Cultural competence among Swedish child health nurses after specific ...

Nursing and Health Sciences (2010), 12, 381–391

Research Article

Cultural competence among Swedish child health nurses after specific training: A randomized trial nhs_542

381..391

Anita Berlin, rn, mmsc(PublicHealth), Gunnar Nilsson, md, phd and Lena Törnkvist, rn, drmedsc Centre for Family and Community Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden

Abstract

An urgent need to improve Swedish primary child health-care nurses’ cultural competence was revealed by previous research among nurses working in, and immigrant parents visiting, primary child health-care services. The aim of this study was to evaluate the extent to which specific training affected how nurses rated their own cultural competence, difficulties, and concerns and to study how the nurses evaluated the training. Conducted as a randomized controlled trial, the effects on a study sample of 51 nurses were assessed by questionnaires in a pre- and post-study design. The findings indicated that the 3 days of training were appreciated by the nurses and had some effects on their cultural competence, difficulties, and concerns. The training might have had positive effects on the nurses’ working conditions as they rated it to have an impact on their ability to cope with the demands of their work activities in the health services. These effects are presumed to contribute to an improved quality of the health services, with a reduction in the risk for health-care disparities among children of immigrant parents.

Key words

cultural competence, nurses, primary child health-care services, randomized controlled trial, study-specific training intervention.

INTRODUCTION Demographic changes in the population have made Sweden into a multicultural society comprised of a wide variety of nationalities. First- and second-generation immigrants constitute 18% of the total population and, in the capital, the number is even higher (Statistics Sweden, 2008). Furthermore, one-third of the children who are seen by the primary child health-care services (subsequently referred to as “health services”) in Stockholm County have parents that migrated to Sweden (Bergström et al., 2009). The primary child health-care nurses (subsequently referred to as “nurses”) working in this service interact with children and parents from diverse cultural groups (Berlin et al., 2006). The results from the authors’ previous research and theoretical models show that a majority of the nurses experience stimulating, but difficult, interactions with immigrant parents (subsequently referred to as “parents”) and their children (Berlin et al., 2006). Many nurses were dissatisfied with the quality of their work (Berlin et al., 2006) and had difficulties in carrying out one of their main tasks; that is, assessing the health risks in these children’s psychosocial home environment (Berlin et al., 2008). A study among parents revealed that they had a

Correspondence address: Anita Berlin, Centre for Family and Community Medicine Stockholm, Karolinska Institute, Alfred Nobels Allé 12, SE-141 83 Huddinge, Sweden. Email: [email protected] Received 26 February 2010; accepted 24 June 2010.

© 2010 Blackwell Publishing Asia Pty Ltd.

general feeling of exposure and anxiety about being misjudged as parents (Berlin et al., 2010). This is alarming as it might risk the provision of high-quality health services on equal terms. Cultural competence is therefore an urgent matter in the health services. Internationally, this competence has been stressed as important because it is known to improve client and health-care provider relationships (Ahmann, 2002; Campinha-Bacote, 2002; Marcinkiw, 2003). According to Campinha-Bacote (2002; 181), cultural competence is defined as an individual process in which health-care providers continually “strive to achieve the ability and availability to effectively work within the cultural context of a client”.

BACKGROUND For several years worldwide, intercultural interaction in health care between clients and caregivers has been described as challenging and problematic (Doswell & Erlen, 1998; Kulwicki et al., 2000; Blackford & Street, 2002; Hudelson, 2006). Training in cultural competence has been suggested as one way to reduce these difficulties (Ahmann, 2002; Campinha-Bacote, 2002; Marcinkiw, 2003). Several previous studies evaluated the effects of training interventions in cultural competence. Both shorter and longer interventions revealed an improvement of the healthcare providers’ knowledge, attitudes, and skills. The learning activities and length of the interventions varied and the most doi: 10.1111/j.1442-2018.2010.00542.x

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common target learners were medical and nursing students (Beach et al., 2005; Price et al., 2005). There is a shortage of clinician-focused interventions (Price et al., 2005) and studies designed as randomized trials (Price et al., 2005; Bhui et al., 2007; Chipps et al., 2008). Furthermore, Price et al. (2005) concluded that the lack of methodological rigor limits the evidence of the impact of cultural competence training and emphasized the need to pay attention to proper design. In addition, Price et al. (2005) suggested five domains of study quality: the proper description of the study’s participants, intervention, outcome assessment, analytical approach, and potential for bias and confounding. Training in cultural competence might be an effective way to support nurses in their clinical work in the health services and is an important area to study. Therefore, the aim of this study was to evaluate the extent to which specific training affects how nurses rate their own cultural competence, difficulties, and concerns and to study how nurses evaluate the training.

MATERIALS AND METHODS Study design The cultural competence training was designed as a randomized controlled trial (Price et al., 2005). The study’s participants were an intervention group (IG) and a control group (CG) of nurses working in the health services in Stockholm and Sörmlands counties. Coded questionnaires were used as the outcome assessment in a pre and post approach.

Setting The clinical part of the health services is carried out at the primary child health-care centers (subsequently referred to as “health centers”). At these health centers, nurses have the primary role for most of the child health activities; for example, preventive health care, such as health education, psychosocial support and advice, vaccinations, and health examinations (Jansson, 2000; Norvenius, 2001; Baggens, 2002; Bergström, 2010). They assess children’s motor and linguistic development and physical, mental, and psychosocial health (including the family’s social situation) and they decide on which kind of intervention or individual support a child and family could need for optimal health development. The nurses generally encounter the children and their parents at the health center, although home visits are arranged in special situations (Bergström, 2010). It is mandatory for the nurses to report to the social service authorities if they have doubts about the conditions in which a child is being raised (Bergström, 2010).

Participants A procedure for selecting the municipalities, health centers, and participating nurses was carried out in order to ensure a geographical spread, with nurses at both smaller and larger health centers having responsibility for children of immigrant parents. The health centers also had to make it possible for © 2010 Blackwell Publishing Asia Pty Ltd.

A. Berlin et al.

the nurses to attend the training. Hence, the selection procedure was done in the following steps: 1 Of the 39 municipalities in Stockholm County, 27 that had registered at least 20% of the children as having immigrant parents, according to the annual statistics report (Bergström et al., 2009), were selected. 2 Fifteen of these municipalities were randomly chosen as an area for the selection of nurses to the IG and 12 of these municipalities were randomly chosen as an area for the selection of nurses to the CG. 3 The nurses in the IG areas (n = 181 at 43 health centers) and in the CG areas (n = 140 at 48 health centers) were listed and given a number. They were randomly selected for participation in the study according to the following criteria: if there were two or more employed nurses at the health center, one of them was selected; if there were more than five employed nurses at the health center, two of them were selected. 4 As more nurses were needed in the IG, Sörmlands County was contacted. Of the nine municipalities, four that had registered at least 20% of the children as having immigrant parents were selected. The nurses (n = 11 at six health centers) were given a number and assigned to the IG (as described in point 3). 5 Among all the selected nurses, 32 in the IG and 16 in the CG did not respond or declined participation for such reasons as reorganization, a heavy workload and time pressures, a shortage of personnel, or sick leave. The final sample was comprised of 51 nurses: 24 in the IG and 27 in the CG. Fifty nurses filled in the pretraining questionnaire (IG: 100%; CG: 96%) and 49 filled in the posttraining questionnaire (IG: 100%; CG: 93%). The majority was born in Sweden. The IG had a higher degree of linguistic ability and previous training in cultural competence. The CG had a higher degree of missing answers (Table 1).

Training A specific content, process, and performance were created.

Content The content was comprised of Campinha-Bacote’s (2002) definition and cultural competence model, as well as studyspecific knowledge regarding nurses’ and parents’ difficulties and concerns that were derived from previous research (Berlin et al., 2006; 2008; 2010). In order to become culturally competent, individuals must proceed through a process of five different levels in the model: 1 Cultural awareness: providers start to examine their own bias, culture, and professional background. 2 Cultural knowledge: providers obtain knowledge of different cultures and ethic groups (e.g. their worldview, traditions, religion, and differences in health-seeking behavior). 3 Cultural skills: the providers’ ability to conduct cultural assessment; that is, collecting relevant data concerning the

Cultural competence and child health nurses

Table 1.

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Characteristics of the nurses in the intervention group (IG) and the control group (CG)

Characteristic Nationality Swedish Finnish Hungarian Missing answers Country of birth Sweden Hungary Europe Middle East Missing answers Linguistic ability Swedish (solely) Finnish English Other language Missing answers Previous training in cultural diversity professional education Not at all to a little Somewhat to very much Missing answers Previous training in cultural diversity during professional courses Not at all to a little Somewhat to very much Missing answers Previous training in cultural diversity-specific courses arranged by the health services Not at all to slightly A lot to quite a lot Missing answers

client’s present problem, as well as making a physical assessment. 4 Cultural encounters: providers’ opportunity to gain experience by directly engaging in face-to-face cultural interactions with clients from different cultural backgrounds, trying to modify existing beliefs, or to prevent the possible stereotyping of these individuals. 5 Cultural desire: providers’ motivation and willingness to become culturally competent. The study-specific knowledge that was derived from previous research concerned: 1 Nurses’ opinions regarding their working conditions and perceived cultural competence (Berlin et al., 2006). 2 Nurses’ difficulties in carrying out an assessment of the health risks in the psychosocial home environment of a child, illuminated by a theoretical model (Berlin et al., 2008). 3 Parents’ perspectives on interacting with the nurses, described in a theoretical model (Berlin et al., 2010). Campinha-Bacote’s (2002) cultural competence model was used as a framework for discussing the results from these studies in the training program.

Nurses in IG (n = 24) N %

Nurses in CG (n = 27) N %

22 2 – –

92 8 – –

21 1 1 4

78 4 4 14

21 2 – 1 –

88 8 – 4 –

20 2 1 0 4

74 7 4 0 15

3 2 14 5 –

13 8 58 21 –

6 2 8 7 4

22 7 30 26 15

23 1 –

96 4 –

20 2 5

74 7 19

18 6 –

75 25 –

21 2 4

78 7 15

20 4 –

83 17 –

19 2 6

71 7 22

Process The following teaching approaches were used: 1 A participatory learning approach (Kiessling, 2004) focused on the nurses’ clinical work. 2 Linking theory to practice (Corlett, 2000) by a theoretical and a clinical/practice section in the training program. The theoretical section included cultural awareness, cultural knowledge, cultural skills, and cultural desire. Training was by lectures and group discussions. The clinical practice section (4 weeks of clinical work at the health center) was comprised of cultural skills and cultural encounters and was aimed at applying what was taught in the theoretical section. 3 Case methodology (Kiessling & Henriksson, 2002; Tomey, 2003) was aimed at training the nurses to manage culturally difficult scenarios in the clinical setting. 4 In the reflective practice groups (Platzer et al., 2000), theoretical study-specific knowledge that was derived from previous research (Berlin et al., 2006; 2008; 2010) was used for reflection and understanding. © 2010 Blackwell Publishing Asia Pty Ltd.

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Table 2.

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Training in the cultural competence of nurses in the health services

Section Theory

Level Cultural awareness

Cultural knowledge

Cultural skill

Cultural skill

Clinical/practice

Cultural skill and cultural encounter

Content, process, and learning activity

Intended learning outcome

Lecture and discussions: History of the health services (“medical culture” and guidelines concerning ethical and multicultural diversity) Results of, and theoretical models from, previous research (i.e. interaction from the perspective of nurses and parents of foreign origin) The theoretical framework of cultural competence Swedish culture (“eye opener” and reflection on one’s own culture) Self-awareness and receptivity to diversity Experiences of differences, ethnocentrism Racism and prejudice Lecture and discussions: Distinguish between refugees and immigrants Present situation of migration to Sweden National policy and the health service’s policy regarding cultural diversity Ethnicity and health Individual- versus group-oriented society Differences in illness and disease (values, beliefs, health systems, healing and wellness, help-seeking behavior, attitudes to health-care provider, religious needs, and nutrition) Ethnopharmacology Lecture and discussions: Different communication styles and barriers Intercultural communication Exploration of the parent’s explanatory model Exploration of the parent’s understanding Description of one’s own view How to work with an interpreter Reflective practice group discussions: Solving culturally difficult scenarios and cases Use of the theoretical models

Awareness concerning the importance of cultural awareness in relation to clients and the importance of training for nurses Awareness and understanding of the nurses’ own culture and professional background, bias, and prejudice

Clinical work in the health services during the 4 weeks: Application of what was learned in the theoretical section Use of the theoretical models when reflecting and solving clinical cases

Performance The training lasted for 3 days, with the third day after 4 weeks of clinical work at the health centers. Pretraining, the IG nurses were instructed to bring two cases that had caused them concerns in their clinical setting to be discussed in the reflective practice groups. During the 4 weeks of clinical work and in at least one case, the IG nurses were instructed to consider the direct face-to-face cultural interactions (Campinha-Bacote, 2002) by using the study-specific theoretical models (Berlin et al., 2008; 2010). Additionally, they were asked to consider and make notes on: What was the © 2010 Blackwell Publishing Asia Pty Ltd.

Knowledge concerning migration, ethnicity, and cultural influence on health National and local policy concerning cultural diversity

Skills in dealing with sociocultural issues concerning assessment, cross-cultural communication, eliciting different perspectives, negotiating, and providing health services Skills in dealing with sociocultural issues concerning assessment, cross-cultural communication, eliciting different perspectives, negotiating, and providing health services Skills in dealing with sociocultural issues in the health services Confidence when dealing with cross-cultural encounters or situations

reason for the visit? What happened? What did you think and feel? What did you do? This was to be discussed on the last day of training. The learning activities and intended learning outcomes, based on the theory of cultural competence (Campinha-Bacote, 2002), and the learning abilities requested in the outcome assessments are illustrated by Table 2.

Outcome assessments Three aspects were assessed as outcomes of the training: cultural competence, experiences of difficulties and concerns,


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Table 3. Outcome assessment and scales for evaluation of the training in the intervention group (IG) and the control group (CG) of nurses, preand post-training

Aspect Cultural competence Participant data, formal training in cultural diversity, open-ended opinions Cultural awareness Cultural knowledge Cultural skills Cultural encounters/situations Cultural desire Experiences of difficulties and concerns Statements of difficulties and concerns Evaluation of the training Attendance days 1–3 Quality Impact on everyday practice Open-ended question Total number of questions

Outcome assessment IG pretraining CG pretraining No. of questions No. of questions

IG post-training No. of questions

CG post-training No. of questions

Self-rating scales

9

9

–

–

9 10 13 14 –

9 10 13 14 –

9 10 13 14 1

9 10 13 14 –

1–5 1–5 1–5 1–5 1–5

14

14

14

14

1–4

– – – – 69

– – – – 69

4 1 1 1 68

– – – – 60

Yes/no 1–5 1–6

and the nurses’ evaluation of the training, as illustrated by Table 3.

Cultural competence The Clinical Cultural Competence Training Questionnairepre (CCCTQ-PRE) and the Clinical Cultural Competency Training Evaluation Questionnaire-post (CCCTEQ-POST) were used (Krajic et al., 2005b). The questionnaires, which cover the levels in Campinha-Bacote’s (2002) cultural competence model, originate from the USA (Like, 2004) and were further developed in Europe and translated into seven different languages, including Swedish (Krajic et al., 2005a). Their reliability and internal consistency have been tested, showing Cronbach’s alpha scores of > 0.8 (Krajic et al., 2005b). The questionnaires’ wording was changed to fit the health services.Also, seven questions were not applicable and were omitted: three participant data questions (no. 5, 7, and 8), two cultural skill questions (no. 9 and 14), and two cultural encounters/situations questions (no. 8 and 9).The Cronbach’s alpha scores were > 0.83. A pilot test of the questionnaires was conducted: two nurses filled in and considered the comprehensibility of each question, resulting in slight changes in wording.

Experiences of difficulties and concerns Fourteen questions with different statements of difficulties were used. Eleven questions were based on the findings from international studies concerning multicultural interactions in health care and providers’ difficulties regarding language barriers (seven questions), assessing a client’s health literacy (one question), compliance (one question), as a health-care provider lacking knowledge regarding cultural aspects (one

question), and feelings of insufficient care provision (one question) (Lynam, 1992; Lea, 1994; Kirkham, 1998; Dynette, 1999; Sharpio et al., 2002). These questions were used in a former study by Berlin et al. (2006).The other three questions were based on the findings from previous studies of the health services and the nurses’ difficulties and concerns regarding the assessment of health risks in the psychosocial home environment of a child (one question), the parents repeatedly failing to come to planned visits (one question), and the parents denying problems and refusing help (one question) (Berlin et al., 2008).

Nurses’ evaluation of the training Seven questions in the CCCTEQ-POST questionnaire evaluated the nurses’ training (see Table 3).

Data analysis The analysis compared the outcome assessments pre- and post-training within and between the IG and CG nurses. First, the data were analyzed by testing the question-toquestion differences in the mean rank pre- and post-training within and between the IG and CG nurses. In order to avoid the problem of mass significance, a P-value of ⱕ 0.01 was considered as a statistically significant training difference. Differences in the mean rank between pre- and post-training within the groups were tested by Wilcoxon’s signed rank test. Training differences between the groups were tested by Wilcoxon’s rank sum test. Differences in the distribution between groups were tested by Pearson’s c2-test and Fisher’s exact test (Rosnier, 2006). As the scales are ordinal, the results are presented as mean ranks. Second, pre- and post-training, the total score of the answers regarding cultural competence and experiences of © 2010 Blackwell Publishing Asia Pty Ltd.

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difficulties and concerns was summarized by giving each alternative a score from 1 to 4 (5). These data were analyzed by repeated-measures analysis of variance (ANOVA). This was done to determine if there was an interaction between training and the repeated factor (pre- and post-training). In this ANOVA, P-values of < 0.05 for the interaction were considered as significant, indicating a training effect.

Power The answers from pre- and post-training were compared on the cultural knowledge question no. 10 (dichotomized into “quite a lot” and “a lot” vs all the others). Expecting a change from 40% of the answers being “quite a lot” and “a lot” at baseline to 85% of the answers being “quite a lot” and “a lot” at follow-up, assuming a two-sided test and a significance level of a = 0.05, a power of 86% was received.

Ethical considerations The study was approved by the Ethics Committee at Huddinge University Hospital, Karolinska Institute, Sweden. The nurses were included if they consented to participation. They received a written form, explaining that participation was voluntary, that they would be anonymous, and that confidentiality was guaranteed.

RESULTS

A. Berlin et al.

5 Cultural desire: 92% of the IG nurses had increased their desire to learn more about the subject of “culturally competent” health services.

Experiences of difficulties and concerns The results revealed one statistically significant change: posttraining, the IG nurses rated lacking cultural knowledge (i.e. religion and traditions) as a lesser difficulty (question 11) (Table 5).

Variance analysis The total scores of pre- and post-training regarding cultural competence, difficulties, and concerns were compared within and between the IG and the CG. A statistically significant interaction was found regarding cultural skills (Table 6), indicating a larger improvement in the summarized scores in the IG when compared with the CG.

Nurses’ evaluation of the training The majority (96%) of the IG participated in all 3 days of the training, were satisfied (96%) with the quality of the training, and felt that the training had “quite a lot” to “a very significant” (92%) impact on their ability to cope with the demands of their work activities in the health services. Ten nurses commented about the training in a positive way.

Cultural competence

DISCUSSION

The nurses’ opinions pre- and post-training regarding their perceived cultural competence and comparisons of their opinions within and between the IG and CG are shown in Table 4: 1 Cultural awareness: no statistically significant changes on this level were found. 2 Cultural knowledge: The IG showed a statistically significant improvement when compared with the CG; that is, improved knowledge regarding the national policy for cultural diversity in the Swedish health-care system (question 9) and the policy for cultural diversity in the health services (question 10). 3 Cultural skills: The IG showed a statistically significant improvement when compared with the CG; that is, improved skills for eliciting the parents’ perspective about health and illness (question 2), eliciting information about the use of folk remedies and/or other alternative healing modalities (question 3), carrying out a culturally sensitive physical examination (question 5), negotiating a culturally sensitive health-care plan for the child (question 6), providing culturally sensitive parent education and counseling (question 7), and providing culturally sensitive preventive health-care services (question 8). 4 Cultural encounters: The IG showed a statistically significant improvement when compared with the CG; that is, improved confidence when identifying beliefs that are not expressed by a parent but might interfere with the child’s health care (question 4).

The 3 days of training were appreciated by the nurses and had some effects on their cultural competence, difficulties, and concerns. The nurses’ level of cultural awareness was not changed but several other statistically significant improvements were revealed; that is, cultural knowledge (two questions), cultural skills (six questions), cultural encounters (one question within the IG), and difficulties and concerns (one question).


Cultural competence The post-training follow-up after 4 weeks might have been too short of a period and could explain why not all levels showed statistically significant results. As discussed by Majumdar et al. (2004: 164), it takes time to “absorb what was learned”. It is also important to stress that a 3 day course cannot change the nurses into fully culturally competent clinicians. According to Campinha-Bacote (2002), this competence is an ongoing process. The result indicates that the cultural competence process had started, as the total sample of participating nurses rated themselves as being culturally aware, the first step in becoming competent. Through training, the IG nurses received a positive effect, especially in relation to their cultural skills, but also in relation to cultural knowledge and cultural encounters; that is, these nurses had “moved beyond” the awareness level and continued the process. Furthermore, the nurses reported that the intervention increased their desire to learn more about cultural


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Table 4. Question-to-question analysis of the cultural competence levels: differences within and between the intervention group (IG) and the control group (CG) of nurses pre- and post-training (“pre” and “post”, respectively)

Variable/level Cultural awareness† Importance of sociocultural in interaction with: 1. Parents 2. Relatives 3. Other visitors 4. Colleagues (nurses) 5. Other staff Self-awareness 1. Cultural identity 2. Cultural stereotypes 3. Biases and prejudices Importance of cultural competence training Cultural knowledge† How knowledgeable are you about: 1. The demographics of ethnic groups 2. The characteristics of diverse ethnic groups 3. The health risks experienced by diverse ethnic groups 4. The health disparities experienced by diverse ethnic groups 5. The sociocultural in treatment/care 6. Ethnopharmacology: variations in medical response 7. Different healing traditions 8. Impact of racism and prejudice in health care 9. National policies of cultural diversity in health 10. The health services’ policy regarding cultural diversity Cultural skills† How skilled are you in dealing with: 1. Greeting in a culturally sensitive manner 2. Parents’ perspective on health and illness 3. Eliciting the use of folk remedies 4. Eliciting the use of folk healers 5. Culturally sensitive physical examination 6. Culturally sensitive health-care plan 7. Culturally sensitive parent education 8. Culturally sensitive preventive health care 9. Culturally sensitive child health care 10. Parents’ health literacy 11. Medical interpreters 12. Cross-cultural conflicts 13. Cross-cultural compliance problems Cultural encounters† How comfortable do you feel in dealing with: 1. Parents of culturally diverse backgrounds 2. Parents with limited Swedish proficiency 3. Parents seeking folk healers 4. Identifying beliefs that are interfering with child health care 5. Non-verbal cues in different cultures 6. Cultural expressions of distress and suffering 7. Advising parents to change practices 8. Culturally diverse professionals 9. Colleagues making derogatory remarks 10. Parents’ comments on your ethnic background 11. Parents’ derogatory comments on other parents’ ethnicity 12. Large groups of accompanying family members 13. Culturally different eating habits 14. Parents need to practice their religion

Mean rank P-value CG IG CG IG CG vs CG IG Training pre‡ pre‡ post‡ post‡ IG pre§ pre–post‡ pre–post‡ effect§

4.19 3.62 3.15 3.96 3.80

4.54 4.04 3.96 4.13 3.88

4.28 3.67 3.25 3.83 3.67

4.46 3.92 3.67 4.08 3.88

0.37 0.15 0.01 0.31 0.76

0.80 0.85 0.91 0.33 0.51

0.69 0.56 0.32 0.96 0.76

0.91 0.91 0.40 0.64 0.52

4.08 1.09 3.85 4.44

4.00 1.05 3.88 4.79

4.13 0.94 3.88 4.36

4.08 0.69 3.75 4.88

0.68 0.63 0.81 0.06

0.71 0.35 0.74 0.41

0.93 0.84 0.53 0.97

0.87 0.42 0.50 0.51

3.50 2.84 2.77 2.42 2.71 1.65 1.54 2.13 2.67 3.04

3.39 2.88 2.63 2.54 2.70 2.08 1.96 2.54 2.39 2.96

3.44 2.88 2.84 2.52 2.71 1.95 1.85 2.18 2.39 3.00

3.81 3.30 2.96 2.74 2.82 2.48 2.36 2.88 3.25 3.32

0.58 0.69 0.68 0.68 0.91 0.19 0.16 0.21 0.71 0.71

0.92 0.71 0.71 0.62 0.78 0.36 0.12 0.32 0.33 0.64

0.16 0.10 0.27 0.88 0.63 0.20 0.03 0.26 0.00 0.01

0.48 0.34 0.77 0.86 0.73 0.78 0.46 0.72 0.00 0.03

3.65 3.63 2.78 2.05 3.06 3.09 3.32 3.57 3.38 4.09 3.46 3.36 3.68

3.54 3.08 2.26 1.77 2.45 2.63 2.58 2.96 2.88 3.83 2.75 2.92 3.29

3.48 3.28 2.38 1.94 2.16 2.68 2.73 3.00 3.00 4.07 3.15 3.30 3.32

4.00 3.74 3.00 2.35 2.74 3.59 3.26 3.54 3.17 4.00 3.27 3.04 3.83

0.85 0.07 0.14 0.71 0.17 0.20 0.04 0.05 0.04 0.32 0.02 0.08 0.22

0.31 3.74 0.09 0.64 0.01 0.13 0.07 0.03 0.15 0.54 0.29 1.00 0.32

0.07 0.02 0.01 0.07 0.23 0.02 0.01 0.03 0.12 0.27 0.05 0.36 0.05

0.04 0.01 0.00 0.03 0.01 0.01 0.00 0.00 0.03 0.69 0.02 0.59 0.04

4.35 4.12 2.65 2.68 2.72 3.04 3.52 4.00 3.29 2.57 3.11 3.30 3.62 3.05

4.33 4.31 2.50 2.39 2.54 2.83 3.54 3.79 2.95 2.53 2.77 3.26 3.75 3.33

4.12 4.00 2.37 2.52 2.74 2.71 3.29 4.14 2.79 2.88 2.81 3.24 3.68 2.91

4.25 4.30 3.00 2.52 2.83 3.22 3.41 4.15 3.15 2.81 3.35 3.38 3.70 3.36

0.72 0.49 0.82 0.50 0.55 0.22 0.89 0.59 0.55 0.88 0.47 0.91 0.66 0.43

0.10 0.53 0.35 0.74 0.79 0.34 0.28 0.56 0.08 0.75 0.19 0.63 0.49 0.56

0.74 0.55 0.22 0.01 0.12 0.06 1.00 0.35 0.77 0.06 0.03 0.17 0.56 0.84

0.40 0.55 0.06 0.03 0.37 0.02 0.57 0.65 0.22 0.78 0.05 0.54 0.92 0.56


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Table 4.

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Continued Results

Cultural desire¶ The desire to learn more about the subject of “culturally competent health services” Decreased a lot to decreased somewhat Remained the same Increased somewhat to increased a lot

N

%

0 2 22

– 8 92

†Questions were based on self-rating scales: higher scores indicated a higher degree of change; ‡differences within the CG and IG were tested with Wilcoxon’s signed rank test; §the training effect between the CG (pre–post) and IG (pre–post) was tested with Wilcoxon’s rank sum test; ¶the question was based on a self-rating scale post-training to the IG. The results are given as mean ranks and P-values. The values in bold are statistically significant at P ⱕ 0.01. The complete questionnaire is available at: http://www.mfh-eu.net/public/experiences_results_tools/ cct_eval_instruments.htm.

Table 5. Question-to-question analysis of the aspect, experiences of difficulties and concerns: differences within and between the intervention group (IG) and control group (CG) of nurses pre- and post-training (“pre” and “post”, respectively)

Variable

CG pre‡

Mean rank IG CG pre‡ post‡

IG post‡

CG vs IG pre§

Experiences of difficulties and concerns† 1. Lacking direct communication 2. Dependence on the interpreter 3. Insecurity about the interpreter’s translations 4. Interpreter’s talking takes a lot of time 5. Being provoked that the parents did not learn Swedish 6. Estimation of the parents’ standard of attainment 7. Not knowing if the health-care advice is fully understood 8. The parents do not comply with the health-care advice 9. Convey knowledge to the parents 10. Not having the ability to fully help 11. Lacking cultural knowledge (i.e. religion, traditions) 12. Assessing psychosocial health risks for the child 13. The parents repeatedly fail to come to planned visits 14. The parents deny problems and refuse help

2.90 2.60 2.40 1.76 1.46 2.31 2.27 1.81 2.04 2.19 2.48 2.42 2.46 2.50

2.90 2.70 2.40 1.71 1.88 2.54 2.75 2.17 2.17 2.40 3.04 2.88 2.83 2.83

2.90 2.50 2.50 1.83 1.96 2.67 2.75 2.29 1.97 2.50 2.50 2.67 2.46 2.83

0.89 0.48 0.93 0.91 0.03 0.19 0.01 0.05 0.65 0.52 0.01 0.04 0.19 0.22

2.90 2.60 2.50 1.88 1.44 2.28 2.52 2.00 1.76 2.20 2.79 2.46 2.44 2.55

P-value CG IG pre–post‡ pre–post‡

0.91 0.78 0.41 0.26 0.65 0.96 0.15 0.10 0.07 0.76 0.05 1.00 0.95 0.92

0.92 0.17 0.63 0.32 0.41 0.41 0.80 0.32 0.20 0.44 0.00 0.19 0.04 1.00

Training effect§

0.96 0.24 0.98 0.97 0.36 0.41 0.22 0.82 0.74 0.55 0.00 0.35 0.10 0.94

†Questions were based on self-rating scales: the alternatives ranged from “Fully correct” to “Not correct at all”. Lower scores indicated a lower degree of experience of difficulties and concerns; ‡differences within the CG and IG were tested with Wilcoxon’s signed rank test; §the training effect between the CG (pre–post) and IG (pre–post) was tested with Wilcoxon’s rank sum test. The results are given as mean ranks and P-values. The values in bold are statistically significant at P ⱕ 0.01.

competence. According to Campinha-Bacote (2002: 38), these nurses had developed a cultural desire, the key to cultural competence: “wanting to rather than having to learn and interact with other cultures”. The selection of specific teaching approaches might have contributed to the statistically significant effects on improved cultural skills. Case methodology is known to change clinical practice (Kiessling and Henriksson, 2002). Moreover, it provides a process of participatory learning that facilitates active and reflective learning and results in the development of critical thinking and effective problem-solving skills (Tomey, 2003). Reflective practice groups also might explain the effect on the nurses’ cultural skills. Platzer et al. (2000: 689) found that this approach developed nurses’ professionalism (i.e. © 2010 Blackwell Publishing Asia Pty Ltd.

autonomy in decision-making) and “a less rule-bound approach to the nurses’ practice”, which might agree with improved cultural skills. This combination of approaches is recommended as cultural competence concerns value judgments and is a type of knowledge that cannot be transmitted easily by lectures. Thus, it requires teaching approaches, such as the combination of theory and practice, including seminars and activities that stimulate discussions and reflection on practice. This combination also might meet the needs of the attendees’ different learning abilities (Stenbock-Hult, 2004). The training seemed to support the nurses in their clinical work. They evaluated the training as having an impact on their ability to cope with demands and rated themselves as


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Table 6. Repeated measures analysis of variance: comparison between the intervention group (IG) and the control group (CG) of nurses preand post-training Aspects for the outcome assessments Cultural competence† Cultural awareness† Importance of the sociocultural in interactions with parents Self-awareness Importance of cultural competence training for nurses in the health services Cultural knowledge† Cultural skills† Cultural encounters† Experiences of difficulties and concerns‡

Group

Pre-training mean scores ⫾ SE

Post-training mean scores ⫾ SE

P-value

CG

18.6 ⫾ 0.8

18.9 ⫾ 0.8

0.700

IG

20.5 ⫾ 0.8

20.0 ⫾ 0.8

CG IG CG

11.5 ⫾ 0.5 11.5 ⫾ 0.5 4.4 ⫾ 0.2

11.8 ⫾ 0.5 11.5 ⫾ 0.5 4.4 ⫾ 0.2

IG

4.8 ⫾ 0.2

4.9 ⫾ 0.2

CG IG CG IG CG IG CG IG

27.0 ⫾ 1.8 26.3 ⫾ 1.8 45.9 ⫾ 2.3 38.1 ⫾ 2.3 52.2 ⫾ 2.2 47.7 ⫾ 2.4 31.9 ⫾ 1.5 35.1 ⫾ 1.5

27.7 ⫾ 1.9 31.3 ⫾ 1.8 42.9 ⫾ 2.4 45.6 ⫾ 2.3 50.0 ⫾ 2.3 52.6 ⫾ 2.4 32.6 ⫾ 1.6 34.1 ⫾ 1.5

0.800 0.600

0.200 0.025 0.100 0.600

†Questions were based on self-rating scales: higher sum scores indicated a higher degree of change. Each alternative was scored from 1 to 5 and then summarized; ‡the questions were based on self-rating scales: the alternatives ranged from “Fully correct” to “Not correct at all”. Lower scores indicated a lower degree of experience of difficulties. Each alternative was scored from 1 to 4 and then summarized. The results are given as means for the summarized scores (⫾SE) and P-values for the interaction between training and the repeated factor (pre, post). The value in bold is statistically significant at P ⱕ 0.05.

being more confident in cross-cultural encounters or situations in their clinical settings. Consequently, they rated themselves as skilled in eliciting the parents’ perspectives and providing culturally sensitive health services. These features are known from the literature as having the utmost importance in providing effective patient-centered consultation (Mead & Bower, 2002) and communication (Teal & Street, 2009). It is reasonable to believe that the parents and children coming to the health center will benefit from the cultural skills that the IG nurses achieved through training. The outcomes for clients from this centered approach seem to be satisfaction and enablement (Mead & Bower, 2002).

Experiences of difficulties and concerns In a former study among nurses in the health services, it was found that a majority experienced difficulties, mainly the feeling of their own inadequate cultural knowledge (Berlin et al., 2006). Post-training, the IG nurses rated lacking cultural knowledge as a lesser difficulty. This agrees with the findings of other studies; that is, added knowledge and better understanding concerning cultural diversity in health-care settings are known to contribute to less anxiety and tension among health professionals (Chevannes, 2002).

Nurses’ evaluation of the training Knowledge of the nurses’ and parents’ difficulties and concerns with interactions in the health services was used when

creating the training program. This might have contributed to the positive evaluation concerning the training’s quality and impact on everyday practice. A slightly similar approach was used in a previous study; that is, a systematic needs assessment among the hospital staff and migrant patients before implementing the training (Schulze et al., 2003), resulting in a positive effect on the staff members’ ethnocultural competence (Krajic et al., 2005b).

Method discussion The strength of this study is that the methodological recommendations by Price et al. (2005) were followed, the training was designed to fit everyday clinical practice, and the Cronbach’s alpha scores were not changed despite the modifications that were made to the CCCTQ-PRE and CCCTEQ-POST questionnaires. A potential bias of this study might be the characteristics of the participants in the IG as they had a higher degree of linguistic ability and previous training in cultural diversity. Thus, they might have had a greater interest in the topic of cultural competence. Moreover, the nurses in the IG had their professional base at the health services in a different county (Stockholm vs Sörmland). These circumstances might limit the generalizability of the study’s findings to all nurses in various settings of the health services. Other possible limitations of the study might include the relatively small sample size and the short time of the follow-up evaluation. © 2010 Blackwell Publishing Asia Pty Ltd.

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CONCLUSION The overall structure of the appreciated training had some effects on the cultural competence and difficulties and concerns among the nurses who received the training when compared to those who did not. Improved cultural competence is a way of responding to the demographic changes in Swedish society. It is also a way to improve the nurses’ working conditions as the nurses feel more skilled and confident when dealing with cross-cultural encounters or situations in the health services. This is presumed to contribute to an improved quality of the health services, with a reduction of the risk for health-care disparities among children. Based on the findings, the implications for health-care providers and decision-makers are to consider funding formal and continuing training in cultural competence for all nurses working in the health services. In addition, supervision should be carried out on a regular basis in order to maintain the positive effects of training.

ACKNOWLEDGMENTS We want to thank all the participating nurses, the Transcultural Centre for cooperation when the authors were planning and performing the theoretical section of the training, and The Centre for Healthcare Science, Karolinska Institute, Sweden for its financial contributions that made this study possible.

REFERENCES Ahmann E. Developing cultural competence in health care settings. Pediatr. Nurs. 2002; 28: 133–137. Baggens C. Children and Parents’ Encounters with the Child Health Care Nurse. Linköping: Department of Communication Studies, Linköping University, 2002 (in Swedish with abstract in English). Beach MC, Price EG, Gary TL et al. Cultural competence: a systematic review of health care provider educational interventions. Med. Care 2005; 43: 356–373. Bergström M. Method Book. Stockholm: Department of Child Health Services, Stockholm County Council. 2010. [Cited 19 April 2010.] Available from URL: http://www.webbhotell.sll.se/bhv/ Metodbok-BHV/. Bergström M, Blennow M, Bågenholm G et al. Child Health Services in the Work of Public Health. Annual Report 2008. Stockholm: Department of Child Health Services, Stockholm County Council. 2009. [Cited 16 June 2009.] Available from URL: http://www. webbhotell.sll.se/Global/Bhv/Dokument/Rapporter/BHV_SLL_ 2008_VB.pdf (in Swedish). Berlin A, Hylander I, Tornkvist L. Primary child health care nurses’ assessment of health risks in children of foreign origin and their parents – a theoretical model.Scand.J.Caring Sci. 2008;22:118–127. Berlin A, Johansson SE, Tornkvist L. Working conditions and cultural competence when interacting with children and parents of foreign origin – Primary child health nurses’ opinions. Scand. J. Caring Sci. 2006; 20: 160–168. Berlin A, Törnkvist L, Hylander I. Watchfully checking rapport with the Primary Child Health Care nurses – a theoretical model from the perspective of parents of foreign origin. BMC Nursing 2010; 9: 14.


A. Berlin et al.

Bhui K, Warfa N, Edonya P, McKenzie K, Bhugra D. Cultural competence in mental health care: a review of model evaluations. BMC Health Serv. Res. 2007; 7: 15. Blackford J, Street A. Cultural conflict: the impact of Western feminism(s) on nurses caring for women of non-English speaking background. J. Clin. Nurs. 2002; 11: 664–671. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J. Transcult. Nurs. 2002; 13: 181–184. Chevannes M. Issues in educating health professionals to meet the diverse needs of patients and other service users from ethnic minority groups. J. Adv. Nurs. 2002; 39: 290–298. Chipps JA, Simpson B, Brysiewicz P. The effectiveness of culturalcompetence training for health professionals in community-based rehabilitation: a systematic review of literature. Worldviews Evid. Based Nurs. 2008; 5: 85–94. Corlett J. The perceptions of nurse teachers, student nurses and preceptors of the theory–practice gap in nurse education. Nurse Educ. Today 2000; 20: 499–505. Doswell WM, Erlen JA. Multicultural issues and ethical concerns in the delivery of nursing care interventions. Nurs. Clin. North Am. 1998; 33: 353–361. Dynette H. Assessing culture: pediatric nurses’ beliefs and selfreported practices. J. Pediatr. Nurs. 1999; 14: 255–262. Hudelson P. Contextualizing cultural competence training of residents: results of a formative research study in Geneva, Switzerland. Med. Teach. 2006; 28: 465–471. Jansson A. [The Nurse in Primary Health Care with a Focus on Child Health Care]. Lund, Sweden: Department of Nursing, Lund University, 2000 (in Swedish with abstract in English). Kiessling A. Participatory learning: a Swedish perspective. Heart 2004; 90: 113–116. Kiessling A, Henriksson P. Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: randomized controlled study. BMJ 2002; 325: 877–880. Kirkham SR. Nurses’ descriptions of caring for culturally diverse clients. Clin. Nurs. Res. 1998; 7: 125–146. Krajic K, Karl-Trummer U, Novak-Zezula S et al. Project summary. Migrant Friendly Hospitals Project. Vienna: Ludwig BoltzmannInstitute for the Sociology of Health and Medicine/World Health Organization Collaborating Centre for Health Promotion in Hospitals and Health Care. 2005a. [Cited 12 March 2005.] Available from URL: http://www.mfh-eu.net. Krajic K, Strassmayr C, Karl-Tummer U, Noval-Zezula S, Pelikan JM. Improving ethnocultural competence of hospital staff by training: experiences from the European “Migrant-friendly Hospitals” project. Divers. Health Soc. Care 2005b; 2: 279–290. Kulwicki AD, Miller J, Schim SM. Collaborative partnership for culture care: enhancing health services for the Arab community. J. Transcult. Nurs. 2000; 11: 31–39. Lea A. Nursing in today’s multicultural society: a transcultural perspective. J. Adv. Nurs. 1994; 20: 307–313. Like RC. Assessing the Impact of Cultural Competency Training Using Participatory Quality Improvement Methods. Project summary. Hartford, CT: Aetna Foundation. 2004. [Cited 11 Jan 2006.] Available from URL: http://www2.umdnj.edu/fmedweb/ chfcd/Aetna_executive_Summary_april_30%20-2004pdf. Lynam M. Towards the goal of providing culturally sensitive care: principles upon which to build nursing curricula. J.Adv. Nurs. 1992; 17: 149–157. Majumdar B, Browne G, Roberts J, Carpio B. Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. J. Nurs. Scholarsh. 2004; 36: 161–166.


Marcinkiw KL. A goal for nursing education. Nurse Educ. Today 2003; 23: 174–182. Mead N, Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Educ. Couns. 2002; 48: 51–61. Norvenius G, Köhler L, Johansson J, Wennergren G. Protection, Prevention, Promotion. Development and Future of Child Health Services. Gothenburg, Sweden: Nordic School of Public Health, 2001. Platzer H, Blake D, Ashford D. An evaluation of process and outcomes from learning through reflective practice groups on a postregistration nursing course. J. Adv. Nurs. 2000; 31: 689–695. Price EG, Beach MC, Gary TL et al. A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. Acad. Med. 2005; 80: 578–586. Rosnier B. Fundamentals of Biostatistics (6th edn). Duxbury, MA: Duxbury Press, 2006. Schulze B, Trummer U, Krajic K, Pelikan JM. Needs Assessment – European Cross Analysis. Summary of Problem Areas. 2003.

391

[Cited 11 June 2003.] Available from URL: http://www.mfh-eu. net/public/files/experiences_results_tools/op_developing/Results_ NeedsAssessment.pdf. Sharpio J, Hollingshead J, Morrison HE. Primary care resident, faculty and patient views of barriers to cultural competence, and the skills needed to overcome them. Med. Educ. 2002; 36: 749–759. Statistics Sweden. [Population of Sweden as of 31 December 2008. Comparative figures per Municipality.] 2008. [Cited January 2009.] Available from URL: http://www.scb.se/Statistik/BE/BE0101/ 2008A01/Be0101KomJmfBef_2008.xls (in Swedish). Stenbock-Hult B. [Critical Approach.] Lund, Sweden: Studentlitteratur, 2004 (in Swedish). Teal CR, Street RL. Critical elements of culturally competent communication in the medical encounter: a review and model. Soc. Sci. Med. 2009; 68: 533–543. Tomey AM. Learning with cases. J. Contin. Educ. Nurs. 2003; 34: 34–38.
