Exploring the education in cultural competence and transcultural care in Spanish for nurses and future nurses: a scoping review and gap analysis

A preliminary peer-reviewed search was carried out to identify publications about the topic in evidence-based databases. The search was performed in Joanna Briggs Institute Evidence Synthesis, MEDLINE, as well as in the Cochrane Library by using intuitive terms such as “cultural competence”, “transcultural nursing”, “education”, “universities'', “Spain” and “Latin America” in English and Spanish; and the lack of publications regarding the topic was evident. Subsequently, another peer-reviewed search was performed through PubMed to identify the Mesh terms used towards establishing the keywords and developing the search strategy. The keywords used were firstly according to MESH terms (“Cultural competency”, “Nursing education”, “Transcultural nursing”, “Nursing students'', “Universities”, “Spain”, and “Latin America”) and later other synonyms were extracted and also added such as: “higher education”, “college”, “cultural nursing education”, “cultural competence” and “practical training”. This search strategy was adapted to each database (Additional file 1). The search took place between the months of February and December 2022 and included studies published in both English and Spanish from 2017 until 2022 throughout PudMed, Web of Science (WOS), Embase, CINAHL, and Google Scholar.

The inclusion criteria were studies with information on training in cultural competence, transculturality, transcultural care, and cultural care or similar terms in Spanish-speaking universities from Spain and Latin America The search was made by using Mesh terms and the Boolean operators: [AND], [OR], [NOT] were used to combine the Mesh terms. The peer-reviewed search retrieved 599 articles. Accordingly, duplicates were eliminated and articles with irrelevant titles and abstracts or that did not meet the inclusion criteria were removed from the review. In the next step, full texts of the articles were read and the ones that did not meet the criteria were excluded. After that, due to the lack of results, another complementary search was made in Google Scholar, which returned a large number of articles. Many of them were rejected because of the title and the summary and finally, only nine articles were considered. The representation of the literature search process is available in Fig. 1.

Later another search was carried out on gray literature. Firstly, contents, skills, and competencies from 47 Spanish universities were revised throughout the White Book of the Nursing Degree published by the National Agency for Quality Assessment and Accreditation in Spain (ANECA) which was created by the Spanish Ministry of Education to adapt the Nursing Program nationwide to the European Higher Education Space (EEES) [39]. Then similar Latin American official reports were summed up. Later the need to conduct a gap analysis came up and started by consulting the training programs of all the Spanish universities and the Latin American ones. All of them were searched for undergraduate and postgraduate programs, including master´s degrees and doctoral programs for nurses as well as research teams publishing on this topic. Subsequently, other training programs in the form of continuing professional development (CPD) offered by HEIs and educational organizations were explored. Additionally, we revised specific resources from the Boards of Nursing, Councils of Nurses, and Government organizations (at the national, regional, and local levels) such as the Repository TESEO that belongs to the Spanish Ministry of Education gathering all the doctoral thesis published by Spanish Universities; as well as other foundations, associations and scientific societies from Spain and Latin America and finally we decided to include some researchers’ insights and approaches related with the topic. Those researchers were four academics belonging to different Spanish Universities who participated as key informants and were identified through their publications on the topic and contacted via their public emails. They individually reviewed the data collected and assessed the process. A gap analysis was especially useful as a method of evaluation to identify in which organizations the educational gaps on cultural competence, transculturality, and cultural care had been covered until now, and the way it had been done.

Even though the academic informants mentioned CPD initiatives on cultural competence and transcultural care that once were active nationwide or in specific regions before 2017, during the search period it was not found any specific training on this topic was provided by the main CPD organizations [50, 51] and not even by the Council of Nurses and Boards of Nurses nationwide. Additionally, it was observed a paucity of proposals in geographic areas of Spain next to the boundaries where multiculturalism is part of daily life. Such is the case of Melilla and Ceuta on the south border with Africa, and the situation is similar in the principal cities that usually receive more foreigners and migration. The Andalusian Health Quality Agency in its quality certification program includes a range of quality standards related to cultural diversity, migration, transculturality, multiculturalism, interculturality, cultural diversity, cultural competence, and migration in the field of health care. However, only until 2005, more than 600 training activities were organized by health centers of the Andalusian public system related to these thematic areas [52] as it has happened in other Autonomous Communities in Spain.

The cases identified in Latin America are even more scarce compared with Spain due to the less number of Master's Degrees and Doctoral Programs available for Nurses as in some Latin American countries the profession is still not allowed to have such postgraduate academic level and their training is technical. However, specific particularities were in some Latin American countries: on the one hand, the fact that some undergraduate nursing programs emphasize the social and cultural aspects of specific ethnic groups and subcultures that are part of their own countries and have been co-living for years. However, that training in cultural competence is supposedly implicit though absent in the written training itinerary. On the other hand, some researchers and academics working in Latin America have completed their doctoral dissertations regarding cultural competence or transcultural care in Spain or associated with experts’ teams from Spain and are even nowadays linked with similar teams from Spain.

In 2019, a study was carried out that highlighted that universities outside Latin America pay more attention to subjects that allow the development of social aspects, studying multiculturalism, among other topics [53]. However, Latin American universities, like the Colombian ones, usually focus more on other subjects such as general psychology, leadership, productivity, physical activity, and innovation [54]. In countries like Chile, different higher education initiatives have been carried out regarding cultural aspects, especially in areas with a higher concentration of indigenous people, however, they have been approached and implemented in a very diverse way far from the professional training for nurses. There are many challenges to be achieved with respect to this intercultural approach, such as respect for diversity and human rights, participation, effective communication, and self-exploration of ethnocentric or culturally relativistic models that negatively affect intercultural dialogue [51]. Moreover, it was evident the need to promote intercultural encounters between clinical professionals as well as to develop teaching methodologies where the contents were transversal and flexible [55]. In Peru, the education in cultural competence for nurses is taught mainly from a contextual perspective, with limited training in interculturality focused on nursing interventions with cultural relevance, and the one that exists, often optional, is not always part of the knowledge contents of the nursing undergraduate program [56]. In Ecuador, the training of nursing professionals is also scarce both in issues related to cultural diversity and in addressing the linguistic barriers that health professionals have to face because Ecuador is a country with numerous subcultures, characterized for being multicultural and multiethnic. As part of their training, recent nursing graduates must complete a year of rural professional practice, where they work in health centers far from cities and where institutions lack resources. Although the topic of interculturality and ethnic groups is not part of the study programs, teachers must teach their students about these topics in some way, since recent graduates are required to take an exam in order to be hired by the Ecuadorian Health System, and in this exam, the "Comprehensive Family, Community, and Intercultural Health Care Model" is evaluated. Countries such as Argentina, Chile, and Colombia face the same difficulties in the limited training of nursing professionals in issues of multiculturalism for the health care of the different communities. All these issues highlight the need to improve work in universities on intercultural health issues and for this to be cross-cutting for all levels so that it is not only included within a subject such as anthropology but is worked on throughout the training period. Incorporating intercultural nursing into practice and its incorporation into care and care plans is also a challenge for Latin American countries [54].

HEIs programs and other official, and technical documents from different organizations have been limited to the period of time between 2017 and 2022 as it was understood that the topic is sensitive to the constant changes implemented in the HEIs’ curricula, and for such reason, we may have left out previous educational initiatives. However, this issue was overcome by including in the gap analysis the voice of key informants represented by academic experts that had been working on this topic even before 2017. The search has also been limited to Spanish and English languages without including publications in other ones as it was understood that the cases would also be language sensitive. Not many scientific publications have been found that meet the study inclusion criteria and that is why most of the data came from the gray literature selected from Spanish-speaking countries. It is also recommended that this review could be conducted prospectively to evaluate changes and improvements regarding the topic. Moreover, this scoping review highlights what type of training is available in Spanish-speaking countries for Nurses in these areas, but not if it is really useful for professionals in practice and generates perceived quality and satisfaction in populations as well as its return on investment.