Nurse Education Today (2004) 24, 428434

Nurse Education Today

intl.elsevierhealth.com/journals/nedt

Nursing students self-efcacy in providing transcultural care

Janet Lim, Jill Downie*, Pauline Nathan
School of Nursing and Midwifery, Curtin University of Technology, GPO Box U1987, Perth 6845, Australia
Accepted 21 April 2004

KEYWORDS
Multicultural; Self-efcacy; Transcultural care; Nursing education

Summary The aim of any health care service is to provide optimal quality care to clients and families regardless of their ethnic group. As todays Australian society comprises a multicultural population that encompasses clients with different cultural norms and values, this study examined undergraduate nursing students self-efcacy in providing transcultural nursing care. A sample of 196 nursing students enrolled in the rst and fourth year of a pre-registration nursing program in a Western Australian University were invited to participate in a survey incorporating a transcultural self-efcacy tool (TSET) designed by Jeffery [Unpublished instrument copyrighted by author, 1994]. The ndings revealed that fourth year students, exposed to increased theoretical information and clinical experience, had a more positive perception of their self-efcacy in providing transcultural nursing skills than the rst year students. In addition, the study found that age, gender, country of birth, languages spoken at home and previous work experience did not inuence the nursing students perception of self-efcacy in performing transcultural care. The study supports the notion that educational preparation and relevant clinical experience is important in providing nursing students with the opportunity to develop self-efcacy in performing effective and efcient transcultural nursing in todays multicultural health care system. It is for this reason that educators need to focus on providing students with relevant theoretical information and ensure sufcient clinical exposure to support student learning in the undergraduate program. c 2004 Elsevier Ltd. All rights reserved.

Background and literature review

The changing demographic trends in the Australian population reect a multicultural society with expressed variations and differences of each cultural
Corresponding author. Tel.: +61-8-9266-3024; fax: +61-89266-2959. E-mail address: j.downie@curtin.edu.au (J. Downie).
*

group in relation to individual beliefs and values regarding health and illness. An individuals social attitudes toward health and illness, participation in early detection and screening programs, clients compliance with treatment and their coping strategies are all known to be profoundly affected by cultural values, beliefs and norms (Jeffery and Smodlaka, 1999a,b). Nurses, who are considered to be the largest group of professional health care

0260-6917/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2004.04.007

Nursing students self-efcacy in providing transcultural care providers face the challenge of maintaining, promoting and providing quality nursing care that is culturally congruent to the clients they serve. Hence, these factors support the need for nursing students to be competent in providing quality nursing care and to prepare them to function condently so that they can understand, communicate and work effectively with culturally diverse groups (Lynch, 1992). Several studies have reported that nurses have difculties in providing quality care to culturally diverse groups. The ethnocentric perspective of many nurses has been demonstrated by negative attitudes towards clients with different cultures (Gorman, 1995; Leininger, 1990; Taylor, 1998). Language barriers and discrimination have been given as some of explanations for the failure of nurses to meet the needs of different cultural groups (Gorman, 1995; Murphy and MacleodClark, 1993; Scammell, 1990). Leininger (1991) stated that it was not easy for nurses to demonstrate condence in acquiring skills that would enable them to provide culturally congruent care. Furthermore, it was difcult for nurses who were not well educated in transcultural nursing to function effectively with culturally diverse groups. Data collected from 517 registered nurses and 250 baccalaureate-nursing students showed that neither group expressed condence in their ability to care for minority ethic clients. The study also revealed that both the registered nurses and student nurses reported the need for transcultural nursing knowledge and the need to modify existing nursing curriculum to increase knowledge and clinical condence in transcultural nursing. These ndings maybe related to factors such as nurses resistance to learn about other cultures or perhaps their lack of awareness of the extent to which they require knowledge and skills to work with diverse clients (Kavanaugh and Kennedy, 1992; Pope-Davis et al., 1994). However, according to Suzanne (1999), knowledge by itself was not sufcient to enable nurses to provide effective transcultural nursing care. She reported that nurses must be able to translate transcultural concepts and skills into practical strategies that were linguistically and culturally appropriate for each patient. She suggested that by doing this they would be more procient in assessing, planning, implementing and evaluating cultural specic nursing care. This supports the notion that nurses not only need to gain sufcient knowledge in regard to transcultural nursing care but they must be efcacious in delivering care to culturally diverse client groups.

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Jeffery and Smodlaka (1999a,b) conducted a longitudinal descriptive study of 51 nursing students during their rst clinical semester and then during their fourth semester. They evaluated their self-efcacy in performing transcultural nursing skills and evaluated changes in perception following a two-year educational experience. The results showed that there were statistically signicant differences between rst and fourth semester nursing students in their perception of self-efcacy in performing transcultural nursing skills. Thus, they concluded that self-efcacy is a dynamic construct that changes over time in response to new experiences and information such as education and clinical experiences. Bandura (1977) dened the term self-efcacy as a persons belief about his or her ability to cope in specic situations. According to Bandura (1977) individuals with adequate belief in their selfefcacy were better able to cope with the demands of a particular situation. Whereas, individuals who perceived a lack of self-efcacy might face difculties in performing specic activities presented to them. In relation to the application of Banduras (1977) self-efcacy theory, nurses who have an opportunity to work with clients from culturally diverse groups might develop an increased sense of condence in performing transcultural care. Hence, it is vital for nurses, who work in a multicultural society, to portray a sense of self-efcacy as it allows them to think critically and make condent decisions (Andrew and Boyle, 1995). The provision of transcultural nursing skills is seen to be a very important aspect of nursing practice in todays multicultural health care environment due to the ever-increasing cultural diversity of the Australian population. To date, a review of the literature has shown that there is a paucity of Australian studies that have investigated the issue of self-efcacy and transcultural nursing, The purpose of this study was to enhance the understanding of undergraduate nursing students selfefcacy in relation to transcultural nursing with an interest in recommendations for nurse educators.

Method
The aim of the quantitative study was to examine undergraduate nursing students perception of self-efcacy in performing transcultural nursing skills for clients from culturally diverse backgrounds. The study was considered important given Australias rapidly growing multicultural population and the dearth of literature that has examined

430 this issue in an Australian context. Specically, the study objectives were to: Identify rst year (semester two) and fourth year (semester seven) undergraduate nursing students perception of self-efcacy in performing transcultural nursing skills. Determine if there was a difference between the rst and fourth year students perception of self-efcacy in performing transcultural nursing. Examine demographic variables in relation to undergraduate nursing students perception of self-efcacy and the provision of transcultural nursing skills.

J. Lim et al. dents self-efcacy in performing transcultural nursing skills. Permission to use the TSET was granted by Jeffery, and consists of 83 items, with a 10-point rating scale anchored from (1) not condent to (10) totally condent. There are three subscales in the TSET; the cognitive, practical and affective subscales. The rst subscale (cognitive) consists of 25-items that rate the respondents self-efcacy in regards to their knowledge of cultural factors that inuence nursing care among culturally diverse groups. The items examined various cultural issues such as race, ethnicity, gender, socio-economics and religious backgrounds. An example of the cognitive subscale is how knowledgeable are you about the ways cultural factors may inuence nursing care? Other items such as health prevention, aging, death and dying, grieving, and loss are also included in this subscale. The second subscale (practical) consists of 28-items which measure the respondents self-efcacy about interviewing culturally diverse clients in regards to their beliefs and values. Interview topics included items such as language preferences, religion, discrimination and attitudes about health and illness. The third subscale (affective) contains 30-items where the respondent is asked to rate their self-efcacy in respect to values, attitudes and beliefs concerning cultural awareness, acceptance, appreciation, recognition and advocacy. An example of one of these items is do you accept differences between cultural groups? Jeffery and Smodlaka conducted four studies to examine the validity and reliability of the TSET (Jeffery and Smodlaka, 1996, 1998, 1999a,b; Jeffery, 2000). A factor analysis approach was used to analyze the factorial composition of the TSET in relation to 1260 culturally diverse undergraduate nursing students perception of self-efcacy in transcultural nursing skills. The results showed that the 83 items were correlated between 0.30 and 0.70, suggesting that all items contributed satisfactorily and uniquely to the measurement of the transcultural self-efcacy construct. Intercorrelations between subscales were statistically signicant at p < 001 (Jeffery, 2000). Internal consistency was also examined using two approaches, split-half reliability and Cronbachs a (coefcient a). Split-half reliability resulted in coefcients ranging from 0.76 to 0.92 for the three subscales (cognitive, practical and affective) and total instrument. Cronbachs a yielded a high level of internal consistency, ranging from 0.92 to 0.98 for the three subscales (cognitive, practical and affective) and total instrument. These ndings suggest that the TSET assesses the multidimen-

Study sample, context and process

The study recruited a convenience sample of rst year (semester two) and fourth year (semester seven) undergraduate nursing students of a preregistration nursing program in a Western Australian University. The reason for choosing these groups was the potential to demonstrate differences in the perception of nursing students selfefcacy from rst year to fourth year. One hundred and nine (109) rst year nursing students completed a questionnaire at the commencement of their second semester of study, while 90 fourth year nursing students completed the questionnaire at the commencement of their seventh semester of study. The rst year students had experienced limited nursing theory and undertaken one observational clinical experience before completing the questionnaire. By contrast, the fourth year students had engaged in extensive theory in relation to holistic care, including transcultural nursing, with many clinical experiences in a variety of nursing contexts. Permission to conduct the study was granted by the University Human Research Ethics Committee and consent to access the sample given by the Head of School and Unit Coordinators responsible for the students learning. Prior to a nursing lecture, students were given a copy of the questionnaire together with an explanatory cover sheet and consent form. Participants took approximately 20 min to complete the questionnaire that was supervised by the researcher and lecturer.

Instrument
The questionnaire included various demographic variables and the transcultural self-efcacy tool (TSET) designed by Jeffery (1994) to measure stu-

Nursing students self-efcacy in providing transcultural care sional nature of transcultural self-efcacy (Jeffery and Smodlaka, 1996, 1998, 1999a,b).

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Analysis
Analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS Version 10). Descriptive statistics were calculated to summarize the demographic data. Self-efcacy strength was calculated using the mean score of each subscale (cognitive, practical and affective) and the Self-efcacy level of each subscale was divided into three categories: low, medium and high. A low level of self-efcacy was rated for participants who selected a 1 or 2 response on the likert scale for more than 80% of the subscale items. A medium level of self-efcacy was rated for participants who responded with anchors 3 to 8 for more than 80% of the subscale items and a high level of self-efcacy was rated for participants who selected a 9 or 10 response for more than 80% of the subscale items. Independent t-tests were used to explore the differences of the three TSET subscales (Knapp, 1990).

Results
Of the sample of 196, the majority of the nursing students were female. In rst year, 94% were females (n 100) and 6% were males (n 6). In fourth year, 84% were females (n 76) and 16% were males (n 14). The participants demographic data are summarized below. In rst year, 67% of participants were aged 1721 years, 14% aged 2226 years, 6% aged 2731 years, 7% aged 3236 years, and 6% aged 37 years and older. Fourth year participants comprised 44% aged 1721 years, 29% aged 2226 years, 8% aged 2731 years, 4% aged 3236 years and 15% aged 37 years older. The results revealed that the majority of rst year participants were born in Australia (81%, n 86), and 11% (n 20) were born in Asia, Europe and South America. By contrast, 74% (n 67) of the fourth year participants were born in Australia and 26% (n 23) born in Europe and Asia. The majority of the participants from both groups reported English as the main language spoken at home (94%, n 100; 94%, n 85). Twenty four percent of the rst year participants (n 25) had previously worked in a health care setting, with only 22% (n 23) currently working in health care. Of the fourth year participants, 64% (n 58) had previously worked in a

health care setting and 53% (n 48) were currently working in health care. Most of the participants in the study reported having some social contact with people from other cultural groups (76%, n 81; 81%, n 73). The TSET was used to measure and explore nursing students perception of self-efcacy in performing transcultural nursing skills. In the current study the 83-items of the TSET demonstrated an a coefcient of 0.93, thus demonstrating highly satisfactory reliability. The three subscales (cognitive, practical and affective) of the TSET demonstrated reliability with an a coefcient of 0.91 for the cognitive subscale, 0.91 for the practical subscales and 0.92 for the affective subscale. Hence, these overall results suggest that the TSET was a reliable tool to measure students selfefcacy in providing transcultural care to diverse cultural groups. Table 1 shows the mean scores for both rst year and fourth year participants in each TSET subscale. For rst year participants, the mean score for the cognitive subscale was 6.04 (SD 1:57), the practical subscale was 6.05 (SD 1:63) and 7.82 (SD 1:23) for the affective subscale. For fourth year participants, the mean score for the cognitive subscale was 6.71 (SD 1:31), 6.63 (SD 1:36) for the practical subscale and 8.16 (SD 1:06) for the affective subscale. The results showed that both rst year and fourth year participants reported higher mean scores on the affective subscale. When the results of all three subscales (cognitive, practical and affective) were compared, the mean scores for the three subscales (cognitive, practical and affective) were higher for fourth year participants than for rst year participants (Table 1). From these ndings it can be said that fourth year students perception of self-efcacy in performing transcultural nursing skills was higher then rst year students perception.

Table 1 scores Subscales

First year and fourth year students mean n Mean 6.04 6.71 6.05 6.63 7.82 8.16 SD 1.57 1.31 1.63 1.36 1.23 1.06

Cognitive First year (semester 2) 106 Fourth year (semester 7) 90 Practical First year (semester 2) 196 Fourth year (semester 7) 90 Affective First year (semester 2) 106 Fourth year (semester 7) 90

432 An independent t-test was used to explore the differences of the three TSET subscales (Table 2) (Knapp, 1990). Results showed that the cognitive subscale revealed a statistically signicant difference between rst year and fourth year participants self-efcacy in regard to their knowledge about the cultural factors that may inuence nursing care (t 3:2, df 194, p < 0:001). Results for the practical subscale showed a statistically signicant difference between the rst year and fourth year participants (t 2:7, df 194, p < 0:008). Similarly, the affective subscale also showed that there was a statistically signicant difference between the rst year and fourth year participants (t 2:1, df 194, p < 0:04). These ndings suggest that there is a difference in the self-efcacy of rst year and fourth year students in relation to transcultural nursing skills with fourth year students more condent. This is possibly related to theory and the clinical experiences of fourth year students during their six semesters of previous study in the nursing program, however, these ndings may also be due to attrition before year four, personal growth or maturational effects. Table 3 shows the level of self-efcacy for both rst year and fourth year participants. In all three subscales; cognitive (89%, n 94; 94%, n 85),

J. Lim et al. practical (92%, n 98; 94%, n 85) and affective (70%, n 74; 70%, n 63) a medium level of selfefcacy for both rst year and fourth year participants was reported. v2 Tests were used to further analyze the relationship between the two year groups of participants and their level of self-efcacy in all three subscales (cognitive, practical and affective). There were no statistically signicant differences between any of the subscales; cognitive subscale (p 0:30), practical subscale (p 0:84) and affective subscale (p 0:98). However, due to the small sample size of this study the results need to be interpreted cautiously. When comparing rst year and fourth year participants demographic data with their perception of self-efcacy in transcultural nursing, the ndings showed that rst year and fourth year participants perception of self-efcacy was not related to their age, gender, country of birth, current work experience, or language spoken at home. However, there was a trend evident that suggested personal experiences with another culture may affect the participants perception of self-efcacy in performing effective and efcient transcultural nursing skills.

Discussion
Table 2 Signicant differences on TSET of rst year and fourth year students Subscales Cognitive Practical Affective T )3.2 )2.7 )2.1 df 194 194 194 p 0.001 0.008 0.04 Mean difference )0.68 )0.58 )0.34

The ndings showed that fourth year nursing students portrayed a higher perception of self-efcacy than rst year nursing students in performing transcultural nursing skills. Both groups of students demonstrated higher perception of self-efcacy in the affective domain, such as their awareness, acceptance, appreciation and recognition of the importance of ones cultural values and beliefs.

Table 3 Subscales Cognitive High Medium Low Practical High Medium Low Affective High Medium Low

Comparison self-efcacy levels between rst year and fourth year students First year n 5 94 7 6 98 2 32 74 0 % 5 89 6 6 92 2 30 70 0 Fourth year n 3 85 2 4 85 1 27 63 0 % 3 94 3 4 94 2 30 70 0 Total cases n 8 179 9 10 183 3 5 137 0

Nursing students self-efcacy in providing transcultural care Both participant groups also demonstrated the lowest perception of self-efcacy in the cognitive domain, including knowledge of cultural factors such as race, ethnicity and gender that may inuence nursing care. This suggests that the students were more effective in the practical and affective domain and least effective in relation to their knowledge of cultural aspects. The results showed that rst year nursing students lack certain knowledge in regards to the importance of cultural factors when compared to fourth year students. In relation to items such as interviewing culturally diverse groups and learning about individuals values and beliefs in association with health and illness the rst year group did not perceive themselves as effective. The reason for this could be related to maturational factors, personal attributes or perhaps that at this stage of their education the rst year students had only been exposed to foundational information such as; different models of health, sociocultural perspectives on health and individual perception and adaptation to health challenges. Also, rst year education had only included one observational clinical exposure before completing the questionnaire. In comparison, the fourth year nursing students had been informed about the theory related to holistic care, including transcultural nursing care. Furthermore, fourth year students had experienced several clinical care settings. The ndings of the current study support the ndings of Bell et al. (1998) who found that frequent clinical exposure did affect the students condence in their ability to communicate effectively with clients. Jeffery and Smodlaka (1999a,b) also showed that students in their fourth semester of clinical experience reported more condence in recognising and accepting the fact that cultural values and beliefs does affect ones perception of health care. In the current study, despite the fact that students in their fourth year had received more information and theory and been exposed to several clinical experiences, they reported having less condence in interviewing clients from diverse cultural groups. This suggests that further studies are required to investigate the impact of theory on practice in regard to nursing students level of selfefcacy in interviewing culturally diverse groups. Jefferys (2000) assumption that self-efcacy is a dynamic construct that changes over time in response to new experience and information (p. 128) is supported by the current study. The results showed that there was a statistically signicant difference in the strength of self-efcacy between rst year and fourth year nursing students in the areas of transcultural nursing skills; cognitive,

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practical and affective. As it appears that nursing students self-efcacy in performing transcultural nursing skills increases with theory and clinical experiences there is a need for nurse educators to ensure that students are well prepared to integrate theory and practice to provide effective transcultural nursing. Findings from the current study are also consistent with several other studies that have demonstrated that clinical experience and appropriate education is an important determinant in creating clinical condence in nurses (Felder, 1990; Rooda, 1993; Jeffery and Smodlaka, 1999a,b; Sandra, 2000). Felders (1990) ndings suggest that inclusion of cultural diversity in education increases nursing students knowledge of culturally diverse clients. The idea of students being culturally sensitive is important as previous studies of registered nurses caring for culturally divergent clients showed that they lacked knowledge of the clients culture and reported having difculty in providing holistic care (Sandra, 2000). This also supports an earlier study that reported that the nurses were only familiar with their own culture and health care practices leading to a negative attitude toward the culture and health practices of different ethnic groups (Rooda, 1993). Both Rooda (1993) and Sandra (2000) support the concept that knowledge of cultural issues is directly related to the students level of educational preparation. It is clear that nursing students not only need to understand nursing theory but they require clinical experience in order for them to continue to develop a sense of efcacy in performing transcultural nursing skills. In addition, the ndings highlight the need for nurses in todays multicultural society to have more knowledge, skills and personal encounters with clients from different cultural groups so that they can acquire the optimal skills and knowledge to deliver effective culturally congruent care.

Conclusion
In conclusion, this study indicates the importance of relating theoretical education and clinical experience to transcultural nursing care in order to increase students self-efcacy with their clients. The implication of the ndings to nurse education, emphasize the necessity to ensure that students are exposed to diverse cultural groups early in their clinical experience in pre-registration programs. This may provide the best opportunity for students to experience transcultural nursing and develop

434 through learning, maturation and personal growth. As students knowledge was found to be decient compared to the practical and affective domains it is recommended that curriculum developers include adequate content related to transcultural care, given the changing multicultural population requiring health care. It is critical for nurse educators to focus on transcultural nursing care to ensure that future generations of nurses are better able to provide effective and efcient care to meet the health care demands of a multicultural society. However, further research is needed to demonstrate this. Graduate nurses need to develop a strong sense of efcacy in providing transcultural nursing care because only then will they have reached their potential and be prepared to provide optimal health care to diverse multicultural groups.

J. Lim et al.
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