Norivy P. Barral, Aljean Cloe Q. Corpuz, Julia Andreigna L. Lagcao, Mae-Lanie O. Poblete*, Reya T. Seno, Elvie A. Paler, Queenie Jane J. Ramel
Mindanao State University-Iligan Institute of Technology (MSU-IIT), Iligan Institute of Technology, Iligan City, 9200 Philippines
*Corresponding Author’s Email: mae-lanie.poblete@g.msuiit.edu.ph
ABSTRACT
Background: The inability of healthcare institutions to provide culturally sensitive care to patients with diverse cultures and beliefs correlates to poor nursing care and a decline in patient outcomes. In providing high-quality nursing care, nurses should be invaluable in demonstrating culturally competent caring behaviors to the diverse patient population. Objectives: This study aimed to determine the significant difference between the self-assessed cultural competency of nurses and the quality of care of nurses as perceived by the patients. Methods: A descriptive quantitative study was employed. Consecutive sampling was used to select the participants who met the inclusion criteria with a total of 98 respondents, 48 of them were nurse respondents and 40 were patient respondents. Questionnaires consist of the socio- demographic profile of the respondents, Patient Satisfaction with Nursing Care Quality Questionnaire, and Cultural Competence Self-Assessment Checklist. Descriptive statistics was used to analyze the data. Results: The results indicate that, on average, the nurse respondents rated themselves as "Pretty Well" in terms of their cultural competency based on awareness (x=3.15), knowledge (x=3.23), and skills (x=3.21). The overall total measure of cultural competence is x=3.20 which means that respondents have a generally positive perception of their overall cultural competency. As to the quality of care, the overall total measure of 4.14 and an SD of 0.48 indicates a Very Good perception of the overall quality of care nurses provide. Moreover, it was found that there is a significant difference in the cultural competency of nurses and the quality of care given to the patients. Conclusion: The study indicates that nurses’ cultural competence tends to affect patient outcomes and that the hospital needs training programs for nurses to increase their awareness of their behaviors and their influence on healthcare outcomes.
INTRODUCTION
Cultural competence concerns recognizing one's cultural values and beliefs in conjunction with the cultures of others. It also has a profound effect on each individual's health-related values, perceptions, and behaviors and affects patient care. The inability of healthcare institutions to provide culturally sensitive clinical care to patients with diverse cultures, beliefs, and behaviors correlates to poor nursing care and a decline in patient outcomes. Whereas culturally aligned care has been coupled with positive healthcare outcomes (Jongen, McCalman, & Bainbridge, 2018). Cultural competency is a vital skill to be developed in the nursing profession; it enables nurses to provide high-quality nursing care to groups with different cultural backgrounds (Deering, 2022).
In line with Campinha-Bacote’s Process of Cultural Competency and Model of Care (2002), cultural competency is an ongoing process of being and becoming, an ongoing effort to develop the ability to provide excellent patient care that is pertinent to the patient's sociocultural context rather than a stopping point. This approach allows nurse professionals to successfully treat patients even when patients’ beliefs, practices, and values directly conflict with conventional medical and nursing guidelines.
As part of the nursing metaparadigm, nurses are invaluable in demonstrating caring behaviors that are expected from the nursing profession (Dalvandi et al., 2019). Caring as a fundamental component of nursing is never obsolete (Kiliç & Öztunç, 2015). It is part of the nurses’ work to focus on identifying the needs of the patients and providing suitable care and resolutions that match their current situations (Ariani et al., 2022). A significant difference between nurses and patients regarding their attitudes toward nurses' caring conduct was found in the study of Dalvandi et al. (2019). As an outcome, nurses must focus on the culturally competent care aspects that are most important to patients. Furthermore, culture is fundamental to both parties since it affects what every patient brings to the medical setting, notwithstanding the endless variety of subgroups and individual religious affiliations. According to Hansson et al. (2013), the inability to recognize the influence of culture can result in negative and stigmatizing attitudes that, unfortunately, were found even among health professionals, including nurses. According to Kaihlanen, Hietapakka, and Heponiemi (2019), increasing awareness and understanding of nurses’ cultural and communicational features appeared to help them recognize the common pitfalls of cross-cultural communication, allowing them to develop their communication skills.
A joint memorandum by the Department of Health, the National Commission on Indigenous People, and the Department of Interior and Local Government was formed to establish guidelines on the delivery of Basic Health Services for Indigenous Cultural Communities/Indigenous People. The DOH-NCIP-DILG Memorandum Circular Number 2013-01 aims to establish a health system that will address health inequity towards people of Indigenous Culture. Meanwhile, the (Joint Commission International, 2016) states that to achieve optimal patient outcomes, healthcare professionals must provide care that meets each patient's needs by incorporating aspects of the patient's culture into the care plan. This promotes the notion that recognizing cultural differences among patients is key to optimal and holistic care. One study found that ensuring workforce diversity and leadership development opportunities for racial/ethnic minority nurses must remain a high priority if we are to realize the goal of eliminating health disparities and, ultimately, achieving health equity (Phillips & Malone, 2014).
Given the endearing role of nurses' cultural competence and perceived quality of care, the relationship between the nurse's cultural competency and the patient’s perceived quality of care needs further study, as it is not particularly prevalent in today's research setting. Thus, this study aimed to determine the significant difference between the self-assessed cultural competency of nurses and the quality of care of nurses as perceived by the patients.
METHODOLOGY
This study utilizes a descriptive quantitative research design to understand the cultural competence and quality of care of nurses in a public hospital as perceived by patients with different cultures. Quantitative descriptive research, also called survey research, measures the variables as numerical data to determine the status of the study’s objectives. The researchers obtained informed consent from the respondents before the data collection. Indications of consent to participate were executed by filling out a consent form at the beginning of the survey. Details provided during the consent procedure were properly explained, and participants were further assured of their participation and could opt out of the survey at any moment and refuse to participate. The respondents were assured of the anonymity, safety, privacy, and secrecy of the data collected throughout the study. The researchers further emphasized to the respondents that they have the right to withdraw from participating whenever they deem it necessary. The collected data was examined with the utmost professionalism.
Consecutive sampling, also referred to as total enumerative sampling, was used in the study to allow researchers to include all people who meet the inclusion criteria and are readily available as part of the sample. There was a total of 48 nurse respondents who qualified using the inclusion criteria of being a registered nurse regardless of employment status, as long as they were able to provide continuous care to the patient for 8-12 hours. On the other hand, there were a total of 40 patient respondents who qualified for the study using the inclusion criteria of being admitted for at least 24 hours and being able to read and write.
There were two survey tools used in the study, one for nurse respondents and the other for patient respondents. For the nurses’ survey, the first part of the questionnaire consists of the socio-demographic, and the second part is the Cultural Competence Self-Assessment Checklist (CCSAQ) with 36 questions, which will serve as a tool for the nurses to assess their cultural competency. The self-assessment tool is designed to explore individual cultural competence in terms of skills, knowledge, and awareness of themselves in their interactions with others. Its goal is to assist an individual in recognizing what they can do to become more effective at working and living in a diverse environment. The scale used in the questionnaire is 1-Never, 2-Sometimes/Occasionally, 3-Fairly Often/Pretty Well, and 4-Always/Very Well. The more points the respondents have, the more culturally competent they are becoming. To analyze the results of the aggregated CCSAQ scores, means are computed for each item. The internal consistency measure is at 0.70, which is considered respectable.
The survey for the patients to complete consists of the socio-demographic profile and the Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ) (Laschinger et al., 2005). The PSNCQQ consists of 19 items plus three extra questions meant to assess satisfaction with the overall quality of care during the hospital stay and the overall quality of nursing care.
The Cronbach reliability estimates for the PSNCQQ are excellent (0.97), according to a study by Ksykiewicz-Dorota et al. (2011). Item total correlations are high, ranging from 0.61 to 0.89. Each item was positively correlated with the others. The mean inter-item correlation was 0.57, and the values of correlations lay within the range of 0.23 - 0.77 which estimates of reliability are comparable across hospital categories. This suggests that patients in various types of hospital systems interpret the PSNCQQ items consistently.
The scoring of the scale was: 1 = excellent, 2 = very good, 3 = good, 4 = fair, and 5 = poor. The PSNCQQ can be scored in two ways. For overall results, the scores for all items can be added together and averaged to generate a single value for each patient. Item means and standard deviations can be calculated for more detailed feedback and more "actionable" results. Another option is to compute the percentage of responses that "strongly agree" with each item. These findings can be used to monitor changes over time or to assess the impact of quality improvement initiatives.
The researchers made use of SPSS software version 21.0 to analyze the data gathered in the study. More specifically, frequency and percentage to treat the socio-demographic profile of the nurse respondents and of the patient respondents; weighted mean and standard deviation to determine the self-assessment cultural competency of nurse respondents and the quality of care of nurses as perceived by the patient respondents; and test for difference (t-test) to determine whether there was a significant difference between the cultural competency of nurses and the perceived quality of care of the respondents.
Ethical Consideration
The researchers were granted ethics approval by the Mindanao State University, Iligan Institute of Technology, College of Health Sciences, Philippines, College Ethics Committee with reference number E-2023-12 on February 27, 2023, to conduct the study and were also permitted by the hospital administrators.
RESULT
Profile of Nurse Respondents
The results showed that the majority of the respondents fell within the age range of 25-31 years (43.8%), followed by 32-38 years (27.1%). In terms of sex, the majority of the respondents were female (89.6%), while only a small percentage were male (10.4%). Regarding marital status, a significant number of respondents were married or cohabiting (58.3%), while 41.7% were single. In terms of ethnic affiliation, the majority of the nurse respondents identified as Bisaya (91.7%), followed by a smaller proportion identifying as Maranao (6.3%), and a very small percentage identified as others (2.1%). When considering religion, the largest group of respondents identified as Roman Catholic (66.7%), followed by Islam (8.3%), and the remaining 25.0% identified with other religions. In terms of clinical experience, the distribution was fairly balanced. Around 12.5% of respondents had less than one year of clinical exposure, while 20.8% had 1-3 years, 25.0% had 4-6 years, and the largest group of 41.7% had seven years or more of clinical exposure. In terms of work experience outside the country, a small proportion of respondents (8.3%) reported having experience working outside the country, while the vast majority (91.7%) had not.
Profile of Patient Respondents
The results indicate that among the patient respondents, the highest frequency of age groups was observed in the range of 18-24 years (25.0%) and 32- 38 years (25.0%). In terms of sex, the majority of patients were female (85.0%), while a smaller proportion were male (15.0%). The huge difference in the number of female and male patient respondents was because the OB ward consists only of female patients. Regarding marital status, half of the patients were single (50.0%), and 45.0% were married or cohabiting. A small percentage reported being separated or divorced (5.0%). When examining the monthly income of the patient respondents, the majority fell within the range of 10,000 and below (82.5%), while a smaller proportion had incomes ranging from 10,001 to 20,000 (17.5%). Patients who identified as Maranao (10.0%) came in second to Bisaya (90.0%) in terms of ethnicity. Regarding religion, the majority of patients identified as Roman Catholic (77.5%), then as Islam (10.0%), and the remaining 12.5% as belonging to other religions. In terms of hospital stay, the majority of patients had a stay of less than 7 days (62.5%), while 27.5% stayed for 1-2 weeks, and a smaller proportion stayed for 3-4 weeks (10.0%). Regarding cultural background, a significant percentage of patients (80.0%) reported being cared for by a nurse whose cultural background was different from theirs, while a smaller proportion (20.0%) reported not having such an experience.
Cultural Competency of Nurse Respondents
Awareness
Table 1 presents the self-assessment of the cultural competency of the nurse respondents in terms of awareness. The results indicate that, on average, the nurse respondents rated themselves as "Pretty Well" in terms of their cultural competency awareness, with a mean score of 3.15 and an SD of 0.26. The highest-rated indicators of cultural competency awareness among the nurse respondents were "Value diversity" and "Know myself," with mean scores of 3.35 and 3.29, respectively. These scores suggest that the respondents perceive themselves as having a high level of awareness and appreciation for diversity and a good understanding of their cultural backgrounds and biases. On the other hand, the indicators with slightly lower mean scores include "Be curious," "Be aware of my privilege," and "Be aware of social justice," with mean scores ranging from 3.00 to 3.08. Although still rated as "Pretty Well," these scores suggest that the nurse respondents feel relatively less confident in being curious about other cultures, understanding their privileges and their impact on healthcare interactions, and being aware of social justice issues related to cultural competence.
Indicators | Mean | SD | Description |
Value Diversity | 3.35 | 0.60 | Very Well |
Know Myself | 3.29 | 0.68 | Very Well |
Share My Culture | 3.19 | 0.70 | Pretty Well |
Be Aware of Areas Of Discomfort | 3.15 | 0.68 | Pretty Well |
Check My Assumptions | 3.10 | 0.59 | Pretty Well |
Challenge My Stereotypes | 3.10 | 0.69 | Pretty Well |
Reflect On How My Culture Informs My Judgment | 3.10 | 0.69 | Pretty Well |
Accept Ambiguity | 3.21 | 0.74 | Pretty Well |
Be Curious | 3.00 | 0.55 | Pretty Well |
Be Aware of My Privilege | 3.08 | 0.61 | Pretty Well |
Be Aware of Social Justice | 3.06 | 0.52 | Pretty Well |
Total Measure | 3.15 | 0.26 | Pretty Well |
Note: 1.00-1.74 Never 2.50-3.24 Pretty Well
1.75-2.49 Occasionally 3.25-4.00 Very Well
Knowledge
Table 2 presents the self-assessment of cultural competency of the nurse respondents in terms of knowledge. The results indicate that, on average, the nurse respondents rated themselves as "Pretty Well" in terms of their cultural competency knowledge, with a mean score of 3.23 and an SD of 0.20. The indicators with the highest mean scores include "Gain from my mistakes" and "Assess the limits of my knowledge," both rated as "Very Well" with mean scores of 3.42 and 3.44, respectively. These scores suggest that the nurse respondents have a strong sense of learning from their mistakes and understanding the boundaries of their knowledge when it comes to cultural competency. Other indicators that were rated relatively high include "Acknowledge the importance of difference," "Understand the influence culture can have," and "Understand the point of reference to assess appropriate behavior," with mean scores ranging from 3.27 to 3.31. These scores indicate that the nurse respondents feel fairly competent in recognizing the significance of diversity, understanding the impact of culture on healthcare interactions, and considering different perspectives to assess appropriate behavior in cross- cultural situations. On the other hand, the indicators with slightly lower mean scores include "Know the historical and current experiences of those I label as 'others'" and "Understand the impact of racism, sexism, homophobia, and other prejudices," with mean scores ranging from
2.92 to 3.17. Although still rated as "Pretty Well," these scores suggest that the nurse respondents feel relatively less knowledgeable about the historical and current experiences of individuals they label as "others" and the broader impact of social biases on healthcare.
Indicators | Mean | SD | Description |
Gain From Mistakes | 3.42 | 0.61 | Very Well |
Assess The Limits of Knowledge | 3.44 | 0.62 | Very Well |
Ask Questions | 3.17 | 0.56 | Pretty Well |
Acknowledge The Importance of Difference | 3.27 | 0.57 | Very Well |
Know The Historical and Current Experiences Those Labelled As “Others” | 2.92 | 0.58 | Pretty Well |
Understand The Influential Culture. | 3.27 | 0.71 | Very Well |
Commit To Life-Long Learning | 3.21 | 0.71 | Pretty Well |
Understand The Impact of Racism, Sexism, Homophobia, and Other Prejudices | 3.17 | 0.52 | Pretty Well |
Know Own Family History | 3.23 | 0.72 | Pretty Well |
Know The Limitations | 3.25 | 0.73 | Very Well |
Be Aware of Multiple Social Identities | 3.10 | 0.59 | Pretty Well |
Acknowledge Inter-Cultural and Intracultural Differences | 3.21 | 0.65 | Pretty Well |
Understand Point of Reference to Assess Appropriate Behavior | 3.31 | 0.66 | Very Well |
Total Measure | 3.23 | 0.20 | Pretty Well |
Note: 1.00-1.74 Never 2.50-3.24 Pretty Well
1.75-2.49 Occasionally 3.25-4.00 Very Well
Skills
Table 3 presents the self-assessment of cultural competency of the nurse respondents in terms of skills. The results indicate that, on average, the nurse respondents rated themselves as "Pretty Well" in terms of their cultural competency skills, with a mean score of 3.21 and an SD of 0.23. The indicators with the highest mean scores include "Adapt to different situations," "Practice cultural protocols," "Act as an ally," "Be flexible," "Be adaptive," "Recognize my own cultural biases," and "Be aware of within-group differences," all rated
as "Very Well" with mean scores ranging from 3.27 to 3.31. On the other hand, the indicator "Seek out situations to expand my skills" received a slightly lower mean score of 2.96, indicating that the nurse respondents feel relatively less proactive in seeking opportunities to further develop their cultural competency skills.
Indicators | Mean | SD | Description |
Adapt To Different Situations. | 3.27 | 0.61 | Very Well |
Challenge Discriminatory and/or Racist Behaviour | 3.19 | 0.67 | Pretty Well |
Communicate Across Cultures | 3.21 | 0.68 | Pretty Well |
Seek Out Situations to Expand My Skills | 2.96 | 0.80 | Pretty Well |
Become Engaged 3.08 .68 Pretty Well | 3.08 | 0.68 | Pretty Well |
Act Respectfully in Cross-Cultural Situations | 3.04 | 0.68 | Pretty Well |
Practice Cultural Protocols | 3.27 | 0.57 | Very Well |
Act As an Ally | 3.27 | 0.64 | Very Well |
Be Flexible | 3.29 | 0.65 | Very Well |
Be Adaptive | 3.29 | 0.68 | Very Well |
Recognize My Own Cultural Biases | 3.29 | 0.62 | Very Well |
Be Aware of Within-Group Differences | 3.3 | 0.66 | Very Well |
Total Measure | 3.21 | 0.23 | Pretty Well |
Note: 1.00-1.74 Never 2.50-3.24 Pretty Well
1.75-2.49 Occasionally 3.25-4.00 Very Well
Quality Care as Perceived by Patients
Table 4 presents the quality of care provided by nurses as perceived by the patient respondents. Each indicator is rated on a scale from 1 to 5, with higher scores indicating better perceptions of care. The results show that, on average, the patient respondents rated the quality of care provided by nurses as very good to excellent across most indicators. The indicator with the highest mean score was "Informing family or friends" (mean =4.48, SD = 0.88), followed closely by "Discharge Instructions" (mean = 4.35, SD = 0.92), “Information given by nurses” (mean=4.28, SD=0.96) and "Skills and competence of the nurses" (mean = 4.28, SD = 1.13), all rated as excellent. This highlights the importance of nurses' competence in delivering high- quality care and providing accurate information to patients. On the other hand, indicators such as "Restful atmosphere provided by nurses" (mean = 3.55, SD = 1.06) and "Privacy" (mean = 3.83, SD = 1.01) received lower mean scores but were still rated as very good. This suggests that patients perceive room for improvement in creating a restful environment and maintaining privacy during care interactions.
Indicators | Mean | SD | Description |
Information You Were Given | 4.08 | 1.02 | Very Good |
Instructions | 4.23 | 0.83 | Excellent |
Ease of Getting Information | 4.15 | 1.00 | Very Good |
Information Given by Nurses | 4.28 | 0.96 | Excellent |
Informing Family or Friends | 4.48 | 0.88 | Excellent |
Involving Family or Friends in Your Care | 4.25 | 0.90 | Excellent |
Concern And Caring by Nurses | 4.15 | 1.10 | Very Good |
Attention Of Nurses to Your Condition | 4.25 | 1.01 | Excellent |
Recognition Of Your Opinions | 3.88 | 1.02 | Very Good |
Consideration of Your Needs | 4.18 | 0.90 | Very Good |
The Daily Routine of The Nurses | 4.23 | 0.83 | Excellent |
Helpfulness | 4.18 | 0.96 | Very Good |
Nursing Staff Response to Your Calls | 4.13 | 1.04 | Very Good |
Skill and Competence of Nurse | 4.28 | 1.13 | Excellent |
Restful Atmosphere Provided by Nurses | 3.55 | 1.06 | Very Good |
Privacy | 3.83 | 1.01 | Very Good |
Discharge Instructions | 4.35 | 0.92 | Excellent |
Total Measure | 4.14 | 0.48 | Very Good |
Note: 1.00-1.79 Poor 1.80-2.59 Fair 2.60-3.39 Good
3.40-4.19 Very Good 4.20-5.00 Excellent
Significant Difference
Table 5 presents the results of a significant difference between the Cultural Competence of Nurses (Total Measure) and the Quality of Care as perceived by the patient. The t-value of 12.774 and the p-value of less than 0.001 indicate a significant difference between the two variables. The significant difference suggests that there is a discrepancy between the overall cultural competence of nurses and the quality of care perceived by the patients. It indicates that, with varying levels of cultural competence, the quality of care given to patients also varies.
Variables | n | Mean | SD | t-value | p-value |
Nurse Cultural Competence | 48 | 3.19 | 0.17 | 12.774*** | <0.001 |
Quality of Care Perceived by Patient | 40 | 4.14 | 0.48 |
Note: ***p<0.001
DISCUSSION
These results have several implications concerning the profiles of the nurse respondents. Firstly, the majority of nurse respondents belonged to young adults, suggesting that this group represents the most significant portion of the nursing workforce. It is essential to consider the specific needs and preferences of this age group when designing interventions or policies related to nursing practice, education, and career development. Secondly, the predominance of female respondents indicates that nursing continues to be a female-dominated profession. This gender disparity may have implications for issues such as gender equality, workforce diversity, and addressing specific challenges faced by female nurses in their professional and personal lives. Furthermore, the representation of different ethnic affiliations and religions among the nurse respondents highlights the importance of cultural sensitivity and inclusivity in healthcare settings. In the study of Handtke, Schilgen, and Mosko (2019), culturally and linguistically diverse people use healthcare services at a lower rate than host communities and face a variety of challenges, including language barriers, legislative constraints, and disparities in health views. Moreover, the distribution of clinical experience among the respondents signifies a range of expertise levels within the nursing workforce. It is crucial to leverage this diversity of experience to promote knowledge sharing, mentorship, and professional growth among nurses. Lastly, the small proportion of respondents with work experience outside the country suggests that international opportunities may not be readily accessible or pursued by the nursing workforce.
The results of the patient respondents have several implications. It is noted that most of the respondents are young adults, with the greatest number of younger respondents belonging to the OB ward; this is because there has been an increase in the number of young pregnant women in recent years. It was further supported in the study of Tabei et al. (2021) that there are 55 births per 1000 women aged 15-19 in the Philippines, noting that the adolescent fertility rate remained high and placing the Philippines as the second country in East Asia and the Pacific that has the highest teenage pregnancy rate, and it is the only country showing an upward trend. Moreover, the income distribution of the patient respondents reflects a significant proportion of individuals with relatively low monthly incomes. This finding emphasizes the importance of addressing financial barriers to healthcare access and affordability. Healthcare systems and policymakers should implement measures to ensure equitable access to healthcare services, regardless of income level. Furthermore, the representation of different ethnic affiliations and religions among the patient respondents highlights the importance of cultural competence in healthcare. According to Smedley, Stith, & Nelson (2003), the disparities in health care based on race and ethnicity are still present despite insurance status, income, age, and the severity of the illnesses being comparable since the death toll from diseases like cancer and heart disease. Diabetes is notably more common in racial minorities, and it is very unacceptable between whites and ethnic minorities. This circumstance is also seen in other healthcare settings in the Philippines. In a study conducted by Hodge et al. (2016), the consumption of health care, notably maternity and child services, revealed "moderate wealth-based disparities" due to underlying socioeconomic characteristics such as parental work level and educational attainment, the mother's religion, and the perceived subjective distance between the mothers' homes and the health facility providing maternal health services. Lastly, the high percentage of patients reporting care by nurses with different cultural backgrounds indicates the multicultural nature of healthcare settings. This finding underscores the importance of fostering cultural diversity and promoting effective communication and understanding between healthcare providers and patients from diverse backgrounds.
The result of the cultural competency of nurses in terms of awareness implies that nurses recognize diversity as an essential binding agent of the interdisciplinary approach to providing high-quality care to patients. This result is further supported by the study of Malabat and Ruiz (2019), which found that nurses who have a general understanding of other cultures and are aware of the institutional barriers will help prevent creating cultural disparities with a stronger sense of self and well-being to ensure better performance in terms of giving the highest quality of care to patients. The high levels of awareness of valuing diversity and knowing oneself among the nurse respondents suggest that these areas can be further leveraged and reinforced to foster a culturally competent nursing workforce. On the other hand, the slightly lower scores in indicators such as curiosity, privilege awareness, and social justice highlight the need for ongoing education and training in these areas to enhance cultural competency among nurses. Overall, the self-assessment of cultural competency awareness among nurse respondents indicates an overall positive perception of their cultural competency.
The result of cultural competency in terms of knowledge suggests that, on average, nurses have a reasonable understanding of cultural competency concepts and principles and possess knowledge that allows them to navigate cross-cultural healthcare situations effectively. The result is in agreement with the study of Kavanagh and Szweda (2017), which states that to ensure that fundamental nursing practice is widely practiced in diversified healthcare institutions, the strategic and ethical aspects of ensuring a knowledgeable, competent, and caring workforce with the indicators associated with learning from mistakes and assessing one’s limit of knowledge need to be observed for the nurses to consistently help in providing high-quality healthcare to patients from different cultural backgrounds. Overall, the self- assessment of cultural competency knowledge among nurse respondents indicates an overall positive perception of their knowledge in this domain. While the nurse respondents rated themselves as "Pretty Well" in most indicators, there is still room for improvement, particularly in areas related to understanding the historical experiences of marginalized groups and the broader impact of social biases. According to a study by Soriano, Aranas, and Tejada (2019), to prevent cultural stigma, holistic care provides a guiding framework for nurses’ caring behavior toward their patients. It acknowledges an individual’s cultural knowledge by acknowledging the completeness and relationship between a person's biological, social, spiritual, and psychological aspects that employ a variety of strategies, including nurse-patient interaction, self-help, higher learning, and therapeutic management.
The result of the self-assessment of cultural competency skills among nurse respondents indicates an overall positive perception of their skills in this domain. The scores suggest that the nurse respondents feel highly skilled in adapting to diverse situations, practicing culturally appropriate protocols, acting as allies for marginalized groups, and being flexible and adaptive in cross-cultural encounters. They also demonstrate a strong ability to recognize their own cultural biases and appreciate the diversity within different cultural groups. The statement was further supported by the study of Irandoost et al. (2022) where nurses took steps to increase their tolerance threshold or adapt better to new situations, such as participating in religious- spiritual activities. The nurses also tried to make the workplace more empathic, spiritualize their work, try to get the support of their families, and strengthen their sense of self-worth and responsibility. Nurses with a strong ability to recognize their own cultural biases and appreciate the diversity within different cultural groups are better equipped to deliver culturally competent care. According to Campinha-Bacote’s Process of Cultural Competency and Model of Care (2002), cultural competency is an “ongoing process of being and becoming, an ongoing effort to develop the ability to provide excellent patient care and require health care providers to see themselves as becoming culturally competent rather than already being culturally competent”. By strengthening practical training, promoting a proactive learning mindset, and creating supportive environments, nurses can further enhance their ability to provide culturally sensitive and inclusive care to diverse patient populations.
As to the quality of care given by nurses based on patient respondents, the result suggests satisfaction with the overall care given by nurses. In the study of Karaca and Durna (2019), information played an important role in patients’ satisfaction and thus suggested that information provided by the nurses should be clear and concise, as it is a crucial nurse responsibility that they should provide complete and relevant information to patients. Moreover, as stated by Kwame and Petrucka (2021), effective communication is an essential factor in nurse-patient interactions and a core component of nursing care. When communication in the nurse-patient dyad is patient-centered, it becomes therapeutic. It allows for trust and mutual respect in the care process, thereby promoting care practices that address patients’ individually unique needs. By actively addressing patient feedback and striving for excellence, healthcare providers can further enhance the patient experience and ensure the delivery of high-quality nursing care. However, negative results of patient satisfaction, as stated in the study by Hermann, Long, and Trotta (2019), were associated with not informing patients or families of the plan of care, not recognizing patient opinions, and nurses not providing clear instructions to patients; therefore, this magnifies the importance of interpersonal communication skills among nurses. The high ratings in overall perceptions of care quality and nursing care reflect positive patient experiences and satisfaction, which can contribute to a positive reputation for the hospital. Additionally, patients' likelihood to recommend the hospital to family and friends is a crucial factor in building trust and attracting future patients.
The significant difference suggests that there is a discrepancy between the overall cultural competence of nurses and the quality of care perceived by patients. It suggests that, in accordance with how the patients perceive them, nurses with varying levels of cultural competence tend to provide care of varying quality. These findings have important implications for nursing practice and patient outcomes. They emphasize the significance of developing and promoting cultural competence among nurses to enhance the quality of care delivered to patients from diverse backgrounds. Cultural Competence training for nursing practitioners can increase patient satisfaction. In the study of Debiasi and Selleck (2017), there is a noticeably higher percentage of nursing practitioners documenting cultural assessment and a significantly lower percentage of stereotyping. The study by Liu et al. (2022) suggests that providing learning and training opportunities can improve cultural competence, and therefore, nurses can give better culturally appropriate care.
CONCLUSION
Therefore, the null hypothesis was rejected, indicating a significant difference between the cultural competence of nurses and the quality of care perceived by the patients. When nurses are culturally competent in rendering care to their patients, they generally meet patients' expectations and demonstrate competence, attentiveness, and effective communication with patients of different cultural backgrounds, providing them with exceedingly high-quality care.
For the future direction of this study, it is recommended that the number of respondents be increased and include private hospitals. It is also recommended to include qualitative research to explore the experiences of nurses and patients.
Conflict of Interest
The authors declare that they have no competing interests.
ACKNOWLEDGEMENT
The authors are sincerely grateful to the nursing administrators of the public hospital where this study was conducted.
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