Measuring Cultural Awareness in NursingStudentsLynn Rew, EdD, RNC, HNC, FAAN; Heather Becker, PhD; Jeff Cookston, PhD;Sihlirin Khosropour, PhD; and Stephanie Martinez, MSN, RN

ABSTRACT

Recognizing the need for a valid and reliable way tomeasure outcomes of a program to promote multiculturalawareness among nursing faculty and students, theauthors developed a cultural awareness scale. In the firstphase of the study, a scale consisting of 37 items was gen-erated from a literature review on cultural awareness,sensitivity, and competence in nursing. A Cronbach'salpha reliability coefficient of .91 was obtained from asample of 72 student nurses. In the second phase, theitems were presented to a panel of experts in nursing andculture to determine content validity. A content validityindex of .88 was calculated, and the total number of itemson the scale was reduced to 36. The scale then was admin-istered to 118 nursing students. Data from the two sam-

Received: August 14, 2000Accepted: July 24, 2001Dr. Rew is Professor and Graduate Advisor, and Dr. Becker is

Research Scientist, School of Nursing, The University of Texas atAustin, Dr. Khosropour is Associate Professor of Psychology, AustinCommunity College, and Ms. Martinez is a staff nurse, Austin StateHospital, Austin, Texas; and Dr. Cookston is Assistant Professor ofPsychology, San Francisco State University, San Francisco,California.

This project was supported by grant #1-D19-NU40157-01, award-ed to Dr. Lynn Rew, from the Nursing Division of the U.S.Department of Health and Human Services. A version of this articlewas presented at the 1998 annual meeting of the AmericanEducational Research Association.

Address correspondence to Lynn Rew, EdD, RNC, HNC, FAAN,Professor and Graduate Advisor, School of Nursing, The Universityof Texas at Austin, 1700 Red River, Austin, TX 78701-1499; e-mall:ellerew @ mail.utexas.edu.

ples then were combired, and factor analysis was con-ducted to support construct validity. Cronbach's alpha forthe combined samples was .82.

T o meet the health care needs of a multicultural pop-ulation, the nursing discipline must educate indi-viduals from diverse cultural and ethnic back-

grounds. The American Association of Colleges of Nursing(AACN) issued a position statement in 1997 regardingissues of diversity in nursing and nursing education. TheAACN (1997) stated that, due to anticipation of anincreasingly more diverse population in the next century,issues related to cultural diversity have become more cen-tral to nursing education. Nursing faculty have an oblig-ation to prepare graduates who are aware of and sensitiveto cultural issues (Capers, 1992; Chrisman, 1998). A vari-ety of innovative approaches to teaching cultural diversi-ty have been described in the literature and range fromentire courses devoted to cultural issues (Lockhart &Resick, 1997) to the introduction of a virtual classroom(Jackson, Yorker, & Mitchein, 1996). Other approacheshave used Internet assignments (Kirkpatrick, Brown, &Atkins, 1998) and non-nursing literature (Bartol &Richardson, 1998).

The concept of cultural competence has appeared inthe nursing literature more frequently in the past 5 yearsthan ever before and has been defined by the AmericanAcademy of Nursing (Lenburg et al., 1995) as "a complexintegration of knowledge, attitudes, and skills thiatenhances cross-cultural communication and appropriateeffective interactions with others" (p. 35). Cultural com-petence has been identified as a critical component ofnursing research (Campinha-Bacote & Padgett, 1995),counseling (Pope-Davis, Eliason, & Ottavi, 1994), andcontinuing nursing education (Campinha-Bacote, 1999).Despite the increased attention to the development of cul-

June 2003, Vol. 42, No. 6 ,249

MEASURING CULtURUL A'NAWRENESS

turally competent nurses through basic and continuingeducation, little evidence exists regarding objective or for-mal evaluationis of these programs. This miay be due, inpart, to ambiguity of terms, such as cultural sensitivity,mnulticulltural awareness, and cultural competence, or thelack of psychometrically sound instrunments developedspecifically for such evaluations. A valid assessment toolcan help indiviiduals idenItify their feelings about culturaldiversity, which is prerequisite to deeper understandingof the phenomenon (Randall, 1994).

With a program grant titled, "Pathways for Studentswith Disadvantaged Backgrounds," funded by theNursing Division of the U.S. Departmenit of Health andHuman Services, faculty at The University of Texas atAustin foeused on increasing their own and their stu-den-ts' awareness of multicultural diversity and its rela-tionship to health care. A Pathways Model (Rew, 1996)was developed to focus on the interaction between nurs-ing faculty and students from a variety of backgrounds,including students who were educatioinally or economical-ly disadvantaged. Using an ecological perspective and atravel metaphor, the Pathways. Model (Rew, 1996, pp.311-312) contained three major concepts:

" "Diversity of roads traveled by students enteringthe learning environment. "

' "A learning landscape that contains a wide varietyof signs, maps, tour guides, an-d other resources..."

X "Unique self-built pathways leading the studentinto the world of professional nursinig practice."'1) ensure there was a valid measure of program out-comes, the Cultural Awareness Scale (CAS) was devel-oped for use by nursinig faculty and students. This articledescribes the process of developinig and testing the scale.

BACKGROUND

Clinton (1996) defined culture as that which helpsindividuals adapt to their environnments. Cultural aware-ness, sensitivity, and competence are concepts with defin-itions that are still evolving. Often, these termas are usedinterchangeably to refer to the same constru-ct. In somecases, their definitions are im-plied, rather than explicitlystated. As more accreditation and other state agenciesestablish and att;empt to enforce cultural competenceguidelines (Lester, 1998), the terms cultural awareness,cultural sensitivity, and cultural competence increasinglyare used or perceived as buzzwords. However, it is impor-tant not to allow these constructs to be dismissed asanother set of new "politically correct" terms whose rele-vance will pass in time.

In her discussion of a college-level course on culturaldiversity for nurses, Clinton (1996) identified culturalawareness and sensitivity as two components of culturalcompetency. When individuals are conscious that peopleare different from one another, partly because of their cul-tural backgrounds, they are culturally aware (i.e., con-scious of culture as a contributing factor to all people'spersonalities, attitudes, and behaviors). When individu-

a's value and respect these cultural differences, they aresaid to be culturally sensitive. A perception of culturalinsensitivity and incompetence in the health care systemcan generate barriers to seeking health care, in additionto creating uncomfortable experiences. Culturally comrpe-tent individuals are not only aware of differences in peo-ple based on knowledge of their cultures but respect imidi-viduals from different cultures and value diversity(Sodowsky, Taffe, Gutkin, & Wise, 1994). Developing cul-tural comiipeterLce is a process of learning to work withpeople from diverse cultural backgrounds, using interper-sonal com-munication, relationship skills, and behavioralflexibility (Lester, 1998).

Therefore, cultural comnpetence can be conceptualizedas consisting of four conmponents:

e Cultuiral awareness (i.e., the affective dimension),Cultural sensitivity (i.e., the attitudinal dimension.

* Cultural knowledge (i.e., the cognitive dimension).e Cultuiral skills (i.e., the behavioral dimension).

Each of these components of cultural competence should.be addressed in nursing classroomis, clinical practice, andr esearch.

Cultural Competence in Nursing ClassroomsThe task of delivering culturally competent education

belongs to faculty. It begins with faculty members' aware-ness of bow their own cultures affect different aspects oftheir lives (Schmitz, Paul, & Greenberg, 1992).Marchesani and Adams (1992) also acknowledged the roleof instructors' awareness of their cultural selves as one offour dimensions of teaching related to cultural diversity:

e Awareness of th-ie role one's cultural background andexperiences play in forming beliefs, attitudes, and behav-iors.

e Knowledge and understanding of how studentsfrom different cultural or ethnic backgrounds may experi-ence the classroom differently.

a Incorporation Of di-verse cultural and social perspec-tives in the curriculum..

e Use of a variety of teaching met:hods to rmore effec-tively accommodate learning styles of students from dif-ferent backgrounds.

Hardiman and Jackson (1992) stressecd the importanceof faculty members knowing their students and theirneeds. They asserted that it is faculty's responsibility tounderstand the stages students go through in developingtheir own racial identities so faculty can become facilitators in this process. It may be that until a certain stage isreached in the development of their own cultural identi-ties, students will not be ready to assimilate irformationabout people from diverse cultures. Redican, Stewart,Johnson. and Frazee (1994) argued that cultural aware-ness and sensitivity affect not only the way health careinformation is delivered but a] so how students are able tointernalize the information.

Assum-ning the best case scenario-tthat all faculty incharge of nursing education somehow become proficientin discussing issues related to cultural sensitivity-their

Journal of Nursing Education250

REW ET AL.

effectiveness still will rely, in part, on students' culturalbackground and diferences in learning styles.McCaughrin (1995) found that different ethnic and racialgroups of college students had diverse preferences forreceiving health-related information from various typesof media (e.g., African American students chose televi-SioII, while Latino students chose newspapers and maga-zines, as their least preferred method of receiving infor-mation about sexually transmitted diseases).

Cultural Competence in Clinical Practice andResearch

Beyond the classroom, in which faculty demonstratetheir cultuiral competence by helping students developcultural awareness and sensitivity, faculty members canfacilitate students' development of cultural competence inclinical nursing practice and research (Campinha-Bacote& Padgett, 1995; Porter & Villarruel, 1993). Measuringoutcomes of educational and research efforts related tocultural competence have been hampered by a lack ofvalid instruments to measure awareness, sensitivity, andcompetence.

Taking a general approach to the topic, Bernal andFroman (1987) developed a 30-item scale to measure com-munity health nurses' degree of confidence (i.e., self-effi-cacy) in providing care for African American, PuertoRican, and Southeast Asian individuals. Based onBandura's (1977) social learning theory, Bernal andFroman (01987) derived iterms from transcuitural nursingand anthropological literature and presented the items toan expert panel for content validity. They administeredthe survey to 190 commulnity health nurses and found thescale to be reliable, wvith an internal consistency estimateof .97. Howeever, they also found that the nurses in theirsa-nple did not feel confident in their abilities to provideculturally competent care to these three cultural groups.Similarly, Alpers and Zoucha (1996) used the CulturalSelf-Efficacy Scale, developed by Bernal and Froman(1987), in a small study of senior nursing students at aprivate university and found that students who receivedsome content on culture felt less confident in providingculturally competent care than those who received nosuch contenit.

To measure cultural competence of nursing students inclinrical practice, Pope-Davis et al. (1994) adapted theMulticultural Couniseling Inventor-y (Sodowsky et al.,1994) and administered the adapted scale to 120 under-graduate nursing students. Their results indicated thatstudents with more work experience had higher scores ongeneral interpersonal skills and knowledge of the role ofcultural factors. EIowever, the scores of these more expe-rienced students did not differ significantly from those ofother students on measures of cultural awareness andrelationships, wvhich was defined as interaction withminority patients.

Warda (1997) developed and tested an 18-item scalespecifically to measure components of culturally compe-tent care for Mexican Americans. The instrument has

some evidence of construct validity and internal consis-tency but requires further psychometric evaluation, Inaddition, it is limited in its focus only on care for MexicanAmericans.

The Cultural Awareness Survey, developed byMotwani, Hodge, and Crampton (1995), was designed toelicit institutions' ways of addressing cultural diversity.The instrument is a survey that can be used by employeesin var-ious positions within a health care institution andmeasures employees' experiences of culture shock andperceptions of respect for diversity within the work enivi-ronment.

Each of these instruments measures a different aspectof cultural competence, and the findings from the studiiesthat ha-ve used them exemplify a common and familiarpicture-merely raising individuals' conscious awarernessof cultural diversity does not ensure cultural competenceoccurs. Meleis (1996) proposed that more research isneeded to establish the knowledge base for providing cul-turally competent nursing care. To that end, she arguedthat, at a minimurn, nurses need more knowledge abouit avariety of populations, culture-specific nursing phenomne-na (e.g., social support), and human responses to diversi-ty, vulner ibility, transitions, and marginalization (Meleis,1996). Meleis (1996) emphasized the importance of study-ing not only the cultural heritage of diverse nursingpatients but how this heritage may have "been used tomarginalize people and deprive them of fair and equitableaccess to health care" (p. 14). However, before nurses -canconduct such research, they first must demonstrate cul-tural awareness, sensitivity, and a miniimal degree of cul-tural competence.

DEVELOPMENT OF THE CULTURALAWARENESS SCALE

From a literature review on cultural awareness, cul-tural sensitivity, cultural competence, nursing clinicalpractice, and nursing education, five key categories wereidentified to reflect the multidimensional nature of cul-tural awareness. These categories then were used as ablueprint to develop a scale to measure cultural aWnLre-ness in nursing students. The original scale contained 37items using a 7-point Likert response format, rangingfrom, strongly disagree (1) to strongly agree (7). Table 1summarizes the names of the categories and the numberof items representing each category on the total scale.

Phase OneParticipants and Procedure, Following approval by the

Departmental Review Committee for the protection- ofhuman subjects, a pilot version of the scale was adminis-tered to students who agreed to participate in a focusgroup. These participants helped the researchers clarifyambiguous items and develop a scale that accurately rep-resented the students' experiences. Seventy-two studentsfrom one nursing school participated in the first phase ofthe study. ll responses were voluntary and anonymoLus.

June 2003, Vol. 42, No. 6 :1251

MEASURING CLTLTURAL. WARENESS

TABLE 1Initial Categories for Cultural Awareness Scale

Category No. of Items

General educational experiences 4

Awareness of attitudes 8

Classroom and clinical instruction 16

Research issues 4

Clinical practice 5

Student participants were undergraduate and gradu-ate nursing students at The University of Texas at Austin,I'venty-six were bachelor of science in nursing students(BS1N), 26 were in the master's of science il nursing pro-gram (MSN), 13 were pursuing a PhD in nursing, and 7were in the RN-to-BSN program. Sixty-two participantswere women, and 10 were men. The sample representedmany ethnic groups and included 52 European American,7 Asian Amierican, 6 African Amrerican, 6 HispanicAmerican, and I American Indian students. Studentswere asked to voluntarily complete the survey at the endof a regularly scheduled class period.

Findings. The internal consistency estimate of reliabil-ity for the total scale was .91 for students and .82 for fac-ulty. Cronbach's alpha coefficients for the five categoriesranged from .66 (Awareness of Attitudes) to .88 (ClinicalPractice and Research Issues) for the studenit version,and .56 (Classroom and Clinical Instruction) to .87(General Educational Experiences:) for faculty. Internalconsistei-cies are listed in Table 2.

Phase TwoParticipants a.nd Procedure. After deternmining the

scale's initial reliability, a second phase of study was con-ducted to provide evidence of scale validity. Ten nursingfaculty represenaiting a variety of institutions and ethnicand racial hackgrounds and who had expertise in cultur-al competence were contacted to foFrm an expert panel.Each ficuity member was mailed a copy of the surveyitems with instructions to indicate how relevant eachitem was to the overall construct ard what category labelsshould identify the grouped items, based on the literaturereview. Seven of the faculty mnembers contacted returnedusable data, from which a conternt validity index (CVI) of.88 was calculated, using the method described by Lynn(1986). Six women and 1 man comiprised the expert parel.Four panel members self-identified as White, not ofHispanic origin, 2 self-identified as Asian or PacificIslander, andd 1 self-identified as African Amnerican.

After a slight rewording of a few items and the elimi-.ilation of one, a seconad research proposal was reviewed bythe Departmental Review Committee for the protection ofhuman suibjects. Following approval, the revised scalewas administered to students recruited from variousclasses at The University of Texas at Austin. OCne hundred

TABLE 2Internal Consistency Reliability Estimates for Cultural

Awareness Scale by Category (Phase One)

Category Reliability Estimate

General educational experiences .83

Awareness of attitudes .66

Classroom and clinical instruction .81

Research issues .88

Clinical practice .88

Total scale .91

eighteen usable surveys were returned in this phase. ThePhase One and Phase 'Fvro samples then w ere combinedfor all subsequent analyses.

The 190 students in the combined samples included168 women and 18 men (4 students = missing data).Participants were 76% European American, 110%

Hispanic American, 9%1ei Asian American, 4% AfricaAmerican, and 1% American Indian. Three fourths of theparticipants were BSN students (including RN-to-BSNstudents), 17%. were MSN students, and 8% were pursu-ing a PhD.

Findings. A factor analysis was conducted using prnn-cipal components analysis with varimax rotation (az =159). Five factors, reflecting the categories initially con-ceptualized in Phase One and validated by the expertpanel in Phase Two, emerged. These five faetors account-ed for 51% of the variance in scale scores, and this solu-tion was consistent with the "bend" in the Scree piot.Table 3 shows the factor loadings for the five-factor solu-tion. All items, except item 23, loaded above .30 on theirrespective factors. The first factor contains 14 ite.ms, per-taining to general eduacational experience related to cul-tural awareness and was labeled General EducationalExperience. The second factor contains 7 iteons andaddresses beliefs. It was labeled Cognitive Awareness.The third factor contains 4 items and was labeledResearch Issues. The fourth factor contains 6 items thatrefer to individuals' belh.aviors t.oward and comfort witipeople from different cultural backgrounds. This factorwas labeled Behaviors/Comfort vith Interactions. Thefifth factor contains 5 items related to and labeled PatientCarelClinical Issues.

Although not all items loaded together as initiallydeveloped, the five factors that emerged are consistentwith the initial conceptual developmei t of the CAS. Thesubscales created from these factor loadings were used insubsequent analyses to support coinstruct validity. Table 4displays the average item means and standard deviation.sfor tlhe total scale and each subscale. Sample size variedacross the subscales because individuals with missingdata fcr an item vere eliminated fromn calculation of thatsubscale. Cronbach's alpha coefficients were computed toassess intern-al consistency reliability for the total scale

Journal of Nursing Education252

REW ET AL

TABLE 3Factor Loadings for Cultural Awareness Scale (n = 159)

General Behavlors/Educational Cognitive Research Comfort with Patient Careo

Item Experience Awareness Issues Interactions Clinical Issues_1. The instructors at this nursing school adequately

address multicultural issues in nursing. .7742. This nursing school provides opportunities for

activities related to multicultural affairs. .6373. Since entering this nursing school, my understanding

of multicultural issues has increased. .7574. My experiences at this nursing school have helped

me become knowledgeable about the health problemsassociated with various racial and cultural groups. .705 - -

5. i think my beliefs and attitudes are influenced by myculture. - .843 - -

6. I think my behaviors are influenced by my culture. - .811 - -

7. I often reflect on how culture affects beliefs, attitudes,and behaviors. - .631

8. When I have an opportunity to help someone, I offerassistance less frequently to individuals of certaincultural backgrounds. - - .730

9. 1 am less patient with individuals of certain culturalbackgrounds. - - - .789

10. I feel comfortable working with patients of all ethnicgroups. - - - .535

11. i believe nurses' own cultural beliefs influence theirnursing care decisions. - .678 - -

12. I typically feel somewhat uncomfortable when I am inthe company of people from cultural or ethnicbackgrounds different from my own. - - - .698

13. I have noticed that the instructors at this nursingschool call on students from minority cultural groupswhen issues related to their group come up in class. - - .405

14. During group discussions or exercises, I have noticedthe nursing instructcrs make efforts to ensure nostudent is excluded. .339 -

15. I think students' cultural values influence theirclassroom behaviors (e.g., asking questions,participating in groups, offering comments). - .515 -

16. In my nursing classes, my instructors have engagedin behaviors that may have made students fromcertain cultural backgrounds feel excluded. .413 -

17. I think it is the nursing instructor's responsibility toaccommodate students' diverse learning needs. - 409 - -

18. My instructors at this nursing school seem comfortablediscussing cultural issues in the classroom. .612

19. My nursing instructors seem interested in learning howtheir classroom behaviors may discourage studentsfrom certain cultural or ethnic groups. .469 - - -

20. 1 think the cultural values of the nursing instructorsinfluence their behaviors in the clinical setting. - .454 - -

21. 1 believe the classroom experiences at this nursingschool help students become more comfortableinteracting with people from different cultures. .635 - - -

Jue20,Vl 2 o 5

II

Ii

I

June 2003, Vol. 42, No. 6 '253

MEASURING CULTURAL AWARENESS

TABLE 3 (Continued)

Factor Loadings for Cultural Awareness Scale (n = 159)

General Behaviors/Educational Cognitive Research Comfort with Patient Care/

Item Experience Awareness Issues Interactions Clinical Issues

22. 1 believe some aspects of the classroom environmentat this nursing school may alienate students fromsome cultural backgrounds.

23. 1 feel comfortable discussing cultural issues in theclassroorm.

24. My clinical courses at this nursing school have helpedme become more comfortable interacting with peoplefromn different cultures.

25. 1 feel that the instructors at this nursing schooi respectdifferences in individuals from diverse culturalbackgrounds.

26. The instructors at this nursing school modelbehaviors that are sensitive to multicultural issues.

27. The instructors at this nursing school use exarnplesand/or case studies that incorporate information fromvarious cultural and ethnic groups.

28. The faculty at this nursing school conducts researchthat considers multicultural aspects of health-relatedissues.

29. The students at this nursing school have completedtheses and dissertation studies that consideredcultural differences related to health issues.

30. The researchers at this nursing school considerrelevance of data collection measures for thecultural groups they are studying.

31. The researchers at this nursing school considerculturai issues when interpreting findings in theirstudies.

32. I respect the decisions of my patients when theyare influenced by their culture, even if I disagree.

33. If I need more information about a patient's culture,I would use resources available onsite (e.g., books,videotapes).

34. If I need more information about a patient's culture,I would feel comfortable asking people I work with.

35. if I need more information about a patient's culture,I would feel cormfortable asking the patient or familymember.

36. I fee. somewhat uncomfortable working with thefamilies of patients from cuiltural backgroundsdifferent than my own.

Percentage of variance

.471

.271

.51 i

.722

.669

.805

.894

.947

.935

.713

.722

.755

.755

15.19 9.99 9.68

.601.

8.17 8.09

and each subscale. As shown in Table 4, the Cronbach'salpha for the total scale was .82. Cronbach's alpha coeffi-cients for the subscales ranged from .71l(Behaviors/Ciomfort with Interactions) to .94 (ResearchIssues).

Table 5 shows the intercorrelations amonig the fivesubscales. Although some subscales, such as Cognlitive

Awareness and Patient Care/Clinical Issues, are related,the Behaviors/Comfort with Interactions subscale has lowcorrelations with other subscales (some of which are neg-ative). Note that 5 of the 6 items on theBehaviorsiComfort with Interactions sulbscale are wordednegatively. Perhaps the tendency to answer differently tonegatively, as opposed to positively, worded items con-

Journal of Nursing Education

I

iIi

254

REW ET AL.

TABLE 4Average Items Scores and Cronbach's Alpha Reliabilities for the Cultural Awareness Scale and Subscales

Subscale Mean SD n No. of Items Cronbach's Alpha

General educational experience 5.18 .87 181 14 .85

Cognitive awareness 5.54 .95 184 7 .79

Research issues 4.41 1.61 176 4 .94

Behaviors/comfort with interactions 5.39 .99 180 6 .71

Patient care/clinical issues 5.99 .88 180 5 .77

Total score 5.32 .53 165 36 .82

Note: All items were rated on a 7-point scale ranging from "strongly disagree" to "strongly agree."

TABLE 5Intercorrelations Among Subscales of the Cultural Awareness Scale

Cognitive Research Behaviors/Comfort Patient CaretSubscale Awareness Issues with Interactions Clinical Issues

General educational experience .02 .15 -.03 .16

Cognitive awareness - .20 -.12 .42

Research issues - - .03 .14

Behavior/comfort with interactions - - - .18

tributes to this subscale's lack of relationship with othersubscales.

To support construct validity, demnographic differenceson the total scale and subscales were computed. No sig-nificant gender differences were found. However, ininori-ty students (i.e., all African American, HispanicAmerican, American Indian, and Asian American stu-dents) provided significantly lower ratings on the GeneralEducational Experience subscale (F = 5.79, p < .05, df =1/177). Scores also were compared among students in thefour semesters of the BSN program and among the threetypes of programs (i.e., BSN, MSN, PhD). The only statis-tically significant difference among students in varioussemesters of the BSN program was on Research Issues (F= 3.66, p < .05, df = 3/124). According to post-hoc analyses,there was a linear increase in ratings on this subscalefrom the first to the fourth semester, with a significantdifference between the junior year and the senior year(i.e., when students take a research course)

There also was a statistically significant difference inResearch Issues scores across nursing programs (F = 3.4,p < .05, df = 4/170). PhD students scored highest and BSNstudents lowest on this scale. In addition, a statisticallysignificant difference was observed on the PatientCare/Clinical Issues subscale IF = 3.04, p < .05, d.f =4/175). Traditional MSN students scored significantlylower than all other groups, although this finding shouldbe interpreted with caution because only 7 students com-prised the traditional MVISN group.

One item on the questionnaire asked whether therewas a time when participants felt uncomfortable work-ingwith a patient from a cultural background different thantheir own. The only statistically significant differenricebetween students who indicated they were comfortable (n= 137) and those who were not (n = 43) was observed onthe Behaviors/Comfort with Interactions subscale.Students who indicated they had been uncomfortableworking with a patient from a cultural background difler-ent from their own provided significantly lower ratings onthis subscale (F = 34.35,p < .001, df= 1/175).

DISCUSSION

Findings from this study should be interpreted withcautiorn because of the relatively small number of partici-pants from one geographic area. In addition, the sampleis relatively sma'. for factor analysis. Participants werefrom a single university, and therefore, findings are notgeneralizable to all nursing students. Further develop-ment of the instrument with larger, diverse populations ofstudents is warranted. However, despite these limita-tions, evidence exists that the CAS provides valid aLndreliable scores for measuring the concept of culturalawareness in nursing students.

Data analyses from bothb study phases support the reli-ability of scores obtained from the CAS. Data analyzed inPhase Two support the multidimensional nature of cul-tural awareness. The first subscale (i.e., General

June 2003, Vol. 42, No. 6 ;'55

MEASURING CULTURAL AWARENESS

Educational Experience) indicates the importance of fac-ulty who can model behaviors that are sensitive to multi-cultural issues. In their positions as educators, facultyneed to serve as culturally competent role models toencourage more individuals from ethnic minority groupsto enter the nursing profession. One reason so few mem-bers of ethnic minority groups currently are nurses maybe their perceptions of nursing faculty as racist (Vaughan,1°,97). Data from tools, such as the CAS, may serve thedual purposes of helping faculty become more aware oftheir inadvertent insensitive behaviors that perpetuatethe perception of racism and demonstrating to membersof ethnic minority groups that the nursing educationalsystemn is striving to address issues related to culturalcompetence.

The highest ratings provided by participants were inthe Patient Care/Clinical Issues subscale. Although itmay be encouraging that nurses consider themselves cul-turally aware in treating patients, it would be wise to con-sider the possibility that unmeasured differences in cul-tural awareness may exist between nurses' perceptionsand those of their patients. It would be valuable to mea-sure patients' p,erceptions of their nurses' cultural aware-ness and comipare them to the nurses' ratings.

It is important to note that the variance was highest

and the average item score was lowest for the ResearchIssues subscaie. In addition, there were more missingdata for this subscale, all of which may reflect partici-pants' lack of information on whicb to base their ratings.As analysis of this subscale by educational level indicates,there was a significant difference between BSN and PhDstudents, which rrmost likely reflects differences in theirexposure to research. Because the majority of partici-pa:nts were BSN students, this also could account for thelower average score on this subscale.

Overall, participants in this study had high meanscores on the five dimensions of cultural awareness, asmeasured by the CAS. These scores were obtained follow-ing completion of tie 3-year Pathways program. Althoughno preprogram data exist vith which to compare, it is pos-

sible that cultural awareness am. ong nursing students inthis school did increase with program exposure. Furtherstudy involving preprogram and postprogram mneasuresusing the GAS are warranted.

CONCLUSION

Clearly there is a need to develop culturally comrkpe-tent nurses in the United States. If the goal of nursingeducation is to educate a diverse population of nursesand to teach all nurses culturally competent practices,then monitoring progress toward these goals is neces-sary. The GAS provides a tangible method for document-ing the first stage of nursing students' development ofcultural competence. Based on findings from the initialt vo phases of developnient, the GAS should producevalid an]d reliable data for further study with larger,diverse sainples.

REFERENCES

Alpers, R.R., & ZOUcba, R. (1996). Comparison of cultural com-petence and cultural confideoce osf senio-c nursing students ina private southern university. Journal of Cultural Diversity,3(1), 9-15.

American Association of Colleges of Nursing. (1997). Diversityand equality of opportunity. Retrieved July 15, 2000, fromhttp://www.aacn.nche.edu/Puiblication s/position s/diverse.htm

Bandura, A. (1977). Self-efficacy: Toward a unifying theory ofbehavioral change. Psychology Review, 84, 191-215.

Bartol, G.M., & Richardson, L. (1998). Using literature to createcultural competence. Itmi.age, 30, 75-79.

Bernal, H., & Froman, R. (1987). The confidence of communityhealth nurses in caring for ethnically diverse populations.image, 19, 201-203.

Campinha-Bacote, .J. (1'999). A model and instrument fbraddressing cultural conmpetencee in health care. Journal ofNursing Education, 38, 203-207.

Camnpinha-Bacote, J., & Padgett, J.J. (1995). Cultural conmpe-tence: A critical factor in nursing research. Journal ofCultural Diversity, 2(1), 31-34.

Capers, C.F. (1992). Teaching cultural content: A nursing educa-tion imperative. Hlolistic NAursing Practice, 6(3), 19-28.

Chrisman, N.J. (1998). Faculty infrastructure for cultural com-petence education. Journal of Nursing Education, 37, 45-47.

Clinton, J.F. (1996). Cultural diversity and health care inAmerica: Knowledge fundamental to cultural competence inbaccalaureate nursing students. Journal o;f CulturalDiversity, 3(1), 4-8.

liardiman, R., & Jackson, BAW. (1992, Winter) Racial identitydevelopment: Understanding racial dynamnies in college class-roonms anTd on campus. New Directions for Teaching andLearning, No. 52. 21-37.

Jackson, C., Yorker, B., & Mitchem, P (1996). Teaching culturaldiversity in a virtual classroom. Journal of Child andAdolescent Psychiatric Nutrsing, 9(4), 40-42.

Kirkpatrick, M.K., Brown, S., & Atkins, T. (1998). Electronie edu-cation. Nurse Educator, 23(2), 15-17.

Lenuburg, C.B., Lipson, J.G., Demi, A.S., Blaniey, D.R., Stern, RN.,Schultz, P.R., et al. (1995). Promnotiog cutltural competence irnand througlh nursing education: A critical review and compre-hensive plan fior action. Washington, DC: American Academyof Nursing.

Lester, N. (1998). Cultural competence: A nursing dialogue.American Journal of Nursing, 98(8), 26-33.

Lockhart, J.S., & Resick, L.K. (1997). Teaching cultural compe-tence: The value of experiential learning and communityresources. Nurse Educator, 22(3), 27-3L

Lynn, M.R, (1986). Deternination and quantification of contentvalidity. Nursing Research, 35. 382-385.

Marchesani, L.S., & Adams, M. (1992, Winter). Dynamics ofdiversity in the teaching learning process: A faculty develop-ment model for analysis and action. New Directions fotrTeaching and Learning, No. 52, 9-20.

McCaughrin, W.C. (1995). The importance of mrulticult-Lural vari-ation in plainning college student health programs.Evaluation & The Health Professions, 18, 202-217.

Meleis, A.I. (1996). Culturally competent scholarship: Substanceand rigor. Advances in Nursing Science, 19(2), 1-16.

Motwani, J., Hodge, J., & Crampton, S. (1995). Managing diver-sity in the health care industry: A conceptual model and anempirical investigation. lealth Care Suzpervisor, 13(3), 16-23.

Pope-Davis, D.B., Eliason, M.J., & Ottavi, T.M. (1994). Are nurs-ing students multiculturally competent? An ex,0ploratoryinvestigation. Journal of Nursing Education, 33, 31-33.

Porter, C.P., & Villarruel, A.M. (1993). Nursing research w-ithAfrican American and Hispanic people: Guidelines for action.Nursing Outlook, 41, 59-67.

Randall, I. (1994). Assessing diversity. The Journal of

Journal of Nursing Education2S6

REW E'I' AL.

Multicultural Nursing, 1(1), 23-25.Redican, K., Stewart, S.H., Johnson, L.E., & Frazee, A.M. (1994).

Professional preparation in cultural awareness and sensitivi-ty in health education: A national survey. Journal of HealthEducation, 25, 215-218.

Rew, L. (1996). Affirming cultural diversity: A pathways modelfor nursing faculty. Journal of Nursing Education, 35, 310-314.

Schmitz, B., Paul, S.P, & Greenberg, J.D. (1992, Spring).Creating multicultural classrooms: An experience derived fac-ulty development program. New Directions for Teaching and

Learning, No. 49, 75-87.Sodowsky, G.R., Taffe, R.C., Gutkin., T.B., & Wise, S.L. (1994).

Development of the multicultural counseling inventory: Aself-report measure of multicultural competencies. Journal ofCoun-seling Psychology, 41, 137-148.

Vaughan, J. (1997). Is there really racisrn in nursing? Journal ofNVursing Education, 36, 135-139.

Warda, M.R. (1997). Developmrent of a measure of culturally com-petent care. Unpublished doctoral dissertation, University ofCalifornia at San Francisco.

June 2003, Vol. 42, No. 2257

COPYRIGHT INFORMATION

TITLE: Measuring Cultural Awareness in Nursing StudentsSOURCE: J Nurs Educ 42 no6 Je 2003

WN: 0315202224004

The magazine publisher is the copyright holder of this article and itis reproduced with permission. Further reproduction of this article inviolation of the copyright is prohibited.

Copyright 1982-2003 The H.W. Wilson Company. All rights reserved.