Background
Cultural competence is one of the new areas of focus within nursing [1]. In nursing, cultural competence is the dynamic process that enables nurses to provide effective, safe, and quality care to clients from diverse cultural backgrounds [2]. Cultural competence is the capacity of nurses that develops gradually and has numerous benefits for clients, nurses, and healthcare organizations [3]. More equality of health and nursing care, clients’ trust in healthcare systems, safety [2, 3] additional knowledge about various cultures, gaining the trust and respect of clients and better interaction with clients for nurses [3] are just some of the benefits of cultural competency of nurses.
The results of the studies regarding the levels of cultural competence among nursing students are various [4‐7]. The findings of a study in Saudi Arabia indicated that the level of cultural competence among nursing students was good [4]. Another study in Austrian acute care settings among nurses and last year’s nursing students indicated that cultural competence level was moderate to high [5]. A multicenter study in four European countries including Spain, Turkey, Belgium, and Portugal indicated a moderate level of cultural competence among undergraduate nursing students [6]. A Multicountry study of nine countries including Chile, India, Iraq, Oman, Philippines, Saudi Arabia, South Africa, Sudan, and Turkey on cultural competence among baccalaureate nursing students found a moderate range of cultural competence among these students [7]. All of these studies emphasized that nursing students as future nurses should be educated to provide competent culturally appropriate care [4‐7].
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There are several theoretical and methodological models of cultural competence in nursing and nursing students [8]. A widely used model to explain the process of cultural competence was created by Campinha-Bacote (2011). Five elements of cultural competence are cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire [1]. Some studies have reported educational intervention’s effects on nurses and nursing students’ cultural competence. In a study, the findings indicated that integrating cultural content in an undergraduate nursing curriculum was effective, especially for the students who had immersion experience in Guatemala [9]. Another study in Canada indicated that cultural competence educational program increased Public Health Nurses’ cultural knowledge [10]. A meta-analysis of 25 studies of educational interventions designed to enhance cultural competence in professional nurses and nursing students showed varied effectiveness of the interventions, more studies recommended in this regard [11].
Considering the above-mentioned literature; cultural competence is an important issue in nursing, nursing students and health systems, and educational systems and nursing schools required to improve this concept in nursing students, Campinha-Bacote is a widely used model in this regard, so this study aimed to evaluate the effects of an educational intervention based on the Campinha-Bacote model on cultural competence of undergraduate nursing students in Tehran, Iran, in 2024.
Methods
Research design and setting
This experimental study was conducted using intervention and control groups, with a pretest-posttest design among third-semester undergraduate nursing students in the School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran, in 2024.
Sample size and sampling process
The expected effect size of 15 was determined using calculations from a previous study [12], which is similar in context. This study found a meaningful difference of 15 between the intervention and control groups for the cultural competence variable, which was both statistically significant and practically relevant for cultural competence. Furthermore, the standard deviation (SD) of the cultural competence variable was reported about 22 in this study. The design effect (DE) is used in cluster randomized studies to account for the intra-cluster correlation (ICC), which reflects the similarity between individuals within the same cluster. The formula for calculating the DE is (DE = 1+(m − 1)×ICC); m is the number of participants per cluster. A design effect of 1.2 was selected for the cluster randomization design. This value is commonly used and recommended in cluster-randomized studies, particularly when ICC is either unknown or expected to be relatively low. A DE of 1.2 is considered a conservative estimate, ensuring that the sample size adjustment accounts for the potential clustering effect while maintaining statistical power. So, with considering 80% power, 95% confidence, and an expected effect size of 15. Using the formula for comparing the means of two groups (intervention and control), the required sample size was calculated to be 34 participants per group. Considering a DE of 1.2 for the cluster randomization design, the sample size was increased to 41 participants per group. To account for potential dropout, an additional 10% was added, resulting in a final target of 45 participants per group. Due to the number of students in the classes being close to the determined sample size and the conditions of the study, all students in the selected classes were included in the study. As a result, 45 students in the intervention group and 46 students in the control group were assessed. Ultimately, three participants dropped out of the intervention group, leaving 42 students in the intervention group and 46 students in the control group for the final analysis.
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Participants in the intervention and control groups were selected from two different classes of third-semester undergraduate nursing students in the School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2024. After the academic annual national exam and the announcement of the acceptance results, students enter the above-mentioned school. Because of the high number of nursing students admitted each semester (100±10 students) and better management of the students, authorities of this school divide students into two similar classes (a class has 50 ± 5 students), class A and class B, in the first semester based on the first letter of the last names of the students. The admission and educational process for all of the students is equal. In this study, class A (46 students) was randomly assigned to the control group, and class B (45 students) was randomly assigned to the intervention group by a coin toss. The process of random assignment was done by the corresponding author of the study and with the supervision of the research team. The statistician expert did not know the codes assigned to the participants in the intervention and control groups. To decrease the transfer of information between the intervention and the control groups, randomization was performed at the educational classes level. On the other hand, their theoretical and clinical courses were on different days. These students had community health nursing theoretical and clinical courses in the various Urban Health Comprehensive Services Centers during the same period and were just in two classes. The theoretical course for class A (control group) was at 15–17 on Tuesday, and for class B (intervention group) was at 15–17 on Saturday. The clinical courses for class A were from Saturday to Monday, and for class B were from Tuesday to Thursday. All of the undergraduate nursing students in these classes who consented were selected for the study (Fig. 1).
Fig. 1
Consort diagram
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Inclusion criteria were verbal and written informed consent, appropriate communication status and desire to participate in the study, being in the third semester of the education, and having community health nursing theoretical and clinical courses. Exclusion criteria were failure to complete the questionnaires, and missing more than one of the education sessions in the intervention group.
Urban Health Comprehensive Services Centers are governmental centers that accept referrals related to prevention, care, and diseases. These centers are responsible for surveillance and managing the health of the determined region. The most important health services delivered to the people in these centers encompass: creating an electronic health record for people, vaccination, disease control, nutrition counseling, mental health, providing Vitamins supplements for children and mothers, family and population health, simple medical treatments, oral and dental health, environmental and occupational health, genetic counseling, child development, marriage counseling, breastfeeding counseling, laboratory services, and school health. Depending on the health problems in the region and the availability of the resources some of the health services of these centers are situational. Nursing students learn some of their clinical courses in these centers and also provide health-related services to clients from different cultures under accurate supervision of nurse educators and other HealthCare Workers (HCWs).
Intervention group procedure
The educational content of this study was prepared based on the cultural competence model developed by Campinha-Bacote (2011), as outlined in Public Health Nursing: Population-Centered Health Care in the Community textbook [1], along with other relevant literature [2, 3, 8, 13‐16] and the knowledge and experiences of the research team.
Two faculty and educational members from the Department of Community Health Nursing at Shahid Beheshti University of Medical Sciences, who were not part of the research team, reviewed the initial educational content. Their feedback was incorporated and revised by the research team as needed. Ultimately, the educational content was finalized and approved by the research team.
The educational intervention in this study was based on the five elements of the Campinha-Bacote model (cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire), along with other important concepts related to cultural care, such as culture, language, race, trust, relationships with clients and some antecedents and barriers to developing cultural competence (Table 1). The final educational content was taught in four sessions (one session per week). Initially, the educational content was presented face-to-face (lecture, Q&A, PowerPoint presentations, and PDF files). Subsequently, PowerPoint slides and educational pamphlets were delivered to nursing students via their cellphones for greater review and convenience.
Table 1
Educational sessions and content offered to the participants of the intervention group
Educational sessions (Time) | Educational content | Instructors | Training location | Training methods and materials |
|---|---|---|---|---|
1 (45 min) | Acquaintance with Urban Health Comprehensive Services Centers and its HCWs, services, stakeholders, and units. Levels of health care service system in Iran. Primary Health Care (PHC) and its characteristics. Acquaintance with clients of health care services in these centers. | First author, Corresponding author (Supervision) | Classroom | Multimethod; lecture (face-to-face presentation with electronic slide PowerPoint, PDF files, question and answer), indirect training including transfer of these files and pamphlets to students’ mobile phones via Email, Bluetooth, WhatsApp, Telegram App, etc. |
2 (60 min) | Cultural competence and the Campinha-Bacote model (introduction, definition) Acquaintance with culture, language, race, trust, and relationship concepts. Impacts of concepts as above-mentioned on health care. | |||
3 (60 min) | Reviewing the elements of cultural competence and the Campinha-Bacote model. The process of cultural competence among undergraduate nursing students, and its effective factors. Practicing the previous contents with two educational scenarios. The first scenario was about overcoming language barriers between clients and nurses. The second scenario was about active listening to clients. | |||
4 (45 min) | The third scenario was about educating the clients on self-care and nutrition regimes upon her/his beliefs, attitudes, and culture. The fourth scenario was about establishing trust and appropriate relationships with different cultural clients. Summarizing the educated content and answering students’ questions. |
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Control group procedure
The control group consisted of undergraduate nursing students from another class who received only the routine community health nursing theoretical and clinical courses at the Urban Health Comprehensive Services Centers during the same period. They did not receive any additional intervention related to cultural competence before or during the study. The educational intervention was provided to those who were willing to receive it only after completing the study.
Instruments
The instrument of this study consisted of two sections; a demographic characteristics form (8 items) and the Cultural Capacity Scale (CCS) (20 items). The demographic characteristics included age, sex, marital status, educational grade average, Iranian ethnic groups, religion, familiarity/fluency in multiple languages, and prior education on cultural competence.
The CCS was developed by Perng & Watson (2012) [17] and can be used to assess and evaluate the levels of cultural competence of nursing students. The initial scale of CCS was developed based on the literature, and one of the theoretical models for developing this scale was Campinha-Bacote [17]. After assessing the elements of the model [1] and domains of the CCS [17], and because of the availability and applicability of the scale for the student, the research team decided that this scale is appropriate for evaluating the impact of educational intervention in this study for nursing students. The CCS contains multidomains but is brief and unidimensional. The CCS consists of items that assess cultural knowledge (6 items), cultural sensitivity (2 items), and cultural skills (12 items). The items of the scale were scored based on a 5-point Likert scale (from strongly disagree (1) to strongly agree (5)), total possible scores range from 20 to 100. Higher scores indicate higher levels of cultural competence [4, 17]. The scale has a reliability estimate (Rho = 0.97), that is analogous to Cronbach’s alpha, and statistically significant (p < 0.001) [17]. The CCS has been widely used in previous studies and was used with permission in this study. The CCS has been translated into Persian and used in several studies, these studies indicated that the Persian version of CCS has content validity and reliability [18, 19]. In a study, Cronbach’s alpha of the scale was reported as 0.84 [19]. The Persian-translated scale was used in this study. Cronbach’s alpha of the scale among the 88 participants of this study was 0.924. Participants in both groups completed the demographic characteristics form and the CCS before, immediately, and one month after the intervention.
Data analysis
Data were described using descriptive statistics (mean, SD, mean difference (MD), frequency, and frequency percentage). Chi-square (χ2), Fisher’s exact test, and independent t-test were used for between groups comparisons. For within group comparisons, one-way repeated measures Analysis of Variance (ANOVA) by considering time as within subjects factor was used. Pairwise comparisons were performed by the Bonferroni post hoc test. Mixed repeated measures ANOVA by considering the group as between subjects factor and time as within subjects factor in model was performed to assess the interaction effect of time and group. The assumption of normality was check and it was established. Moreover, sphericity assumption was checked and if necessary, the Greenhouse-Geisser correction was applied. Data analysis was performed by Statistical Package for the Social Sciences (SPSS) software (version 26; IBM Corp., Armonk, NY, USA). The significance level was set at p < 0.05.
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Results
The mean age of the undergraduate nursing students was 20.85 ± 1.71 years, and the educational grade average was 16.96 ± 1.19 out of 20. Most participants were female (54.5%) and 83% were familiar/fluent in a language other than their native language. All participants were single, and their formal language was Persian (Farsi). Participants were from various Iranian ethnic groups, including Fars, Turks, Kurds, Lurs, and others. The intervention and control groups were homogeneous in terms of demographic variables (p > 0.05), except for the educational grade average, which was higher in the control group (p = 0.046) (Table 2).
Table 2
Demographic characteristics of undergraduate nursing students in the intervention (n = 42) and control (n = 46) groups
Demographic variables | Categories | Intervention n(%) | Control n(%) | Statistic test | p-value |
|---|---|---|---|---|---|
Age | Years | 20.93 ± 1.67a | 20.78 ± 1.76a | t = 0.40 | 0.692 |
Educational grade average | Out of 20 | 16.69 ± 1.22a | 17.20 ± 1.12a | t = -2.02 | 0.046* |
Sex | Female | 23 (54.76) | 25 (54.35) | χ2 = 0.01 | 0.969 |
Male | 19 (45.24) | 21 (45.65) | |||
Religion | Islam | 42 (100) | 45 (97.82) | Fisher’s exact test | > 0.99 |
others | 0 (0) | 1 (2.17) | |||
Iranian ethnic groups | Fars | 26 (61.91) | 25 (54.34) | Fisher’s exact test = 3.89 | 0.437 |
Turks | 7 (16.67) | 4 (8.69) | |||
Kurds | 3 (7.14) | 6 (13.04) | |||
Lurs | 3 (7.14) | 8 (17.39) | |||
others | 3 (7.14) | 3 (6.52) | |||
Familiarity/fluency in bilanguages or multiple languages | Yes | 36 (85.71) | 37 (80.43) | χ2 = 0.43 | 0.511 |
No | 6 (14.28) | 9 (19.56) | |||
Prior education about cultural competence | Yes | 11 (26.19) | 8 (17. 39) | χ2 = 1.01 | 0.316 |
No | 31(73.81) | 38(82.61) |
Independent samples t-test was conducted to compare the scores of cultural competence and domains between the intervention and control groups before the intervention. The results showed no statistically significant differences between the two groups before the intervention (p > 0.05), indicating that the groups were similar at baseline. However, immediately and one month after the intervention, the scores for cultural competence and its domains were significantly higher in the intervention group compared to the control group (p < 0.05), except for cultural sensitivity measured one month after the intervention (t = 1.26, p = 0.21) (Table 3).
Table 3
Comparison of the cultural competence and its domains scores among undergraduate nursing students in the intervention (n = 42) and control (n = 46) groups over time
Cultural competence and its domains among undergraduate nursing students… | Time point | Group | T (p-value) | |
|---|---|---|---|---|
Intervention (42) | Control (46) | |||
Score (SD) | Score (SD) | |||
Cultural knowledge | Pre-intervention | 20.07 (3.54) | 19.30 (3.72) | 0.99 (0.326) |
Immediately after intervention | 21.71 (3.51) | 18.58 (4.07) | 3.84 (< 0.001) * | |
One-month after intervention | 21.50 (2.80) | 18.78 (3.54) | 4.01 (< 0.001) * | |
Effect of time by one-way repeated measure | ||||
F (df time, df error) | 4.44 (1.69, 69.42) | 0.68 (1.74, 78.19) | ||
(p-value) | (0.02) * | (0.48) | ||
Interaction of time and group by mixed repeated measure ANOVA | ||||
F (df time×group, df error) | 4.05 (1.74, 148.57) | |||
(p-value)** | (0.024) * | |||
Partial Eta squared | 0.045 | |||
Cultural sensitivity | Pre-intervention | 6.62 (1.68) | 6.89 (1.59) | -0.78 (0.438) |
Immediately after intervention | 7.26 (1.51) | 6.50 (1.53) | 2.34 (0.021) * | |
One-month after intervention | 7.07 (1.44) | 6.67 (1.51) | 1.26 (0.21) | |
Effect of time by one-way repeated measure | ||||
F (df time, df error) | 2.99 (2, 82) | 0.82 (2, 90) | ||
(p-value) | (0.06) | (0.44) | ||
Interaction of time and group by mixed repeated measure ANOVA | ||||
F (df time×group, df error) | 3.13 (1.99, 169.31) | |||
(p-value)** | (0.046) * | |||
Partial Eta squared | 0.038 | |||
Cultural skills | Pre-intervention | 40.50 (7.40) | 39.98 (7.35) | 0.33 (0.741) |
Immediately after intervention | 43.02 (5.82) | 38.85 (7.43) | 2.92 (0.005) * | |
One-month after intervention | 42.55 (6.04) | 38.63 (7.03) | 2.79 (0.006) * | |
Effect of time by one-way repeated measure | ||||
F (df time, df error) | 3.43 (1.46, 59.84) | 0.64 (1.62, 73.28) | ||
(p-value) | (0.05) * | (0.49) | ||
Interaction of time and group by mixed repeated measure ANOVA | ||||
F (df time×group, df error) | 3.24 (1.59, 135.83) | |||
(p-value)** | (0.061) | |||
Partial Eta squared | 0.037 | |||
Total cultural competence | Pre-intervention | 67.19 (11.51) | 66.17 (11.89) | 0.41 (0.685) |
Immediately after intervention | 72.00 (10.14) | 63.93 (12.36) | 3.33 (0.001) * | |
One-month after intervention | 71.12 (9.70) | 64.09 (10.95) | 3.18 (0.002) * | |
Effect of time by one-way repeated measure | ||||
F (df time, df error) | 4.79 (1.48,60.82) | 0.76 (1.63,73.59) | ||
(p-value) | (0.02) * | (0.44) | ||
Interaction of time and group by mixed repeated measure ANOVA | ||||
F (df time×group, df error) | 4.21 (1.63, 139.25) | |||
(p-value)** | 4.21 (1.63, 139.25) | |||
Partial Eta squared | 0.047 | |||
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To evaluate changes over time in both the intervention and control groups one-way repeated measures ANOVA was performed. The analysis revealed that the changes in scores over time (pre-intervention, immediately, and one month after the intervention) for cultural competence and its domains were higher statistically significant in the intervention group (p ≤ 0.05), except for cultural sensitivity (p = 0.06). This suggests that the intervention led to meaningful improvements over time compared to the baseline. In contrast, changes in scores over time in the control group were not statistically significant (p > 0.05), indicating that no significant change occurred over time in this group without the intervention. The Bonferroni post-hoc comparison procedure revealed statistically significant differences in total cultural competence and cultural knowledge between pre-intervention and immediately after the intervention in the intervention group (p < 0.05). No statistically significant differences were observed for the other measurements in either the intervention or control groups (p > 0.05) (Table 3) (Fig. 2).
Fig. 2
The comparisons of the cultural competence and its domains among undergraduate nursing students in the intervention and control groups at measurements over time.× Bonferroni post-hoc test was significant between measurements
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The mixed repeated measures ANOVA adjusted for educational grade average, which was significantly higher in the control group, also indicated that the interaction effect between time and group was statistically significant for cultural competence and its domains (p < 0.05) except for cultural skills (p = 0.061), indicating that the pattern of changes over time was different between the intervention and control groups. Effect sizes for the ANOVA were quantified using partial eta squared, with interpretations classified as follows: values less than 0.01 were considered negligible, values between 0.01 and 0.06 indicated a small effect, values between 0.06 and 0.14 signified a moderate effect, and values greater than 0.14 represented a large effect [20]. Partial eta squared for cultural competence and its domains ranged from 0.037 for cultural skills (which was not statistically significant with a p-value of 0.061) to 0.047 for total cultural competence, reflecting a small effect size. These findings indicate that the intervention had a discernible impact on the intervention group compared to the control group, although the effect size was small (Table 3).
Discussion
The results of this study indicated that the two intervention and control groups were similar in terms of most demographic characteristics, cultural competence, cultural knowledge, cultural sensitivity, and cultural skills before the intervention. Immediately and one month after the intervention cultural competence and its domains were higher in the intervention group than in the control group. Furthermore, the interaction effect of time and group was significant for cultural competence, cultural knowledge, and cultural sensitivity, indicating that changes in these variables over time differed between the groups, suggesting a positive effect of the intervention.
The results of an experimental study conducted in Iran using a mobile app-based cultural care training program demonstrated improvements in the cultural capacity and humility of undergraduate nursing students. Before the intervention, there was no significant difference in the total cultural capacity, cultural knowledge, cultural sensitivity, and cultural skill between the intervention and control groups, but after the intervention there was a significant difference in the total cultural capacity and cultural knowledge scores between groups. Furthermore, there was an improvement in the total cultural capacity and its subscales in the intervention group before and after the educational intervention [21]. These findings are consistent with the present study, the reason for this similarity could be due to the participants, context, and instruments of the two studies, although the educational intervention and method of training in the two studies were different. Another study in Iran indicated that virtual training program improved the cultural knowledge, cultural skills, and total cultural competence of nurse educators [22]. The findings of the above-mentioned study regarding the level of cultural knowledge, cultural skills, and total cultural competence before and after the intervention in the two intervention and control groups, are consistent with the present study. Cultural sensitivity was not in the subscales of the mentioned study. A quasi-experimental study in South Korea with a transcultural nursing simulation-based learning program indicated that the levels of total cultural competency, cultural sensitivity, and cultural skills increased significantly in the intervention group over time compared with the control group, whereas cultural knowledge did not [23]. The findings of the above-mentioned study regarding the interaction of time and group in the domains of total cultural competence and cultural sensitivity are consistent with the present study, whereas in regards to the domains of cultural knowledge, and cultural skills are inconsistent with the present study. Methods of educational intervention and different time points of measurement between the above-mentioned and present study may account for these discrepancies. A group pre- and posttest intervention design in a tertiary teaching hospital in South Korea, showed that the mobile app-based cultural competence training program improved the cultural competence, cultural knowledge, cultural sensitivity, and cultural skills of nurses [24]. Another study in the United States of America (USA) indicated that the cultural knowledge and cultural skills among Bachelor of Science in Nursing (BSN) students after international service-learning experiences improved [25]. The results of the above-mentioned studies are consistent with the present study. Although the educational interventions and methods, cultural competence constructs, and methods of analysis are different in these studies. A systematic review study confirms this difference between the studies [26]. Probably, educational intervention with real-life experiences in different clinical settings appears to have a greater impact on nursing students’ cultural competence and its subscales, particularly in enhancing cultural skills.
A mixed-method study abroad in India indicated that there was no statistically significant improvement in the scores of the intercultural effectiveness scale and intercultural sensitivity scale among health professions students during the study [27]. The results of this finding differ from the present study. The educational intervention and methods, participants, and evaluation instruments used in the Indian study were different from those in the present study, which may account for the discrepancies. However, qualitative analysis of students’ reflections in the Indian study indicated that students’ awareness, openness, and intercultural competence skills had developed [27]. This highlights the complexity of assessing cultural competence and the importance of multiple evaluation methods.
The partial eta results indicated that the intervention was effective on cultural competence and its domains, although the effect sizes were small in the present study. The findings of a systematic scoping review study indicated that diverse approaches are available to increase the health workforce’s cultural competence. Cultural competency training is just one intervention strategy. For example, professional development intervention is another strategy. There was also heterogeneity in the outcomes reported across the studies [28]. These issues should be considered when designing interventions for cultural competency for each group in healthcare organizations. On the other hand, educational intervention methods for cultural competence are various such as simple lecture and discussion formats, bolstered lecture and discussion formats by including reflective journaling or a multimedia component, immersion or simulation techniques to develop cultural competence through behavioral and attitudinal changes, role-playing and simulation [11], case scenarios, tutorials, service-learning projects with local and international communities, and various teaching-learning [26]. It is clear that each educational method has short-term and long-term effects, and the education method should be chosen according to the available resources and the situation.
Limitation
There are several limitations to consider in this study. First, the use of a self-report instrument may have influenced the accuracy of the data, as responses may not fully reflect the actual levels of cultural competence. Future studies could benefit from incorporating more accurate and objective scales to evaluate these concepts. The participants in this study had community health nursing clinical courses at the Urban Health Comprehensive Services Centers, but due to the high number of students, health centers, and four training sessions, it was not possible to conduct educational interventions in clinical settings with real clients. As a result, the research team decided to provide this educational intervention in the classroom with educational content that was close to the real environment. Future research could provide these interventions in the form of service-learning educational interventions. Furthermore, the study participants were selected from a nursing school, which may limit the generalizability of the findings to other contexts. Finally, data collection was conducted immediately and one month after the intervention. Longer follow-up periods (e.g., 3–6 months) may be beneficial in future studies to assess the durability and long-term effects of the educational intervention.
Conclusion
The results of this study showed that an educational intervention based on the Campinha-Bacote model can improve cultural competence and its domains among undergraduate nursing students. Nursing schools and educational organizations should strive to provide their students with more theoretical and clinical experiences related to cultural competence. Future research can be focused on designing, implementing, and evaluating more specific educational interventions based on the needs of nursing students, and culturally diverse clients with real-life experiences in different clinical settings.
Acknowledgements
The authors would like to appreciate the Shahid Beheshti University of Medical Sciences (SBMU), the school of Nursing and Midwifery of the university for their support, cooperation, and assistance throughout the study. We would also like to thank all the undergraduate nursing students who took part in the study.
Declarations
Ethics approval and consent to participate
The necessary permits and approvals for this study were obtained from the Research Ethics Committees of School of Pharmacy and Nursing & Midwifery-Shahid Beheshti University of Medical Sciences (Approval ID: IR.SBMU.PHARMACY.REC.1402.195, Approval Date: 2024-01-15). The protocols were in accordance with the Declaration of Helsinki. Participants were provided with information about the research and its objectives, the confidentiality of their information, their right to withdraw from the study, and their access to the study findings. Written informed consent was obtained from all participants, and the necessary permissions were obtained from authorities before sampling.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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