET in relation to 1260 culturally diverse undergraduate nursing students’ perception of self-efficacy in transcultural nursing skills. The results showed that the 83 items were correlated between 0.30 and 0.70, suggesting that all items contributed satisfactorily and uniquely to the measurement of the transcultural self-efficacy construct. Intercorrelations between subscales were statistically significant at p < 001 (Jeffery, 2000). Internal consistency was also examined using two approaches, split-half reliability and Cronbach’s a (coefficient a). Split-half reliability resulted in coefficients ranging from 0.76 to 0.92 for the three subscales (cognitive, practical and affective) and total instrument. Cronbach’s a yielded a high level of internal consistency, ranging from 0.92 to 0.98 for the three subscales (cognitive, practical and affective) and total instrument. These findings suggest that the TSET assesses the multidimen-
Nursing students’ self-efficacy in providing transcultural care sional nature of transcultural self-efficacy (Jeffery and Smodlaka, 1996, 1998, 1999a,b).
Analysis Analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS Version 10). Descriptive statistics were calculated to summarize the demographic data. Self-efficacy strength was calculated using the mean score of each subscale (cognitive, practical and affective) and the Self-efficacy level of each subscale was divided into three categories: low, medium and high. A low level of self-efficacy was rated for participants who selected a ‘1’ or ‘2’ response on the likert scale for more than 80% of the subscale items. A medium level of self-efficacy was rated for participants who responded with anchors ‘3’ to ‘8’ for more than 80% of the subscale items and a high level of self-efficacy was rated for participants who selected a ‘9’ or ‘10’ response for more than 80% of the subscale items. Independent t-tests were used to explore the differences of the three TSET subscales (Knapp, 1990).
Results Of the sample of 196, the majority of the nursing students were female. In first year, 94% were females (n ¼ 100) and 6% were males (n ¼ 6). In fourth year, 84% were females (n ¼ 76) and 16% were males (n ¼ 14). The participants’ demographic data are summarized below. In first year, 67% of participants were aged 17–21 years, 14% aged 22–26 years, 6% aged 27–31 years, 7% aged 32–36 years, and 6% aged 37 years and older. Fourth year participants comprised 44% aged 17–21 years, 29% aged 22–26 years, 8% aged 27–31 years, 4% aged 32–36 years and 15% aged 37 years older. The results revealed that the majority of first year participants were born in Australia (81%, n ¼ 86), and 11% (n ¼ 20) were born in Asia, Europe and South America. By contrast, 74% (n ¼ 67) of the fourth year participants were born in Australia and 26% (n ¼ 23) born in Europe and Asia. The majority of the participants from both groups reported English as the main language spoken at home (94%, n ¼ 100; 94%, n ¼ 85). Twenty four percent of the first year participants (n ¼ 25) had previously worked in a health care setting, with only 22% (n ¼ 23) currently working in health care. Of the fourth year participants, 64% (n ¼ 58) had previously worked in a
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health care setting and 53% (n ¼ 48) were currently working in health care. Most of the participants in the study reported having some social contact with people from other cultural groups (76%, n ¼ 81; 81%, n ¼ 73). The TSET was used to measure and explore nursing students’ perception of self-efficacy in performing transcultural nursing skills. In the current study the 83-items of the TSET demonstrated an a coefficient of 0.93, thus demonstrating highly satisfactory reliability. The three subscales (cognitive, practical and affective) of the TSET demonstrated reliability with an a coefficient of 0.91 for the cognitive subscale, 0.91 for the practical subscales and 0.92 for the affective subscale. Hence, these overall results suggest that the TSET was a reliable tool to measure students’ selfefficacy in providing transcultural care to diverse cultural groups. Table 1 shows the mean scores for both first year and fourth year participants in each TSET subscale. For first year participants, the mean score for the cognitive subscale was 6.04 (SD ¼ 1:57), the practical subscale was 6.05 (SD ¼ 1:63) and 7.82 (SD ¼ 1:23) for the affective subscale. For fourth year participants, the mean score for the cognitive subscale was 6.71 (SD ¼ 1:31), 6.63 (SD ¼ 1:36) for the practical subscale and 8.16 (SD ¼ 1:06) for the affective subscale. The results showed that both first year and fourth year participants reported higher mean scores on the affective subscale. When the results of all three subscales (cognitive, practical and affective) were compared, the mean scores for the three subscales (cognitive, practical and affective) were higher for fourth year participants than for first year participants (Table 1). From these findings it can be said that fourth year students’ perception of self-efficacy in performing transcultural nursing skills was higher then first year students’ perception.
Table 1 scores Subscales
First year and fourth year students mean n
Mean
SD
Cognitive First year (semester 2) 106 Fourth year (semester 7) 90
6.04 6.71
1.57 1.31
Practical First year (semester 2) 196 Fourth year (semester 7) 90
6.05 6.63
1.63 1.36
Affective First year (semester 2) 106 Fourth year (semester 7) 90
7.82 8.16
1.23 1.06
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J. Lim et al.
An independent t-test was used to explore the differences of the three TSET subscales (Table 2) (Knapp, 1990). Results showed that the cognitive subscale revealed a statistically significant difference between first year and fourth year participants’ self-efficacy in regard to their knowledge about the cultural factors that may influence nursing care (t ¼ 3:2, df ¼ 194, p < 0:001). Results for the practical subscale showed a statistically significant difference between the first year and fourth year participants (t ¼ 2:7, df ¼ 194, p < 0:008). Similarly, the affective subscale also showed that there was a statistically significant difference between the first year and fourth year participants (t ¼ 2:1, df ¼ 194, p < 0:04). These findings suggest that there is a difference in the self-efficacy of first year and fourth year students in relation to transcultural nursing skills with fourth year students more confident. This is possibly related to theory and the clinical experiences of fourth year students during their six semesters of previous study in the nursing program, however, these findings may also be due to attrition before year four, personal growth or maturational effects. Table 3 shows the level of self-efficacy for both first year and fourth year participants. In all three subscales; cognitive (89%, n ¼ 94; 94%, n ¼ 85),
practical (92%, n ¼ 98; 94%, n ¼ 85) and affective (70%, n ¼ 74; 70%, n ¼ 63) a medium level of selfefficacy for both first year and fourth year participants was reported. v2 Tests were used to further analyze the relationship between the two year groups of participants and their level of self-efficacy in all three subscales (cognitive, practical and affective). There were no statistically significant differences between any of the subscales; cognitive subscale (p ¼ 0:30), practical subscale (p ¼ 0:84) and affective subscale (p ¼ 0:98). However, due to the small sample size of this study the results need to be interpreted cautiously. When comparing first year and fourth year participants’ demographic data with their perception of self-efficacy in transcultural nursing, the findings showed that first year and fourth year participants’ perception of self-efficacy was not related to their age, gender, country of birth, current work experience, or language spoken at home. However, there was a trend evident that suggested personal experiences with another culture may affect the participants’ perception of self-efficacy in performing effective and efficient transcultural nursing skills.
Discussion Table 2 Significant differences on TSET of first year and fourth year students Subscales
T
df
p
Mean difference
Cognitive Practical Affective
)3.2 )2.7 )2.1
194 194 194
0.001 0.008 0.04
)0.68 )0.58 )0.34
Table 3 Subscales
The findings showed that fourth year nursing students portrayed a higher perception of self-efficacy than first year nursing students in performing transcultural nursing skills. Both groups of students demonstrated higher perception of self-efficacy in the affective domain, such as their awareness, acceptance, appreciation and recognition of the importance of one’s cultural values and beliefs.
Comparison self-efficacy levels between first year and fourth year students First year
Fourth year
Total cases
n
%
n
%
n
Cognitive High Medium Low
5 94 7
5 89 6
3 85 2
3 94 3
8 179 9
Practical High Medium Low
6 98 2
6 92 2
4 85 1
4 94 2
10 183 3
Affective High Medium Low
32 74 0
30 70 0
27 63 0
30 70 0
5 137 0
Nursing students’ self-efficacy in providing transcultural care Both participant groups also demonstrated the lowest perception of self-efficacy in the cognitive domain, including knowledge of cultural factors such as race, ethnicity and gender that may influence nursing care. This suggests that the students were more effective in the practical and affective domain and least effective in relation to their knowledge of cultural aspects. The results showed that first year nursing students lack certain knowledge in regards to the importance of cultural factors when compared to fourth year students. In relation to items such as interviewing culturally diverse groups and learning about individual’s values and beliefs in association with health and illness the first year group did not perceive themselves as effective. The reason for this could be related to maturational factors, personal attributes or perhaps that at this stage of their education the first year students had only been exposed to foundational information such as; different models of health, sociocultural perspectives on health and individual perception and adaptation to health challenges. Also, first year education had only included one observational clinical exposure before completing the questionnaire. In comparison, the fourth year nursing students had been informed about the theory related to holistic care, including transcultural nursing care. Furthermore, fourth year students had experienced several clinical care settings. The findings of the current study support the findings of Bell et al. (1998) who found that frequent clinical exposure did affect the students’ confidence in their ability to communicate effectively with clients. Jeffery and Smodlaka (1999a,b) also showed that students in their fourth semester of clinical experience reported more confidence in recognising and accepting the fact that cultural values and beliefs does affect one’s perception of health care. In the current study, despite the fact that students in their fourth year had received more information and theory and been exposed to several clinical experiences, they reported having less confidence in interviewing clients from diverse cultural groups. This suggests that further studies are required to investigate the impact of theory on practice in regard to nursing students’ level of selfefficacy in interviewing culturally diverse groups. Jeffery’s (2000) assumption that “self-efficacy is a dynamic construct that changes over time in response to new experience and information” (p. 128) is supported by the current study. The results showed that there was a statistically significant difference in the strength of self-efficacy between first year and fourth year nursing students in the areas of transcultural nursing skills; cognitive,
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practical and affective. As it appears that nursing student’s self-efficacy in performing transcultural nursing skills increases with theory and clinical experiences there is a need for nurse educators to ensure that students are well prepared to integrate theory and practice to provide effective transcultural nursing. Findings from the current study are also consistent with several other studies that have demonstrated that clinical experience and appropriate education is an important determinant in creating clinical confidence in nurses (Felder, 1990; Rooda, 1993; Jeffery and Smodlaka, 1999a,b; Sandra, 2000). Felder’s (1990) findings suggest that inclusion of cultural diversity in education increases nursing students’ knowledge of culturally diverse clients. The idea of students being culturally sensitive is important as previous studies of registered nurses’ caring for culturally divergent clients showed that they lacked knowledge of the client’s culture and reported having difficulty in providing holistic care (Sandra, 2000). This also supports an earlier study that reported that the nurses were only familiar with their own culture and health care practices leading to a negative attitude toward the culture and health practices of different ethnic groups (Rooda, 1993). Both Rooda (1993) and Sandra (2000) support the concept that knowledge of cultural issues is directly related to the students’ level of educational preparation. It is clear that nursing students not only need to understand nursing theory but they require clinical experience in order for them to continue to develop a sense of efficacy in performing transcultural nursing skills. In addition, the findings highlight the need for nurses in today’s multicultural society to have more knowledge, skills and personal encounters with clients from different cultural groups so that they can acquire the optimal skills and knowledge to deliver effective culturally congruent care.
Conclusion In conclusion, this study indicates the importance of relating theoretical education and clinical experience to transcultural nursing care in order to increase students’ self-efficacy with their clients. The implication of the findings to nurse education, emphasize the necessity to ensure that students are exposed to diverse cultural groups early in their clinical experience in pre-registration programs. This may provide the best opportunity for students to experience transcultural nursing and develop
434 through learning, maturation and personal growth. As student’s knowledge was found to be deficient compared to the practical and affective domains it is recommended that curriculum developers include adequate content related to transcultural care, given the changing multicultural population requiring health care. It is critical for nurse educators to focus on transcultural nursing care to ensure that future generations of nurses are better able to provide effective and efficient care to meet the health care demands of a multicultural society. However, further research is needed to demonstrate this. Graduate nurses need to develop a strong sense of efficacy in providing transcultural nursing care because only then will they have reached their potential and be prepared to provide optimal health care to diverse multicultural groups.
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