Using a model to design, implement, and evaluate a training program for improving cultural competence among undergraduate nursing students: a mixed methods study

Culture and care are crucial for human survival. Understanding the cultural diversity and its components, such as distinct practices, beliefs and values, communication patterns, mental process, behaviors, traditions, and philosophy of clients can assist healthcare providers to respond in a culturally sensitive manner. Cultural diversity is used to implement healthcare services and programs. Now, healthcare systems are full of clients (families, individuals, communities, and populations) with varied cultures [1]. Changing population demographics and the cultural diversity necessitate examination and change of care processes; therefore, healthcare providers must provide culturally diverse nursing care. According to the American Nurses Association (ANA), cultural competence and professional growth is an important part of the nursing code of ethics. ANA introduced a new standard, culturally congruent care, to the Nursing: Scope and Standards of Practice, as the number of culturally and ethnically diverse clients increases [2, 3].

Leininger’s sunrise model can be used to culturally assess patients or clients, so nurses and other healthcare providers can identify worldview, cultural and social components of community, and also decision and action modes to provide culturally congruent care [1]. Culturally congruent care considers the client’s cultural values, beliefs, worldview, and lifeways, while making decisions about their health and well-being or preventing illness, disabilities, or death [4]. Culturally congruent care is evidence-based nursing that respects the healthcare consumer’s and other stakeholders’ cultural values, beliefs, worldview, and practices. As culturally congruent care encompasses all consumers, healthcare delivery systems, and nursing roles; therefore, practice evaluation ranges from fairly simple to complex. Culturally congruent care improves skills, behaviors, and practice of healthcare providers and patient satisfaction [5].

Cultural competence can provide culturally congruent care [5] and includes a set of congruent behaviors, attitudes, and policies that enable a system, agency, or professionals to work effectively in cross-cultural situations [6]. Campinha-Bacote’s model defines cultural competence consists of five components: cultural awareness, cultural knowledge, cultural skills, cultural encounter, and cultural desire [7]. Most nurses will achieve culturally congruent care and competencies through the lifelong professional development. This process begins with academic education and continues throughout the nurse’s professional life [5]. Therefore, nursing students must develop cultural competence during their studentship. However, cultural competence is not a major attitude in the nursing education. Nursing students may feel unprepared to deliver culturally competent care to culturally diverse clients [7].

Several descriptive studies conducted in different countries [8‐11] and in Iran [12] found that nurses and nursing students had low to moderate levels of cultural competence. All studies emphasized the training programs to promote nursing students’ cultural competence. Interventional studies also revealed the effectiveness of training programs in promoting nursing students and graduates’ cultural competence [11, 13‐15]. Several studies showed that cultural care education increased cultural safety among the healthcare team, nurses, and nursing students to prevent cultural bias, unhealthy, discriminatory, or degrading attitudes toward patients, and to build trust in patients and their families [16, 17]. A systematic review also found that nursing students considered lack of cultural competence and self-efficacy, and language as barriers to assessing patients from other cultures. Cultural encounters, knowledge, and experiences were the most important facilitators of cultural competence. Cultural diversity education, experience with taking care of patients from different cultures, and special populations were key factors influencing cultural competence. Researchers emphasized that nursing students’ cultural competence should be improved through cultural care education [7]. Undergraduate nursing students must develop cultural competence through undergraduate nursing curricula during their studentship. Effective strategies should integrate cultural competence into the undergraduate programs. However, there is limited research on the most effective method to promote cultural competence in undergraduate nursing students. This finding supports the literature that a culturally competent curriculum or experience will promote cultural competence in undergraduate nursing students [6]. Other researchers highlighted in a mixed methods study that the experiences and perspectives of students, nurse educators, and nurses should be studied using qualitative data in order to improve students’ cultural competence. The training program should then be tailored to the needs of the students and evaluated quantitatively [18]. Another study emphasized that nursing programs had to address educational need of students. Students’ involvement in training programs helps them realize their crucial roles in designing and developing curricular. Moreover, nurses and nurse educators’ varied approaches and perspectives strengthen the training programs. Therefore, educators can help future nurses provide care for multicultural populations better [18].

It is not clear how to teach cultural care to nursing students. We aimed to address this gap by designing, developing, implementing, and evaluating appropriate teaching and learning approaches in cultural care training program contextualized within a systematic model. The Talbot and Verrinder model in health education can be a guide to design, implement, and evaluate cultural care training program for promoting cultural competence among nursing students. Therefore, subjects for cultural care education must be identified to prepare nursing students for cultural competence. Additionally, the effects of this program on nursing students’ cultural competence can contribute to future cultural nursing education activities, strategies, tactics and educational contents. However, the literature does not adequately address training programs for improving nursing students’ cultural competence. Further rigorous mixed methods studies are needed to design and evaluate training programs in different contexts and cultures. Therefore, this study aimed to design, implement, and evaluate a cultural care-training program to improve cultural competence of undergraduate nursing students.

This study aimed to design, implement, and evaluate a cultural care training program for improving cultural competence of undergraduate nursing students. Designing this program based on the documentations of the qualitative study, review of the literature, and expert panel could improve the cultural competence of undergraduate nursing students.

In support of our results, researchers acknowledged that health educators frequently used psychosocial models when designing, implementing, and evaluating outcomes of curriculum and health education interventions. Models serve as a starting point for exploring clients’ perspectives, beliefs, values, and practices. After understanding clients’ viewpoints, practitioner and clients can collaborate more effectively to find workable solutions. Incorporating models helps students develop cultural competence [23]. Moreover, Tessier et al. (2021) suggested that needs assessment was critical for familiarity of instructors with the organizational context, appropriate educational contents, understanding of participants’ practical experiences, and the value of training. It can assist instructors in identifying participants’ main concerns and experiences to enhance the effectiveness of training programs. Such needs assessment also helps instructors establish a conducive learning environment by fostering relationships with participants [37]. Creswell and Guetterman (2019) also believe that people are the best source of describing their own situation, cultural context, needs, feelings, and experiences [38]. Researchers in another study emphasized that cultural competence education should be congruent concerning the needs, the levels of receptivity of the learners, as well as context, culture, policies and guidelines, and accreditation of educational institutions. Diverse patients, community representatives, consumers and advocates should participate in the design, implementation, and evaluation of cultural competence curricula whenever possible [39].

In addition, evidence suggests that cross-cultural learning can be improved by reconsidering educational philosophies and learning and teaching methods in theory and practice as well as exploring the benefit of cultural care. Therefore, students can communicate with individuals from other cultures [40, 41]. Using a literature review and consultation with academics, Allen et al. (2013) developed the teaching-learning methods and learning objectives for nursing students’ cultural care education. The teaching-learning method was modified with experiential learning and role-playing. Then, they evaluated students’ learning through quantitative study using pre and post-test. The study findings supported the effectiveness of this strategy in promoting students’ confidence in cultural nursing care [21]. Two meta-analyses revealed that the best way to educate cultural competence was through a variety of educational strategies, including lectures, in-depth, interactive exercises and discussions, case study analysis, genograms, presentation of articles, selected readings and web-based learning and data collection, videos, simulations, role-playing, seminar, in-service-based learning, poster presentations, interview with clients, and development of a measuring tool [26, 42]. Researchers systematically reviewed 11 studies to evaluate cultural care training program. The results showed that cultural competence interventions/programs were integrated into core theoretical courses, or offered as elective courses. Debates, discussions, case scenarios, practicums, simulation, international learning projects, experiential learning, storytelling, and lectures were among the various types of teaching methods. Ten studies reported a statistically significant increase in the level of cultural competencies. Educational content, teaching methods, and training courses were not uniformly described in the literature. More comprehensive, valid, and reliable measurement tools are needed to evaluate the education provided for nursing students [7].

In the quantitative part of this study, the training program was piloted and evaluated in a group of nursing students. After the implementation of the cultural care training program, cultural competence in the intervention group increased significantly compared with the control group. Cultural competence in the intervention group was promoted from “moderate” level to “high” level. Consistent with our results, several interventional studies evaluated and validated the effectiveness of cultural care training programs with cultural competence questionnaires [13, 23, 43‐48]. Bauer and Bai (2018) used a model to develop a curriculum to enhance cultural competence among students of Nutrition and Food Science. They selected subjects, assignments, and activities based on a review of publications and websites from governmental, educational, and professional organizations. Evaluation of pre- and post-test data showed a significant improvement in students’ cultural competence [23]. Researchers in another study reported that cultural competence of senior oral health students increased significantly after receiving cultural competence training. They emphasized that cultural competence is a multifaceted structure, and an online training program is not enough to meet the needs of culturally diverse patients. Clinical work experiences and the community where students study help them to strengthen their level of cultural competence. In addition, patient feedback and health outcomes are important components of cultural care learning [49]. Lin et al. (2015) in one study conducted cultural care training and found that the cultural competence of nursing students improved; however, the overall effectiveness of the training decreased over time and in follow-up. The researchers stressed that cultural care training and assessment of its effectiveness in students and nurses’ learning should be done continuously [22].

Singleton (2017) demonstrated that after completing the cultural care program, PhD nursing students in New York raised their cultural competence and self-efficacy. According to the researcher, American Nursing PhD curricula were acceptable and sufficient in accomplishing national and professional goals to improve the practice of culturally competent nurses since these programs promoted learning based on societal requirements and demands to provide cultural care [50]. Our research suggests that nursing researchers examine the curriculum of undergraduate and postgraduate nursing students in Iran to achieve national and professional goals, equip students with appropriate cultural competence, and develop a program based on the needs of these target groups and the needs of a multicultural society. Researchers argue that most nurse educators teach cultural care to students and learners through a discontinuous training program that is limited to theoretical topics. Although these training programs can help increase cultural competence, they are insufficient for long-term motivation, attitudes, and behavior change after graduation. Nurse educators and students should pay special attention to cultural competence as a lifetime process, and participation in training programs is required even after years of working in the clinical settings [44]. Above-mentioned studies may be consistent with the present study because of new and diverse educational content and duration of training.

However, two studies showed that cultural care training in the form of cross-cultural communication workshops [24], simulation-based educational method, and in-service-based learning project were not effective in improving participants’ cultural care competence [51]. They suggested the need to develop and organize cultural training programs more coherently to increase the number of programs with fewer participants.

The findings of study have implications for curriculum developers and nurse educators. Cultural competence must be an important outcome for graduate nursing students. In order to prepare nursing students to enter the clinical settings, cultural competence should be considered in undergraduate nursing education. For this purpose, it is necessary to change the perspective, increase the cultural competencies of nurse educators, and create organizational cultural competence. Moreover, cultural competence must be used as a key part of the professionalization process in various fields of nursing, including education, clinic, community, research and management. Therefore, this requires proper context, adoption of long-term strategies, spending of more time and energy and understanding of the multicultural approaches by policy makers, curriculum designers, nurse educators, and educational managers in nursing schools. This study helps nurse educators to focus specifically on educational specific needs of undergraduate nursing students and teaching and learning approaches to improve cultural competence students using a simple and effective method. The use of a specific model makes the work of an instructional designer more systematic. To address cultural care in the design of health education programs and community health nursing education, Talbot and Verrinder (2005) model, which is more relevant to cultural competence, was used in this study to design the training program. Models act as a guide to curricular development. No curriculum model alone is sufficient for the entire curriculum of an educational center that educates a diverse population with multifaceted goals. Curricular designers and developers need to be aware of existing models to make intelligent decisions about their designs. The instructional design models were employed by taking into consideration the following principles: instructional designs are systematic and reflective processes through which instructional principles are used in the teaching and learning programs by differentiating materials, resources, activities, and evaluation. In instructional design processes, the designers are required to know and inquire about the theories of learning, systematic analysis of learners, and management methods to enhance their ability to employ information technology and evaluate the teaching and learning processes appropriately. An appropriate instructional design model should guide the professional designers to form the instructions according to the learners’ viewpoints rather than from the content perspective. As a result, considering the learners, aims (or learning attainments/outcomes), methods, and evaluations is of great importance in instructional design processes [52]. A common message behind all the instructional design models maintains that various types of learning require various learning conditions. Given that the instructional design models are adopted based on various learning needs, designers try to match the requirements pertinent to each learning situation with the responding models during the design process. Although there are many instructional design models, the majority of these models consist of these essential phases ADDIE: analysis, design, development, implementation, and evaluation [53]. Given the continuous social, environmental and cultural changes in the nursing schools, offering a credible model is not possible for designing training programs. In this regard, nurse educators with higher levels of awareness about different instructional design models are better equipped to choose a model that is appropriate to their classes and courses. In-service training (professional development opportunities) is needed because each of the nurse educators must be well-trained in new century skills [52]. Novice instructional designers should be trained in specific communication and even project management skills. Education and training provide them with knowledge and skills on how to operate in specific situational contexts effectively [54].

This study described the usability of the Talbot and Verrinder’s model to design, implement, and evaluate a cultural care training program aimed at improving nursing students’ cultural competence. This systematic model helped to integrate experiences and viewpoints of students, nurse educators, nurses, and experts into research evidence for assessing the educational needs of students, organizing detailed educational content, assignments and activities for students, selecting teaching and evaluation methods in the curriculum. Teaching methods were effective, and evaluation of data revealed the effectiveness of this form of program in improving students’ cultural competence. This program was an example of the design and development a cultural care curriculum and contributed to the literature on cultural competence in nursing education. Moreover, these findings can assist nurse educators to design effective cultural care training and education using systematic models to better prepare future nurses to provide culturally congruent care to multicultural clients. Further studies are also suggested to assess cultural competence in healthcare providers and evaluate effectiveness of different approaches and models to enhance their competence in different cultures and contexts.