Nurses Cultural Competence in Southwest Ethiopia: A Cross-Sectional Study.

Background: Diversity is a challenge and an opportunity, resulting in a change toward providing services suited to clients' cultural needs and desires. Nurses working with culturally diverse populations face unique challenges because of the coexistence of diverse cultural and ethnic societies. Hence, the study's purpose has been to evaluate the current state of cultural competence and the factors that influence it among nurses in Southwest Ethiopia.
Methods: From December 1 to December 30, 2021, nurses at eight public healthcare facilities in southwest Ethiopia were enrolled in a facility-based cross-sectional study. Participants were selected using a simple random sampling. A self-administered questionnaire was used to collect the data. Epi data 4.1 was used to enter the data, and SPSS version 26 was used for analysis. To identify factors associated with cultural competence, bivariate and multivariable linear regression analyses were performed. The significance level was set at p < 0.05.
Results: Two hundred thirty-seven nurses took part in the study, yielding an 86.1% response rate. The mean age was 28.83 years (standard deviation = ±5.48). The mean cultural competence score among healthcare professionals was 1.95 ± 0.32. Marital status (p < 0.05) and the use of healthcare interpreters (p < 0.05) were significantly associated with cultural competence.
Conclusion: Nurses had a low level of cultural competence. Cultural competence varies according to a number of factors, including marital status and the use of healthcare interpreters. Nurses are better suited to focus on the ethnic diversity of their patients, which necessitates the provision of cultural competence training for nurses.

Background

Diversity is a challenge and an opportunity, resulting in changes in service delivery suited to patients’ cultural requirements and desires.1

Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals to enable them to work effectively in cross-cultural situations.2

Nurse practitioners are at the forefront of providing high-quality care to different ethnicities, and must understand the value of cultural competence when caring for diverse patients.3 Ethiopia is one of the world’s most populous and ethnically diverse countries. It is home to about 86 ethnic groups, each with their own unique linguistic and social rules, ideologies, and religious practices.4 Ethiopia is Africa’s second-largest asylum seeker country, with over 800,000 people displaced from neighboring nations.5

Several studies have found that certain cultural groups are more likely to be underserved, to perceive negative treatment, and to experience disparate treatment outcomes.6,7 Cultural diversity is one of the causes of conflicts between patients and caregivers in nursing. The conflict can be based on a number of themes, such as culturally based needs for patient care participation, cultural communication difficulties, and family needs for self-determination and cultural norms.8 Increased cultural competence among practitioners, on the other hand, has now been related to higher levels of client satisfaction,9 medication compliance10 and decision making.11 Culturally competent care is a useful weapon for eliminating health inequities among people of various cultural origins, races, and ethnicities.12,13

As the world’s population becomes more diverse, the need to address cultural competence becomes more apparent.14 This is particularly important in cases of discriminatory treatment, because the professional’s identity, sexual preference, ethnic background, and sex are frequently exaggerated.15 Medical errors are greatly exacerbated by communication errors caused by linguistic and cultural differences.16

Interactions between societies have become increasingly common as a result of technological advancements.17 As the world continues to evolve and different countries’ populations become more diverse, health professionals’ ability to care for people from all backgrounds has become increasingly important.18 Realizing our expanding global community, numerous sectors and professional societies have been stressed the importance of culturally competent professionals in the current work environment.19

Cultural competencies and capabilities are important aspects of the profession that nurses must possess in order to give the highest level of care.20 Nurses can also help close these discrepancies by respecting their clients’ perceptions.21 On the other hand, providers’ lack of understanding of cultural beliefs and traditions can be an impediment to health-care utilization.22 Despite the fact that Ethiopia is a multicultural society, data on cultural competence among Ethiopian nurses in the research field are scarce. Hence, the study’s purpose has been to evaluate the current state of cultural competence among nurses in Southwest Ethiopia as well as the factors that influence it.

Methods

Study Design, Setting, and Population

In Ethiopia’s Bench Sheko Zone of the Southwest People’s Regional State, a multi-center, institution-based cross-sectional study was conducted. In the Bench Sheko zone, there are two administrative towns, six woredas, two hospitals, 26 health facilities, and 129 care centers. The research was carried out between December 1 and December 30, 2021.

Nurses working in government healthcare institutions in the Bench Sheko Zone were the study’s source population. The study included all nurses working at selected public healthcare facilities, as well as those with more than six months of experience.

Sample Size and Sampling Procedure

G power 3.1 was used to calculate sample size. For the multiple regression analysis, a minimum sample size of 262 participants was necessary (effect size 0.1, significance level 0.05, and power of 0.95). We gathered information from 275 nurses, allowing for a 5% non-response rate.

Eight public health facilities were chosen through a lottery system. The number and list of nurses were obtained from each public health institution’s human resource office. Based on this information, the study population was assigned proportionally to each institution. Consequently, the participants in this study were chosen using simple random selection.

Data Collection Tools and Procedures

A self-administered questionnaire was used to collect the data. Data were collected using the

Inventory for assessing the process of cultural competence among healthcare professionals- Revised (IAPCC-R). It includes 25 items that assess the five cultural constructs of desire, awareness, knowledge, skills, and encounters. The IAPCC-R employs a 4-point likert scale. Higher scores indicate a higher level of cultural competence.23

The second section included socio-demographic information such as age, gender, religion, ethnicity, place of birth, marital status, mother tongue, health facility type, clinical experience, patient care related in-service training, and use of healthcare interpreters. Data were gathered by eight BSc nurses and four Adult health nurse specialists who served as supervisors.

Operational Definition

Cultural competence;

The cultural competency of nurses was assessed using 25 items on a four-point Likert scale ranging from 25 to 100. The nurses’ scores ranged from one to five, with the aggregate mean score divided by 25.23

On the basis of this score, the cultural competence level was classified as low, moderate, or high.

A low level was defined as a mean score between 1 and 2.33, a moderate level as a mean score between 2.34 and 3.67, and a high level as a mean score between 3.68 and 5.24

Data Processing and Analysis

Epi data 4.1 was used to enter the data, and SPSS version 26 was used for analysis. To summarize the data, descriptive statistics such as frequency, percentage, standard deviation, and mean have been used. The link between cultural competency and the explanatory variables was first investigated using bivariate linear regression. Candidates for multivariable linear regression were variables with a p-value of less than 0.25 in bivariate linear regression. A multivariable regression analysis was applied to adjust for possible confounders. The statistical significance level was set at P<0.05. Before the data were evaluated, the linear regression assumptions were tested. The Kolmogorov–Smirnov test validated the normality assumption. The variance inflation factor (VIF) was used to test the collinearity assumption and determine the correlation between the independent variables. According to the findings, all variables had a VIF of less than 5.

Results

Socio-Demographic Characteristics

The questionnaires were completed by 237 of the 275 invited participants, yielding an 86.1% response rate. The average age was 28.83 years (SD =±5.48 years). One hundred thirty-six (57.4%) were male and 111 (46.8%) were Orthodox. Amharic was the primary language used in one-third (35.4%) of them. Most participants (71.7%) worked in hospitals. Most nurses (80.6%) received patient-related in-service training (Table 1).

Table 1

Socio-Demographic Characteristics of Nurses at Selected Public Health Institutions in Southwest Ethiopia, 2021

Variables	Categories	Frequency	Percentage
Age (years)	<25	48	20.3
M=28.83 years	25–29	108	45.6
SD=5.48 years	30–34	46	19.4
	≥35	35	14.8
Sex	Male	136	57.4
	Female	101	42.6
Religion	Orthodox	111	46.8
	Muslim	38	16.0
	Protestant	88	37.1
Ethnicity	Amhara	72	30.4
	Bench	75	31.6
	Sheko	34	14.3
	Oromo	32	13.5
	Others	24	10.1
Place of birth	Urban	139	58.6
	Rural	98	41.4
Marital Status	Single	80	33.8
	Married	157	66.2
Primary language	Amharic	84	35.4
	Benchigna	73	30.8
	Shekogna	33	13.9
	Others	47	19.8
Health facility type	Health Center	67	28.3
	Hospital	170	71.7
Clinical experience in years	<5	132	55.7
	5–10	80	33.8
	>10	25	10.5
Patient care related in-service training	Yes	191	80.6
	No	46	19.4
Healthcare interpreter utilization	Yes	165	69.6
	No	72	30.4

Abbreviations: M, Mean; SD, Standard Deviation.

The Level of Cultural Competence

The means and standard deviations of the cultural competence levels were calculated. The average IAPCC-R result was 1.95 (SD =±0.32) out of a possible total of 5 points, indicating a low level of cultural competence. On the cultural knowledge scale, 2.01 (SD±0.52), the highest mean score was found. On the cultural awareness scale, the lowest mean score was 1.87 (SD±0.46). The study’s findings indicate that the participants considered themselves culturally inept (Table 2). For each item the highest mean was 2.11 ± 0.83 which related to the “I am aware of the cultural limitations of existing assessment tools that are used with ethnic groups” followed by 2.1 ± 0.84 which is related to the “I am aware of some of the stereotyping attitudes, preconceived notions and feelings that I have toward members of other ethnic/cultural groups”, while the lowest mean was 1.79 ± 0.63 which related to the “I feel that cultural competence is an ongoing process”, followed by 1.81 ± 0.64 which is related to the “Cultural competence mainly refers to one’s competency concerning different ethnic groups”.

Table 2

The Level of Cultural Competence Among Nurses in Southwest Ethiopia, 2021

Variables	Possible Score	Mean (SD)	Minimum	Maximum
Cultural awareness scale	1–5	1.87(SD±0.46)	1.00	3.4
Cultural knowledge scale	1–5	2.01(SD±0.52)	1.00	3.8
Cultural skill scale	1–5	1.98(SD±0.49)	1.00	3.6
Cultural encounter scale	1–5	1.99(SD±0.49)	1.00	3.4
Cultural desire scale	1–5	1.90(SD±0.52)	1.00	3.4
Total IAPCC-R score	1–5	1.95(SD±0.32)	1.04	2.84

Abbreviation: IAPCC-R, Inventory for assessing the process of cultural competence among healthcare professionals- Revised.

Factors Associated with Cultural Competence Among Nurses

Multivariable linear regression analyses revealed factors associated with cultural competencies among healthcare professionals. In a bivariate linear regression, age, place of birth, marital status, clinical experience, and the use of healthcare interpreters were found to be substantially associated with cultural competency among healthcare workers at p<0.25. To investigate the factors related to cultural competency, all independent variables with p<0.25 in the bivariate linear regression analysis were added to the multivariable linear regression analysis. At a significance level of 0.05, the backward elimination approach was used to select the variables for the final model.

The findings revealed that marital status and use of healthcare interpreters were significantly associated with cultural competence among nurses. Accordingly, single nurses showed an increase in cultural competence by 0.16 (β =0.16, p=0.001) compared with married nurses. Those who had used interpreters showed an increase in cultural competence by 0.13 (β =0.13, p=0.005) compared with those who had not used interpreters (Table 3).

Table 3

Multivariable Linear Regression Analysis of Cultural Competence Among Nurses at Selected Public Health Institutions in Southwest Ethiopia, 2021

Predictor Variables	Unstandardized Coefficients		P-value	95% CI
	β	SE		Upper	Lower
Age (in years)	−0.003	0.007	0.601	−0.017	0.010
Place of birth
Urban (Ref)	–	–	–	–	–
Rural	−0.061	0.042	0.150	−0.144	0.022
Marital status
Single	0.160	0.047	0.001*	0.067	0.252
Married (Ref)	–	–	–	–	–
Clinical Experience	0.003	0.008	0.673	−0.012	0.019
Interpreter
Utilization
Yes	0.130	0.045	0.005*	0.041	0.220
No (Ref)	–	–	–	–	–

Note: *=p<0.05.

Abbreviations: β, Beta; SE, Standard Error; CI, Confidence Interval.

Discussion

This study assessed the current state of cultural competence and its associated factors among nurses. According to the findings, the mean score for a nurse’s cultural competence was 1.95. This outcome is similar to that of a study of Ethiopian nurses in tertiary hospitals, which found that participants’ overall cultural competence level was low to moderate (1.94 ± 0.65), with the highest mean being scored for cultural sensitivity (2.54 ± 0.69) and the lowest mean being scored for cultural skill (1.62 ± 0.98).25

The finding was lower when compared to a study conducted in South Korea26 and Ethiopia27 among nurses with a total mean of 3.07 and 3.39 respectively. The average cultural competence score among the Korean nurses was 36.84 (SD = 3.61), with an item mean of 3.07 (SD = 0.30). Similarly, Ethiopian nurses’ overall cultural competence mean score was 3.39 (SD =0.61) on a scale of 1 to 5, indicating a moderate level of cultural competence. It’s possible that this is due to differences in sample size and research area. The study conducted in Korea included 143 rural nurses whereas that conducted in Ethiopia included 543 nurses. This difference in sample size may have affected the data precision. Furthermore, the low cultural competence of nurses in southwest Ethiopia may be attributed to participants’ lack of education and competency Training.

Another notable element of the research was the identification of cultural competence-related characteristics. As a corollary, marital status and use of healthcare interpreters were found to be related to cultural competency.

According to the findings of this study, being single predicts greater cultural competence than being married. This result is consistent with the results of a Turkish study of nurses and physicians, which found that single doctors and nurses performed better than married healthcare professionals.28 A possible reason for this might be that the responsibility of the family may affect feelings towards diverse communities.

The current study’s findings also show that using a healthcare interpreter improves cultural competence. This is consistent with studies from Israel and Ethiopia, which found that the availability of interpreter services was significantly related to cultural competence.1,25 In the current study, 69.6% of the participants used healthcare interpreters. Similarly, a study conducted in tertiary hospitals, Ethiopia, revealed that respondents who used a translator for a language in which they were not fluent outperformed those who did not, and 42% of respondents used translators for languages in which they were not proficient, did not use qualified translators.25 One reason could be that conversing with clients in their native tongue enhances their adherence to and knowledge of the ailment.29

There are some limitations to this study. The study used self-reported data from nurses, which could have resulted in social desirability bias. The findings may not be generalizable to other public health institutions and private clinics in Ethiopia because the study was limited to eight public health institutions in southwest Ethiopia. Because the study was cross-sectional, causality could not be determined.

Conclusions

Nurses’ cultural competence was poor. According to the findings of this study, cultural competency differs depending on marital status and the use of healthcare interpreters. The findings of this study encourage Ethiopian nursing curriculum developers to include cultural competence in their current curricula, as well as the necessity for cultural competency training for nurses. Future researchers, including nurses working in private clinics, should conduct additional research. To determine cause and effect relationships, a large sample size longitudinal study is required. Ultimately, this study contributes to our understanding of the benchmark levels of the various constructs of cultural competence. These findings suggest that our measures have potential for future use as the field seeks to implement necessary cultural competence training and, with it, the evaluation of training efforts.