Background
Today’s nurses are at the forefront of patient care and spend more time delivering nursing care than other healthcare professionals. Therefore, the increasing cultural diversity and transformations in healthcare delivery demand a nursing curriculum that emphasizes culturally competent practices throughout the education system [1, 2]. The importance of cultural competence in nursing education has been widely acknowledged, as it equips students with the necessary skills to effectively deliver care to diverse patient populations [3]. According to previous studies, cultural competence is not given significant importance in the nursing educational system and nursing students may experience a sense of inadequacy in their ability to deliver culturally competent care to diverse populations [4, 5]. Therefore, nursing students must prioritize developing an understanding of their own cultural behaviors, attitudes, beliefs, and values as well as acquiring the essential assessment and communication skills to engage effectively with individuals from diverse cultural backgrounds [6].
Based on evidence, professional values are considered influential factors in the cultural sensitivity of nurses and nursing students [7, 8]. Professional values are essential components that empower nurses to navigate ethical dilemmas, prioritize patient needs, and ultimately deliver compassionate and ethical care that prioritizes safety and quality [9]. Professional values, which serve as guiding principles for professionals, are defined as the standards that provide a framework for evaluating the beliefs and attitudes that influence their behavior [10, 11]. These values provide guidance for nurses on how to effectively interact with diverse individuals, including patients, healthy individuals, colleagues, team members, and the public. Furthermore, they serve as a foundation for fostering ethical conduct and professionalism among nurses, ultimately contributing to the delivery of safe and high-quality care [12, 13].
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Spiritual well-being is also considered an influential factor that affects the cultural competence of nurses and nursing students [14, 15]. Spiritual well-being is an important component of a healthy lifestyle. It connects the internal forces in a coordinated and integrated manner. This characteristic is associated with traits of stability, peace, harmony, coordination, and a sense of being in close contact with God, society, and the environment [16, 17]. Spirituality and spiritual well-being yield valuable insights into healthcare demands, individuals’ resilience towards spiritual challenges, and the interventions required to address and manage healthcare crises [18]. Healthcare professionals, particularly those in the nursing field, are prone to experiencing such emergencies [19]. By emphasizing the subject of spirituality and its influence on spiritual care within the nursing profession, there is a significant opportunity to improve the quality of healthcare provided in health centers [20].
The relationship between cultural competence and professional nursing values was argued in the literature review. The results of the study conducted by Kandemir et al. in Turkey showed that there was a significant positive relationship between professional nursing values and the cultural competence of surgical nurses [21]. Also, Lee et al. in their study which was conducted on nursing students in South Korea found that professional nursing values play an important role in promoting the cultural competence of nursing students [8]. The relationship between cultural competence and spiritual well-being of nurses and nursing students was not examined in the literature review. Nevertheless, Sandage et al.’s study which was conducted among graduate trainees in the United States indicated that spiritual well-being was positively associated with their cultural competence [22].
In Iran, cultural competence training is not included in nursing student curricula and the majority of them do not receive adequate training in this field. Therefore, in order to plan and implement effective interventions in this field, it is important to assess nursing students’ cultural competence and its influential factors. Based on the study’s hypotheses, professional values, and spiritual well-being were selected as factors that may affect nursing students’ cultural competence. Despite the pairwise association among cultural competence, professional values, and spiritual well-being that has been previously explored, the internal procedure by which the three variables affect each other remains unknown. So, the purpose of the present study was to investigate the relationship between cultural competence, professional values, and spiritual well-being of nursing interns.
Methods
Design
This descriptive-correlational study was conducted over a six-month period, from March to August 2024.
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Sample size
Participants
The study was conducted on the nursing interns affiliated with the Universities of Medical Sciences in Tehran City, the capital of Iran (Tehran, Shahid Beheshti, and Iran). The participants were recruited by convenience sampling, who satisfied the following inclusion criteria: (1) Internship in the hospital for more than 1 month and consent to participate in this survey (2) having the requisite amount of time available for study involvement in relation to graduation obligations. The exclusion criteria were those who hadn’t completed filling out all the questionnaires for various reasons. A total of 200 nursing interns participated in the study. Shahid Beheshti provided 37.5% (n = 75) of the samples, Tehran provided 32.5% (n = 65), and Iran supplied 30% (n = 60).
Measurements
The medical science graduates’ cultural competence questionnaire
This questionnaire was developed and psychometric by Naghizadeh et al. in Iran among 542 medical science graduates. This questionnaire is 50 items with eight dimensions of cultural attitude (9 items), cultural orientation (7 items), self-awareness (5 items), awareness of cultural diversity (5 items), knowledge about health behaviors and beliefs and physiological differences (6 items), knowledge of perceptions of different cultures (space, time, and touch) (7 items), behavioral and speech habits (4 items), and contingent behavior (7 items). The questionnaire uses a 5-point Likert scale for responses, ranging from completely agree (score 5) to completely disagree (score 1). The total score of the questionnaire is between 50 and 250. When it comes to scoring, a score between 50 and 116 signifies a low level of cultural competence, while a score between 117 and 183 indicates a medium level of cultural competence, and a score between 184 and 250 represents a high level of cultural competence. The questionnaire has undergone rigorous testing and validation processes, including the establishment of face validity, content validity, and both exploratory and confirmatory factor analyses. The questionnaire’s reliability was established through Cronbach’s alpha coefficient, which achieved a score of 0.96 for the entire questionnaire and a range of values from 0.88 to 0.89 for the eight domains of the questionnaire [25]. Utilizing Cronbach’s alpha, the present study determined the reliability of this questionnaire to be 88%.
The nurses professional values scale-revised (NPVS-R)
The NPVS-R is a 26-item scale that measures five key professional values in nurses: caring (items 16, 17, 18, 20, 21, 22, 23, 24, and 25), activism (items 4, 10, 11, 19, and 26), trust (items 1, 2, 9, 14, and 15), professionalism (items 5, 6, 7, and 8), and justice (items 3, 12, and 13). The scoring system utilizes a 5-point Likert scale, with 1 point representing “not important,” 2 points for “somewhat important,” 3 points for “important,” 4 points for “very important,” and 5 points for “the most important.” The score range for this survey is between 26 and 130, where higher scores signify a greater understanding of the professional values held by nurses. The scores below 43, between 43 and 86, and above 86 indicated low, medium, and high importance, respectively. This scale, designed and standardized by Weis and Schank to measure nurses’ perception of professional values, has demonstrated sufficient reliability and validity in their studies [28, 29]. The psychometric properties of the Persian version of the scale were examined by Parvan et al. (2012) who involved university board members and professional translators in the process to ensure the accuracy of the translation. A panel of experts, composed of master’s degree nurses and Ph.D. nursing professors, evaluated the scale’s face and content validities by considering its relevance and comprehensiveness from their professional viewpoints. The required changes were implemented as instructed. A Cronbach’s alpha coefficient of 0.91 was found to support the reliability of the scale, suggesting a strong internal consistency among its items [30]. The present study evaluated the reliability of the questionnaire through Cronbach’s alpha coefficient, yielding a result of 93%.
Spiritual well-being scale (SWBS)
The spiritual well-being scale was developed by Palutzian and Ellison [31]. The scale consists of two subscales of religious well-being (RWB) and existential well-being (EWB). Ten items (odd number) measure RWB, and ten items (even number) measure EWB. Eight items [1, 2, 5, 6, 9, 12, 13, 16] are adverse questionnaires. The scales are rated from 1 (strongly disagree) to 6 (strongly agree). The total score ranges from 20 to 120, and the two subscale scores range from 10 to 60 with a higher score indicating higher religious and existential well-being. Inverse scoring was used for negative questions. Scores 20–40, 41–99, and 100–120 are considered weak, moderate, and high spiritual well-being, respectively. Cronbach’s α in the original version were 0.91, 0.91, and 0.93 for RWB, EWB, and full scale, respectively [31]. Internal consistency of the Persian version was 0.82, 0.87, and 0.90, respectively [32]. In the present study, the reliability of this questionnaire was calculated at 89% by alpha Cronbach’s coefficient.
Data gathering
The period for data collection spanned from March 1, 2024, to August 31, 2024, encompassing a duration of six months. Once ethical approval was secured, the researchers employed convenience sampling to recruit nursing interns from three medical sciences universities. The study was conducted at six educational hospitals affiliated with Shahid Beheshti, Iran, and Tehran University of Medical Sciences (namely Imam Khomeini, Shariati, Imam Hossein, Shohada Tajrish, Hazrat Rasoul, and Firuzgar hospitals). Through face-to-face interactions and on-site discussions, the participants were provided with a comprehensive explanation of the research objectives. Subsequently, upon completion of the informed written consent form, they were requested to fill out the paper-based questionnaires. Researchers collected the questionnaires once they had been filled by the participants. Additionally, in order to improve the participation of participants, the questionnaires were also provided to them through a Google form electronic link. Since the researchers were not their professors, the participants did not feel compelled or forced to fill out the questionnaires.
Statistical analysis
The statistical software SPSS 16 was employed to carry out the data analysis. According to the results of the Kolmogorov-Smirnov test, it has been determined that the distribution of variables related to cultural competence, professional values, and spiritual well-being was normal. The researchers utilized the Pearson correlation test and linear regression analysis to examine the relationship between cultural competence, professional values, and spiritual well-being in nursing interns. A maximum alpha bias level of 0.05 was set for testing hypotheses.
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Ethical considerations
The ethics committee at Shahid Beheshti University of Medical Sciences has reviewed and confirmed the ethical considerations of this research (No: IR.SBMU.RETECH.REC.1402.789). The participants were given reassurances that their information would be kept confidential throughout the study, and it was made clear that their decision to participate or not would have no impact on the educational processes and their evaluation. Throughout the study, the researchers made sure to maintain anonymity.
Results
The mean age of the participants was 24.30 ± 1.86. Most of the participants were male (80%), single (97.5%), with moderate economic level (77.5%), and without work experience (52%) (Table 1).
Table 1
Sociodemographic variables of participants (n = 200)
Variable(s) | n (%) |
|---|---|
Gender | |
Male | 80 (40%) |
Female | 120 (60%) |
Marital Status | |
Single | 195 (97.5%) |
Married | 5 (2.5%) |
Economic Status | |
Weak | 24 (12%) |
Moderate | 155 (77.5%) |
Good | 21 (10.5%) |
Work Experience | |
Yes | 96 (48%) |
No | 104 (52%) |
Variable(s) | Mean ± SD |
Age (year) | 24.30 ± 1.86 |
The mean scores of cultural competence, professional values, and spiritual well-being of participants were 151.26 (7.14), 74.24 (10.62), and 71.23 (8.45), respectively. According to the findings, the mean scores of cultural competence, professional values, and spiritual well-being were moderate in nursing interns (Table 2).
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Table 2
The mean core of cultural competence, moral value, and spiritual well-being of the participants
Variables | Mean | Std. Deviation | Min | Max |
|---|---|---|---|---|
Cultural Competence | 151.26 | 7.14 | 129 | 171 |
Cultural Attitude | 27.52 | 2.11 | 22 | 33 |
Cultural Orientation | 21.24 | 1.95 | 16 | 29 |
Self-Awareness | 15.22 | 1.85 | 10 | 20 |
Awareness of Cultural Diversity | 14.97 | 1.70 | 11 | 20 |
Knowledge of Health Behaviors, Beliefs, and Physiological Differences | 17.94 | 1.56 | 13 | 23 |
Knowledge of the Concepts of Different Cultures (Space, Time, Touch) | 21.06 | 1.71 | 17 | 25 |
Behavioral and Speech Habits | 11.97 | 1.60 | 7 | 17 |
Contingent Behavior | 21.34 | 1.89 | 17 | 32 |
Professional Values | 74.24 | 10.62 | 63 | 118 |
Caring | 26.73 | 4.01 | 19 | 43 |
Activism | 12.38 | 3.35 | 8 | 23 |
Trust | 14.41 | 2.48 | 9 | 23 |
Professionalism | 12.47 | 2.10 | 6 | 20 |
Justice | 8.25 | 1.42 | 6 | 14 |
Spiritual Well-Being (SWB) | 71.23 | 8.45 | 53 | 104 |
Religious Well-Being (RWB) | 36.17 | 4.91 | 23 | 53 |
Existential Well-Being (EWB) | 35.05 | 5.32 | 25 | 53 |
The findings showed a significant relationship between cultural competence and professional values (r = 0.460, P < 0.001), and between cultural competence and spiritual well-being (r = 0.489, P < 0.001) of nursing interns (Table 3).
Table 3
Pearson correlation coefficient between cultural competence, professional values, and spiritual well-being of the participants
Variables | Cultural Competence | ||||||||
|---|---|---|---|---|---|---|---|---|---|
Cultural Attitude | Cultural Orientation | Self-Awareness | Awareness of Cultural Diversity | Knowledge of Health Behaviors, Beliefs, and Physiological Differences | Knowledge of the Concepts of Different Cultures (Space, Time, Touch) | Behavioral and Speech Habits | Contingent Behavior | Total | |
Professional Values | 0.217** | 0.180* | 0.374** | 0.351** | 0.137 | 0.231** | 0.007 | 0.293** | 0.460** |
Caring | 0.239** | 0.207** | 0.412** | 0.284** | 0.142* | 0.183** | -0.050 | 0.252** | 0.433** |
Activism | 0.263** | 0.089 | 0.338** | 0.336** | 0.179** | 0.150** | -0.082 | 0.265** | 0.398** |
Trust | 0.060 | 0.142* | 0.184** | 0.268** | -0.032 | 0.162* | 0.110 | 0.217** | 0.283** |
Professionalism | 0.014 | 0.180* | 0.171* | 0.244** | 0.149* | 0.265** | 0.101 | 0.173* | 0.321** |
Justice | 0.198** | 0.036 | 0.262** | 0.195** | 0.038 | 0.183** | 0.049 | 0.218** | 0.305** |
Spiritual Well-Being (SWB) | 0.425** | 0.359** | 0.385** | 0.260** | 0.167* | 0.133 | -0.241** | 0.332** | 0.489** |
Religious Well-Being (RWB) | 0.359** | 0.318** | 0.324** | 0.042 | -0.016 | 0.128 | -0.111 | 0.251** | 0.357** |
Existential Well-Being (EWB) | 0.343** | 0.277** | 0.312** | 0.375** | 0.279** | 0.092 | -0.281** | 0.295** | 0.447** |
The results demonstrated that with each unit increase in professional values and spiritual well-being, the cultural competence of nursing interns increased by 0.200 and 0.296 units, respectively. In general, spiritual well-being (β = 0.350, P < 0.001), professional values (β = 0.297, P < 0.001), and moderate economic status (β=-0.213, P = 0.005) were the most effective predictors of nursing intern’s cultural competence which explained 34.7% of the variance of this variable (Table 4).
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Table 4
Multiple regression results of participants’ cultural competence
Model | Unstandardized Coefficients | Standardized Coefficients | T | P-value | 95% Confidence Interval for B | R2 | ||
|---|---|---|---|---|---|---|---|---|
B | Std. Error | Beta | Lower Bound | Upper Bound | ||||
Professional Values | 0.200 | 0.043 | 0.297 | 4.614 | < 0.001 | 0.114 | 0.285 | 0.347 |
Spiritual Well-Being (SWB) | 0.296 | 0.054 | 0.350 | 5.498 | < 0.001 | 0.190 | 0.402 | |
Economic Status (Weak = Reference) | ||||||||
Economic Status (Moderate) | -3.636 | 1.293 | -0.213 | -2.812 | 0.005 | -6.186 | -1.086 | |
Economic Status (Good) | -2.794 | 1.774 | -0.120 | -1.575 | 0.117 | -6.293 | 0.704 | |
Discussion
The purpose of this study was to investigate the relationship between cultural competence, professional values, and spiritual well-being of nursing interns. A significant correlation was found between cultural competence and both professional values and the spiritual well-being of nursing interns.
This study evaluated the level of cultural competence of nursing interns and reported it to be at a moderate level. Consistent with the current study, the findings of Lee et al. [33] indicated a moderate level of cultural competence among senior baccalaureate nursing students, attributing this outcome to the implementation of well-developed curricula and training in this field. The findings of Majda and Farokhzadian studies [34, 35] were in line with the previously mentioned research, suggesting that the highest cultural competence level competence was associated with participation in intercultural communication workshops and cultural care training programs.
According to the results of the present study, the mean score of professional values showed to be at a moderate level in nursing interns. Hajilo et al. [36] discovered that nursing students hold favorable professional values, suggesting the incorporation of these values into the students’ academic programs as a practical approach. These findings resonate with the results of the current study. Furthermore, Nazari et al.’s [37] study reported a high mean score for professional values among nursing students, surpassing the results of the present study. The differences in professional values may be explained by the distinct societal contexts and the differing characteristics of the study populations.
Another finding of the current study indicates a moderate level of spiritual well-being among nursing interns. These results are consistent with the findings of the Abbasi et al.’s study [23]. Also, the research conducted by Fabbris et al. [38] revealed a high level of spiritual well-being among nursing students, suggesting that sociocultural differences may play a role in explaining these divergent findings.
The current investigation also explored the link between cultural competence and professional values of nursing interns and found that these two factors are significantly correlated. The findings of Kandemir et al.‘s study [21], which are consistent with the present study, showed a statistically significant association between cultural competence and professional values. Moreover, in a study conducted by Lee et al. [8] the mediating role of professional nursing values on the relationship between compassion competence and cultural competence among nursing students was explored. The findings of this study indicated that professional nursing values played a crucial role in promoting cultural competence and supported the results of this research.
The results of this study also demonstrated that the cultural competence and spiritual well-being of nursing interns were significantly correlated. The studies conducted by Soriano and Mousavizadeh [15, 22] were parallel to the present study and found a significant correlation between spirituality and intercultural competence in the populations of nurses and graduate students.
Another finding of our study was to highlight that professional values and spiritual well-being as the most effective predictors of nursing interns’ cultural competence. Given the significance of cultural competence, enhancing this variable through identifying the influential factors and then academic and in-service training holds the potential to elevate the quality of nursing care provided to clients.
Limitations
Although three universities participated in the study, none of them were private; the study was conducted at governmental universities only. Convenience sampling also limits the generalizability of the results. There is also a social desirability bias associated with the variables’ self-report nature.
Conclusion
According to our findings, it is furthermore recommended to expend attention to the development of cultural competence in nursing students by promoting professional values and spiritual well-being. Since it has been shown that adopting appropriate educational strategies and supporting students helps improve their cultural competence, integrating these educational strategies into the nursing curriculum and improving the quality of education in nursing schools may help increase the nursing interns’ cultural competence.
Acknowledgements
The researchers would like to take this opportunity to express their sincere gratitude and appreciation to the Dean of the nursing school as well as the honorable Research Vice President of Shahid Beheshti University of Medical Sciences, without whom this research would not have been possible.
Declarations
Ethics approval and consent to participate
During the study, participants were informed of the purpose of the study, and their personal information was kept confidential. They were informed of the voluntary nature of the study and were allowed to withdraw at any time. All the participants gave written informed consent to participate in the study. The Shahid Beheshti University of Medical Sciences’ Review Board approved the study (No: IR.SBMU.RETECH.REC.1402.789). All methods were performed in accordance with the relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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