Nurse Education Today 62 (2018) 9–15

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Nurse Education Today

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Exploring the cultural competence of undergraduate nursing students in T

Saudi Arabia
⁎
Jehad O. Halabi , Jennifer de Beer
College of Nursing - Jeddah, King Saud bin Abdul Aziz University for Health Sciences, Jeddah, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: To explore the cultural competence of undergraduate nursing students at a college of nursing, Saudi
Cultural competency Arabia.
Culturally competent care Design: A descriptive exploratory design was used to explore the Saudi undergraduate nursing students' level of
Nursing students cultural competency.
Saudi Arabia
Method: The convenience sample included 205 nursing students affiliated with a college of nursing at a health
science university in Jeddah, Saudi Arabia. Data was collected using the Inventory for Assessing the Process of
Cultural Competence-Revised (IAPCC-R) consisting of 25 items. The tool reported acceptable reliability of
Cronbach alpha 0.89.
Results: The majority of students were culturally aware and dealt with people from different cultures. One-third
preferred to have training on culture over a period of time. Half the students preferred studying a special course
related to working with people from different cultures. Cultural desire reported the highest mean while cultural
knowledge scored the lowest among the cultural competence subscales despite students being exposed to some
cultural knowledge content in their training.
Conclusions: Implementing the guidelines for culturally competent care assure covering all aspects of care with
consideration of cultural heritage as a main concept. Comparative study of nurses' and students' perception is
further recommended.

1. Introduction cultural competence results in holistic care, increases the patient's

Cultural competence is variously defined in terms of the outcomes
for individual patients and groups or as the attitudes, and behaviors of
practitioners and organizations or a combination of both. While there is
never likely to be a single definition which is wholly acceptable to all,
the following typifies the definitions found in the literature. The most
frequently cited definition is by Campinha-Bacote (1999, p. 278) who
defines cultural competence as an ongoing process of seeking cultural
awareness, cultural knowledge, cultural skill and cultural encounters in
which the “healthcare provider continuously strives to achieve the
ability to effectively work within the cultural context of the client”.
Cultural competence leads to several health outcomes variables in-
cluding an increase in quality of nursing performance, care provider-
patient rapport and well-established intersubjectivity. Similarly, cul-
tural competence leads to treatment effectiveness, as well as cost ef-
fectiveness. Cultural competence increases provider-based variables,
which include personal and professional growth in values, commu-
nication and nursing practice. In terms of receiver-based variables,
quality of life, health care satisfaction, a good perception of health care
providers and better adherence to prescribed medication (Suh, 2004).
Further to this, Gӧzum et al. (2016) highlights that culture plays a
vital role in health perceptions, health behaviors and response to
medical treatment so health care personnel should improve their cul-
tural competence as culturally competent nursing care aims to improve
the quality of health care by reducing cultural disparities that arise
when different cultures meet in the health care context (Almutairi et al.,
2015; Douglas et al., 2014). As more people from diverse cultures seek
access to health care resources, nurses are responsible for “under-
standing, facilitating, and integrating traditional culture into modern
approaches to health and nursing care” (Darnell and Hickson, 2015, p.
102). In addition, cultural competence includes nurses determining
whether they understand the patient's cultural needs so as to remove
any barriers that may affect the patient's health outcome (Darnell and
Hickson, 2015).
Cultural competence can be achieved in nursing education by de-
veloping a taxonomy that include the antecedents described above:

⁎
Corresponding author at: P.O. BOX 9515, Mailcode 6565, KSAU-HS, CON-J, Saudi Arabia.
E-mail addresses: halabiJE@ngha.med.sa (J.O. Halabi), beerje@ngha.med.sa (J. de Beer).

https://doi.org/10.1016/j.nedt.2017.12.005
Received 12 January 2017; Received in revised form 9 September 2017; Accepted 3 December 2017
0260-6917/ © 2017 Elsevier Ltd. All rights reserved.
J.O. Halabi, J. de Beer
awareness, knowledge, sensitivity, skills and encounters. In addition,
nursing students will be able to identify some beliefs and practices used
to care for individuals from diverse cultures if nurse educators are in-
corporating culturally competent care in their programs (de Beer and
Chipps, 2014). Cultural competence work by scholars such as Leininger
et al. provided support for teaching nursing students about the beliefs,
values and practices of diverse groups which develops cultural con-
gruence in nursing students (Holland, 2015). Seright (2010) found that
80% of American rural nurses considered themselves not culturally
competent. Therefore, it is important to assess cultural competence
even in homogenous rural parts of the USA.
1.1. Nursing in Saudi Arabia
This cultural competence is applicable to the Kingdom of Saudi
Arabia (KSA), which is a country with a unique blend of Arabic people
with Islamic influence (Almutairi, 2015). The uniqueness of the Saudi
culture is further coupled with a large number of expatriates residing in
KSA. In mid-2013, it was estimated that 9.4 million non-nationals from
approximately 18 countries reside in KSA with a total population of
28.83 million (De Bel-Air, 2014). The rapid annual growth of the Saudi
population (3.2%) places a huge demand on the Saudi healthcare
system. Furthermore, they bring in a difference in religion, culture and
social values and languages which can often create barriers between
nurses and patients (AlYami and Watson, 2014).
In addition, there are further demands on the health care systems
due to the chronic shortage of Saudi health care professionals, espe-
cially nurses. There are 55,429 nurses working in KSA representing
(52%) of the total health care professional workforce. Of these, only
24,689 (44.5%) are Saudi, while the rest are expatriates. Nursing stu-
dents fall within the category of Saudi nurse workforce (4.1%) (Almalki
et al., 2011). It is within this backdrop that the authors believe in the
significance of exploring the cultural competence of student nurses
within an undergraduate nursing program in KSA.
Caring for patients from diverse backgrounds is a daily reality for
nurses who are expected to provide both clinically safe and cultural
competent care. Nurses need cultural competence in the management
of patients within a cultural context. A health care system staffed by a
culturally competent workforce produces high quality care to diverse
populations leading to elimination of health disparities (de Beer and
Chipps, 2014).
Nursing programs have a responsibility to adequately prepare their
graduates to provide culturally competent care (Von Ah and Cassara,
2013). However, prior to the mid-1980’s nursing programs did not in-
clude cultural competency in the curricula. Since then, nursing orga-
nizations and educational institutions have recommended and devel-
oped standards for cultural competency (Douglas et al., 2014) learning
strategies to be included in academic content. These strategies are in-
tegrated throughout years of formal education and vary in terms of
objective, curricula, learning interventions and evaluations (Gallagher
and Polanin, 2015).
Von Ah and Cassara (2013) and Adams (2010) reported the sig-
nificance of adequately addressing cultural competence in the under-
graduate nursing curriculum by providing students with the knowledge
and clinical experience that will enable them to be comfortable and
sensitive to the needs of diverse patient populations. de Beer and Chipps
(2014) highlighted that nurses who lack cultural competence may be
putting patients at risk for delays in treatment, inappropriate diagnosis,
non-compliance with health care treatment and even deaths.
Given the influence of globalization on health care services, nurses
need to have sufficient cultural competence to effectively manage pa-
tients from different cultures. Hence, the development of cultural
competence in nursing has become an important aspect (Lin, 2016).
The purpose of this study was to explore the cultural competence of
undergraduate nursing students at a college of nursing, Jeddah, KSA.
The specific objectives were to explore undergraduate nursing student's
10
Nurse Education Today 62 (2018) 9–15
knowledge about cultural competence; their cultural awareness; their
cultural encounters; their cultural desire; and their cultural skills. No
previous studies were located in the literature with nurses or students
from the Middle East. This is the first study of its kind in the country
and the Arab region.
2. Methods
2.1. Design and Setting
This research followed a positivist research paradigm assuming a
quantitative exploratory descriptive design. A college of nursing in the
Western region of the KSA was the setting for this study. The College
offers two undergraduate (Baccalaureate) Programs in Nursing Science:
the first is known as Stream I, catering for high school graduates and
extends over a period of 4 years. The second is known as Stream II,
catering for university graduates who wish to join Nursing as a second
career. The two programs are preceded by a foundation program of one
semester, and followed by internship program of one year length. The
aim of the program is graduating independent, critical thinkers who are
able to care for the patient, families and communities by providing care
that is of the highest standard possible. The curriculum within this
college incorporates cultural contents over the 4 years of studying.
However, in the first year of the program, within the Fundamentals of
Nursing module, cultural contents are formally incorporated. Over a 3-
hour scheduled class presentation, students were introduced to the
main concepts of culture, culture competent care, and how to provide
cultural sensitive nursing care in a culturally diverse health care en-
vironment. Culture theories as well as the culturally competent models
of care are introduced. Students are involved in clinical rotations
throughout the program and during this rotation students are exposed
to patients and staff from a multicultural background.
2.2. Sample and Data Collection
A convenience sampling method was used to recruit undergraduate
nursing students, from Stream 1 and Stream 11, registered at the female
nursing college during the study semester. The total number of students
(240) from all four years of training who met the inclusion and exclu-
sion criteria was targeted for this study as the population number was
small. Students that were included in the study completed the
Fundamentals of Nursing module and were registered within the col-
lege at the time of data collection. Students that were excluded from the
study did not complete the Fundamentals of Nursing module and were
not registered in the college during data collection. Completion of the
Fundamentals of Nursing module was a prerequisite for inclusion into
the study as this module covers the cultural contents taught within the
program. In addition, not being registered as a student within the time
of data collection did not qualify students to participate in the study
even if these students completed the Fundamental of Nursing module.
Two-hundred and forty questionnaires were distributed to students.
Only 205 students consented to partake in the study by completion of
the questionnaires making the response rate 86%. Questionnaires were
handed to students by the researchers at the beginning of lectures and
were collected at the end of the lecture day. This was done so as to
allow students sufficient time to complete the questionnaire.
2.3. Instrument
A questionnaire consisted of two sections; the first covered the de-
mographic data detailing age, marital status, cultural, residence, level
of study, stream or program of study, GPA, clinical experience, ex-
posure to cultural information and level of training, and the second was
the Inventory for Assessing the Process of Cultural Competence-Revised
(IAPCC-R) designed by Campinha-Bacote (1999) and revised in 2002.
This inventory is a four-point Likert self-administered scale consisting
J.O. Halabi, J. de Beer Nurse Education Today 62 (2018) 9–15

of 25-items measuring the level of cultural competence of healthcare Table 1

professionals, including the five constructs of this model: cultural Demographic characteristics of participants (N = 205).
awareness, cultural knowledge, cultural skill, cultural encounter and
Characteristics n % M (SD)
cultural desire.
The IAPCC-R tool was translated into Arabic by a bilingual re- Age
searcher for the purpose of this study using two of the commonly used < 20 6 2.9 21.68
20–24 185 90.2 (1.85)
techniques in the literature including translation-back-translation and
> 24 14 6.8
bilingual technique (Claro et al., 2012; Gjersing et al., 2010). The Marital status
English version of the IAPCC-R tool had a well-established overall re- Single 172 83.9
liability with Cronbach alphas ranging from 0.78 to 0.83 (de Beer and Married 33 16.1
Chipps, 2014; Kardong-Edgren and Campinha-Bacote, 2008; Steinke Educational program (stream)
Stream I (traditional) 184 89.9
et al., 2015). The Arabic version was piloted with 20 students and the
Stream II (accelerated) 21 10.1
results showed a Cronbach alpha of 0.87. Content validity of the ori- Study level (seniority)
ginal tool was established using the known groups' technique with 200 Senior 93 45.4
registered nurses attending a cultural competence workshop Junior 112 54.6
GPA (out of 5) 3.43 (0.54)
(Campinha-Bacote, 2002).
< 2.0 (below average) 4 2
2.0–3.0 (good) 61 29.8
2.4. Ethical Considerations 3.01–4.0 (very good) 108 52.7
> 4.0 (excellent) 22 10.7
Ethical approval was obtained from the Research and Ethics Missing 10 4.9
Exposure to cultural competence
Committee of the college. The researchers provided assurance to all the
Yes 120 58.5
respondents that they are under no obligation to participate in the study No 85 41.5
and they can withdraw at any time. Respondents were also assured of Caring for patients from different cultural backgrounds
protection any harm (physical and psychological). Confidentiality, Yes 70 34.1
No 47 22.9
privacy and anonymity were maintained by ensuring that the ques-
Did not have clinical 88 44.9
tionnaires were anonymous and data was untraceable back to any re- Dealing with people from different cultural
spondent. Informed consent (written) was obtained from the re- backgrounds
spondents. Yes 160 78
No 45 22
Preference to work with patients from different
2.5. Data Analysis
cultures:
Prefer to work with patients from own culture only 7 3.4
The SPSS-20 was used to analyze the data including descriptive and Prefer to work with patients from different cultures 8 3.9
inferential statistics to test correlations and comparisons among vari- only
Prefer to work with patients from the two together 45 22.0
ables. Each construct consisted of five questions with a score ranging
No difference, all patients are same for me 145 70.7
from 5 to 25. The total score for all constructs ranged from 25 to 100, Preference to study a course specially for dealing with
indicating which participants were culturally proficient different cultures
(score = 90–100), competent (score = 75–89), aware Yes 102 49.8
(score = 51–74); or incompetent (score = 25–50) (Campinha-Bacote, No 55 26.8
Not sure 48 23.4
2002).
Suggested period/time for studying a course about
culture
3. Results Basic Sciences years 43 21.0
Nursing Sciences Years 43 21.0
3.1. Characteristics of Respondents No difference or preference 69 33.7
Do not like to study a course 50 24.4

Two-hundred and five female nursing students completed and re-

turned the questionnaire for a response rate of 86%. The mean age
21.68 (SD = 1.85) and most of them were from stream-I (89.8%) (see
Table 1). The participants split almost half senior-junior where 54.6%
(n = 112) were junior (first year in nursing courses) and 45.4% were
seniors (last year in the program) (n = 93). Most of them were single
(83.9%) residing at home in an urban large multicultural city where
they studied. The mean GPA (M = 3.43, SD = 0.54; range 1.90–4.88)
was corresponding to a category of good distribution (2.75 to 3.74 out-
of-5) at this college. All students included in this study were Saudi of
origin.
3.2. Exposure to Cultural Concepts
About 42% of participants reported previous study about culture
apart from the cultural content in the Fundamental Nursing module and
78% reported having dealt with people from different cultures pre-
viously. Sixty percent of the senior students who had clinical training
reported dealing with patients from different cultures during their
clinical training.
When asked about their preference to work with patients from dif-
ferent cultures if they had a choice, the majority (71%) reported no
difference among patients where they considered all patients to be the
same. About a quarter (22%) preferred to work with both categories of
patients at the same time (nationals and different cultures). Only a few
made distinctions of preference to work with patients from different
cultures (3.9%) as opposed to patients from only their own culture
(3.4%).
Only 85 students (41.5%) reported they studied about culture and
cultural competence at various courses other than Fundamentals of
Nursing course. Majority of students indicated they were oriented to
culture at the university while studying fundamentals of nursing course,
which is mandatory to all students, communication, Islamic and Arabic
culture courses in the pre-professional year, and indirectly in courses
that integrated culture concepts. This finding was significant as all
students included in the study completed the Fundamentals of Nursing
course.
Students were asked for their preference to study a special course
related to culture and how to deal with other cultures. Fifty percent
were in favor of studying such a course while the other 50% was split
between not wanting to study such a course (27%) and being ‘not sure’
(23%) about whether they wanted to study such a course. Regarding

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J.O. Halabi, J. de Beer Nurse Education Today 62 (2018) 9–15

Table 2

Cultural knowledge M ± SD
Mean scores of cultural competence scale and subscale for sample of Saudi nursing stu-
dents (N = 205).

Culture scale/subscale Total possible score Mean Standard deviation

2.30⁎⁎⁎

2.17⁎⁎⁎
2.24
1.94
2.10
2.32
2.04
2.31
2.18
2.25

2.02

2.04
Culture desire 20 16.11 2.17

±
±
±
±
±
±
±
±
±
±
±
±
Culture awareness 20 13.81 1.79

11.11
11.09
11.14
11.09
11.30
11.06
11.10
11.12
11.76
10.65
11.40
10.11
Culture encounter 20 13.40 1.90
Culture skills 20 12.50 2.01
Culture knowledge 20 11.11 2.20

Cultural skill M ± SD
Overall cultural competence 100 66.96 7.03

1.59⁎

2.09⁎
2.03

1.77
2.24
2.16
1.95
1.97
2.05

1.91
2.05
1.83
the suggested time for studying a course about culture, 21% of students
suggested the course be offered in the pre-professional years while 21%

±
±
±
±
±
±
±
±
±
±
±
±
12.40
13.42
12.44
12.57
12.49
12.52
12.61
12.37
12.89
12.23
12.60
12.15
suggested that the course be offered during other nursing courses. The
rest of the students (58%) had no preference about when the course
should be offered.

Cultural encounter M ± SD
3.3. Cultural Competence (Overall IAPCC-A)

1.72⁎

1.91⁎

2.03⁎

1.92⁎
Results showed an overall acceptable level of Cronbach's alpha

1.89
2.02

2.04
1.93
1.93

1.86

1.77

1.73
(α = 0.89) as internal consistency and reliability and a normal dis-

±
±
±
±
±
±
±
±
±
±
±
±
tribution and satisfactory overall mean cultural competence score of

13.44
13.09
13.69
13.09
13.26
13.48
13.65
13.10
13.76
13.15
13.56
12.84
66.96 out of 100 (equals to 2.67/4) (see Table 2), with a range of 38 to
88. Looking at the five subscales, the ‘cultural desire’ scale reported the
highest mean score (16.11) while ‘culture knowledge’ reported the

Cultural awareness M ± SD
lowest mean score (11.11). Pearson's correlations between the different
cultural competence constructs showed statistically significant scores at
the p < 0.01 level (2-tailed) for all the five constructs indicating high

1.81⁎⁎
1.93⁎
1.82
1.54
1.62

1.56
1.92
1.77
1.80

1.73
1.78
1.78
validity among cultural components.
When categorizing the scores in terms of the five cultural compe-
±
±
±
±
±
±
±
±
±
±
±
±
tence categories, 86.8% of students (n = 178) fell under ‘culturally
13.80
13.90
13.56
14.09
13.86
13.83
13.64
14.02
14.20
13.54
13.92
13.42
aware’ category (possible range score 51–74), while 11.7% fell in the
‘culturally competent’ category (possible score 75–90). Only one stu-
Cultural desire M ± SD

dent reported being ‘culturally proficient’ (possible score 90–100) and

two were ‘culturally incompetent (possible score 25–59)’. Chi-square
Interrelationship of demographic variables with cultural competency scores of Saudi nursing students (N = 205).

was done to compare the two streams regarding the cultural compe-
2.30⁎

2.14⁎
2.18
2.13
2.08
2.28
2.13
2.25
2.30
2.00

2.05

2.22
tence categories, and results indicated no relationship between stream
±
±
±
±
±
±
±
±
±
±
±
±
and cultural competency category. Students from both streams fell
under the ‘cultural awareness’ category as a general category.
16.08
16.38
16.05
16.18
16.35
16.02
16.30
15.89
16.50
15.84
16.27
15.55

3.4. Demographic Differences in Cultural Competency Scores

Total competency score M ± SD

Stream-II-students reported slightly higher mean-scores

(M = 67.90, SD = 5.53) in the overall competence score than stream-I
(M = 66.85, SD = 7.19) as well as in the ‘culture desire’, ‘culture
7.40⁎⁎⁎

awareness’, and ‘culture skills’ (see Table 3). The mean-score of cultural
7.25⁎⁎
7.19
5.53
6.36
7.73
6.57
7.35
7.15
6.91

6.35

5.34

competency was higher for stream-II (M = 13.42, SD = 1.59) related

±
±
±
±
±
±
±
±
±
±
±
±

to culture skills compared to stream-I (M = 12.40, SD = 2.03). The

66.85
67.90
66.89
67.03
67.27
66.94
67.32
66.52
69.12
65.42
67.76
64.08

results of independent sample t-test showed statistically significant

difference conditions; t(27) = 2.70, p = 0.000). This was the only
significant difference among the two streams. Even though stream-I
High achiever (> 3.0)
Low achiever (< 3.0)

reported higher mean-scores in ‘culture knowledge’ and ‘encounters’,

Younger (< 21 yr)
Older (> 21 yr)

the difference among the two groups was not significant.

3.4.1. Age
Junior
Senior

There was a negative correlation (− 0.010), however not sig-

Yes

Yes
No

No
II

nificant, between age and the overall cultural competence score.

I

Meanwhile, the culture knowledge construct scored the lowest

Previous study of culture

(M = 11.11; SD = 2.20) for all students. There was a negative corre-

Demographic variable

Exposure to culture

lation (− 0.016) but no statistical significance between age and culture

knowledge. However, for age and the culture encounter construct, there
p ≤ 0.001.
Level of study

p ≤ 0.01.
p ≤ 0.05.

was a negative (− 0.154) statistically significant correlation

(p < 0.02) between the two variables.
Stream
Table 3

GPA
Age

Paired sample t-test for age and cultural competence overall and
⁎⁎⁎
⁎⁎
⁎

subscale was conducted. It showed differences related to age among

12
J.O. Halabi, J. de Beer
younger and older students. The overall competence was significantly
higher among younger students (M = 45.27, SD = 7.29) and condi-
tions; t(204) = −88.88, p = 0.000). Furthermore, results showed that
all cultural constructs were significantly different among different age
groups (p < 0.000). Younger students between the ages of 20 to
24 years were more culturally competent than older students > 24-
years of age. However, there was a negative (but not significant) cor-
relation between age and the total score on cultural competence.
3.4.2. Grade-Point-Average (GPA)
Looking at GPA scores, the overall competence score was not sta-
tistically significant when correlated with GPA. Similarly, all compe-
tence sub-constructs were not significantly correlated with GPA. The
overall competence score was negatively but statistically significantly
different among GPA groups (high achievers GPA, 66.94% and low
achievers, 67.27% (t = −125.27, p = 0.000). Similarly, all sub-con-
structs were scored significantly different among GPA groups (see
Table 3). The ‘culture desire’ construct scored the highest among both
groups of high-achievers and low-achievers (M = 16.02; and 16.35
respectively). However, the ‘culture knowledge’ construct scored the
lowest (M = 11.06 and 11.30 respectively) with no significant corre-
lations.
3.4.3. Level of Study
The t-test was used to explore any statistically significant differences
between senior and junior students in relation to the total cultural
competency score and its sub constructs. Looking at seniority of stu-
dents and comparing mean scores, the junior students had a higher total
mean score of (M = 67.32, SD = 7.15) than seniors (see Table 3),
however this was not statistically significant. Similarly, there were no
significant differences in the four sub-constructs, yet, there was a sta-
tistically significant difference (t = 2.05, p = 0.04) between seniors
and juniors in their ‘cultural encounter’. Chi-square tested the re-
lationship between the level of study and the category of cultural
competency and showed no statistical significant relationship between
the two variables.
3.4.4. Exposure to Culture and Cultural Competency Content
Eighty-five students (69.12%) reported having exposure to culture
and cultural competency studies in their training apart from the fun-
damental Nursing Course completed. The cultural competence mean
score was higher for students who studied about culture (M = 69.12,
SD = 7.40) compared to students who did not study any culture con-
tent (M = 65.42, SD = 6.35) (see Table 3). Independent t-test showed
significant statistical difference in the total culture score between the
two groups conditions; t(203) = 3.83, p = 0.000). The results further
reported that previous studying of culture leads to a higher mean score
in all the five sub constructs of cultural competency, and showed a
statistically significant difference ranging from p = 0.000 to p < 0.03.
Chi-square was used to test the relationship between exposure to
culture and the category of cultural competency. Results showed a
statistical significant relationship (χ2 = 9.68, p < 0.02) between the
two variables. Friedman test was conducted to determine if there is a
significant change in level of cultural competency across study levels in
relation to the total score and the five sub-constructs of culture com-
petence. Results showed a significant change in students level of com-
petence, χ2 (5, N = 205) = p < 0.000).
4. Discussion and Conclusion
This study contributes to the understanding of the cultural compe-
tence among Saudi nursing students. It is the first study to assess cul-
tural competence within a Saudi context. The principal findings re-
vealed that about 12% of students felt they were culturally competent,
while just one of 205 students believed she was culturally proficient.
The majority of the students were culturally aware, a finding similar to
13
Nurse Education Today 62 (2018) 9–15
that of Calvillo et al. (2009), Nokes et al. (2005), and Krainovich-Miller
et al. (2008), who reported that the majority of undergraduate students,
regardless of education or intervention, scored in the culturally
awareness range in the IAPCC-R tool. Furthermore, according to several
authors such as Andrews and Boyle (2003) and Leininger (2002), cul-
tural awareness is the first step towards developing cultural compe-
tence.
Only 42% of students had previous training on culture as a subject.
According to Dunagan et al. (2014), teaching nursing students how to
be culturally competent is essential in order to provide optimal care for
patients. In addition, these authors emphasized that teaching cultural
content to students as they progress in their training leads to significant
increase in cultural competence. These are similar to our findings,
where one-third of the participants preferred to have training on culture
over a period of time. In addition, only 42% of students confirmed they
were exposed to cultural content in their training. This was a significant
finding, as all students involved in this study completed the Funda-
mental of Nursing course. A study conducted by Malcolm (2013) on
Bachelor of Nursing (BSN) students revealed that even though cultural
competency education has been integrated into undergraduate pro-
grams, there is a dearth of data on the evaluation of the outcomes and
effectiveness of these programs.
Furthermore, half of the students in our investigation preferred to
study a special course related to different cultures and how to care for
people from diverse ethnicities. In addition, most students reported
having cared for people of different cultures. Douglas et al. (2014)
suggested that competence in cross-cultural practice requires a con-
tinued interest in learning and experience. Cultural competence is an
ongoing process and requires more than formal education. This includes
students requiring actual experience working with people of other
cultural groups (Caffrey et al., 2005).
The results of this study further revealed that junior students were
more educated than the higher level in terms of cultural knowledge. A
possibility for this finding could be attributed to the fact that higher
level students were not exposed enough to culture training in com-
parison to lower level students. This could be due to the fact that the
culture content taught in the Fundamental of Nursing module evolved
over time in terms of its content.
Most students scored highest in the ‘culturally aware’ category.
Kardong-Edgren et al. (2010) also indicated that, on average, most
graduating students from six programs within their study fell under the
‘cultural awareness’ category. These authors posit that prolonged ex-
posure to deliberate cultural content maybe responsible for higher
cultural awareness scores. This is opposite to the findings in this study,
where the lower level students were more culturally aware than senior
students. Furthermore, Krainovich-Miller et al. (2008) reported that the
majority of undergraduate students, regardless of education or inter-
vention, scored in the ‘cultural awareness’ range on the IAPCC-R.
Kardong-Edgren et al. (2010) attributed these findings to possibly a
function of the evaluation tool and suggested that probably a new tool
to evaluate student populations is needed.
It is noted that stream-II students reported a statistically significant
higher mean score related to ‘culture skills’ as compared to stream-I-
students. This could be attributed to the fact that stream-II-students are
older, hold undergraduate degrees, graduates of university and joined
nursing as a second career. Therefore, these students might have had
more exposure to cultures. From the ‘cultural competence’ score,
stream-II-students scored higher on overall cultural competence than
stream-I-students. Stream-I-students joined the university directly from
high school whereas stream-II-students are university graduates with
science as a major focus. Our results showed that although stream-II-
students were more ‘culturally aware’. They scored higher than stream-I
in overall score, cultural desire, cultural awareness, and cultural skill;
whereas they scored lower on cultural encounter and cultural knowl-
edge. Stream-II-students have had cultural interactions at the university
level since they join the program after having a first science degree at
J.O. Halabi, J. de Beer
another university.
Overall, both streams scored higher means in the cultural construct
in categories of ‘cultural desire’ and ‘cultural awareness’ and lowest in
‘cultural knowledge’. In contrast, Kardong-Edgren et al. (2010) reported
that students without a prior degree were less culturally aware. This
could be due to the fact that students with fewer life experiences have
less understanding of the importance of culture when delivering care to
their patients. In addition, these authors reported that “cultural mate-
rial is not presented in a vacuum” …, “university world also has an
influence where students are exposed to other cultures in so many
ways” (Kardong-Edgren et al., 2010, p. 284).
The findings of the current study also highlighted that students
scored the highest on the ‘cultural desire’ construct and the lowest on
the ‘cultural knowledge’ construct. This indicates that students have a
strong desire towards becoming culturally competent. Cultural desire
represents an affective construct. Leng (2002) asserts that affective
characteristics can be learned capabilities that affect human perfor-
mances and recommends a two-prong strategy of “taught and caught”
students can catch affective characteristics from an informal environ-
ment like peer groups and field trips, while “more structured activities
can include sharing of success stories, meeting with actual role models,
role playing, simulations, using videos, games, the media, and case
studies” (Leng, 2002, p. 5). Using this approach, cultural desire can be
‘caught’ from other nursing students, faculty who model cultural desire,
cultural encounters and/or invited speakers who are passionate about
cultural competence in healthcare delivery.
In contrast, ‘cultural knowledge’ scored the lowest from the cultural
competence construct, despite students being exposed to some cultural
knowledge content in their training. This could be attributed to the fact
that the questions on the knowledge content of tool for the under-
graduate nursing students were not what students are familiar with.
Furthermore, incorporating teaching strategies that emphasize a cul-
tural component and competency are important. This could include
presenting materials in lectures, using audiovisuals and new technolo-
gies such as social media that are widely used by most students, and
using the blackboard and electronic online methods to incorporate
more cultural concepts. These methods were supported by some authors
who reported inclusion of cultural material in distance learning edu-
cation (Arbour et al., 2015; Kardong-Edgren et al., 2010). The study is
limited by the convenience sample of participants from various courses
during class time at the end of the class session.
In conclusion, this study is the first that assessed Saudi nursing
students' perception of culture competence. The most significant
finding of this study was that the majority of students (86.8%) were
more cultural aware rather than competent. Students who had previous
studies of cultural contents and who were previously exposed to other
cultures were more cultural aware than those who had no previous
studies or exposure to other cultures. Students scored the highest on the
cultural desire and the lowest on the cultural knowledge construct.
They have the willingness and motivation to learn about cultures and
work with clients from culturally diverse backgrounds. Their motiva-
tion is encouraging to assure future development of students' awareness
about culture sensitivity and competence care. Implementing the
guidelines for culturally competent care is an overall umbrella that can
assure covering all aspects of care with consideration of culture as a
main component of care (Douglas et al., 2014). This should start at
basic education levels and should be sustained throughout their clinical
training while students are socializing into nursing. Future studies need
to further assess these students after graduation and understand their
progress in further sustaining and developing culturally competent
care. Comparative study of nurse's and students' perception is further
recommended from a qualitative perspective so as to gain in depth
understanding about the phenomena at hand.
14
Nurse Education Today 62 (2018) 9–15
Acknowledgement
The authors wish to acknowledge the editorial assistance and sup-
port of Marilyn “Marty” Douglas, PhD, RN, FAAN in the preparation of
this manuscript.
Conflict-of-Interest
Authors declare that they have no conflict of interests.
Sources of Support
This study was self-funded.
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