Improving the Cultural Competence of
Nursing Students: Results of Integrating
Cultural Content in the Curriculum and an
International Immersion Experience
Rosalie A. Caffrey, PhD; Wendy Neander, MN; Donna Markle, MS; and
Barbara Stewart, PhD
ABSTRACT
The purposes of this study were to evaluate the effect
of integrating cultural content (ICC) in an undergraduate
nursing curriculum on students’ self-perceived cultural
competence, and to determine whether a 5-week clinical
immersion in international nursing (ICC Plus) had any
additional effect on students’ self-perceived cultural com-
petence. Cultural competence was measured using a 28-
item scale regarding students’ self-perceived knowledge,
self-awareness, and comfort with skills of cultural com-
petence. Pretest scores from admission into the program
were matched with posttest scores obtained just prior to
graduation for 32 students, 7 of whom also participated
in a 5-week immersion experience in Guatemala. Results,
expressed in effect sizes, showed small to moderate gains
for the 25 students in the ICC group, and very large gains
for the 7 students in the ICC Plus group, related to per-
ceived cultural competence. These results are consistent
with the two-phase (cognitive and affective) development
of cultural competence proposed by Wells.
I
ntegration of cultural content into nursing education-
al programs has been a goal advocated by a number of
nursing education organizations. The National League
Received: August 26, 2003
Accepted: July 14, 2004
Dr. Caffrey is Professor Emerita, Ms. Neander is Assistant Pro-
fessor, and Ms. Markle is Associate Professor, Oregon Health &
Science University, School of Nursing, Ashland, and Dr. Stewart is
Professor Emerita, Oregon Health & Science University, School of
Nursing, Portland, Oregon.
Address correspondence to Rosalie A. Caffrey, PhD, Professor
Emerita, Oregon Health & Science University, School of Nursing, 1250
Siskiyou Boulevard, Ashland, OR 97520; e-mail: caffreyr@ohsu.edu.
234
JNE0505CAFFREY.indd 234
for Nursing has required that cultural content be included
in nursing curricula since 1977, and accreditation criteria
reflect this requirement (Poss, 1999). The American Acad-
emy of Nursing (1995), the American Association of Col-
leges of Nursing (1998), and the Pew Health Professions
Commission (1995) have all published vision statements
and recommendations for the inclusion of cultural content
in nursing and other health care provider educational pro-
grams.
However, cultural competence as an educational out-
come has been difficult to assess. As the U.S. population
continues to grow and become more culturally diverse,
cultural competence has emerged as a critical element of
professional nursing practice. A concern, then, is whether
nursing education is meeting the need for preparing cul-
turally competent nurses.
How does one become culturally competent? Wells
(2000) proposed a model that incorporates two phases—
the cognitive (acquisition of knowledge) and the affective
(attitudinal and behavioral changes)—in the development
of cultural competence. The cognitive phase is character-
ized by transitioning from cultural incompetence (lack
of knowledge) to cultural knowledge, and then cultural
awareness. The affective phase builds on the cognitive
phase and includes the development of cultural sensitiv-
ity, cultural competence, and finally cultural proficiency.
The affective phase “requires actual experience working
with diverse groups” (Wells, 2000, p. 193).
Cultural competence, then, is an ongoing process requir-
ing more than formal knowledge. Values and attitudes are
the foundation for a commitment to providing culturally
competent care, and their development requires experi-
ences with culturally diverse individuals and communities.
St. Clair and McKenry (1999) do not believe cultural com-
petence can be achieved without living in another culture,
even if only for a short period of time. Students have lim-
ited ability to grasp and overcome their own ethnocentrism
Journal of Nursing Education
4/22/2005 8:11:16 AM

without an opportunity to actually live in another culture.
Since this is not always feasible for all students, how can
cultural competence be included in the educational experi-
ence? What level of cultural competence should be expected
of new nursing graduates? What is the added value of an
immersion experience in international nursing?
Evaluation of the effectiveness of the educational pro-
cess on the development of cultural competence in new
graduates is needed to provide guidance in curriculum de-
velopment. Students’ self-perceived knowledge, attitudes,
and skills can provide a measure of their comfort with
their learning related to cultural competence and can pro-
vide a proxy measure of their commitment to the ongoing
process of becoming culturally competent practitioners.
This study was designed to accomplish two objectives:
● Evaluate the effect of integrating cultural content
(ICC) in an undergraduate nursing curriculum on stu-
dents’ self-perceived cultural competence.
● Determine whether a 5-week clinical immersion in
international nursing (ICC Plus) had any additional effect
on students’ self-perceived cultural competence.
METHOD
Design
We used a two-group, pretest-posttest, quasi-experi-
mental design to compare students in the ICC group (n
= 25) and students in the ICC Plus group (n = 7) on per-
ceived cultural competence.
Sample
The sample consisted of 32 nursing students in a bacca-
laureate nursing program at a university in southern Ore-
gon. These students were admitted as juniors in 2000 and
graduated in 2002. Five students identified themselves as
at least partially from a different ethnic group than Eu-
ropean American. The group contained no male students.
Of the 10 students who applied to travel to Guatemala
for a 5-week clinical immersion the last term of their se-
nior year (ICC Plus), 7 were selected. Selection criteria
included the student’s interest, the faculty’s assessment of
the student’s ability to work in groups, an acceptable aca-
demic standing, and acceptable clinical performance eval-
uations. The 25 students in the ICC group continued with
traditional senior-year clinical assignments. The students
ranged in age from 20 to 44. The mean age of the students
in the ICC Plus group (mean age = 25.3, SD = 8.7) was not
statistically different from that of the students in the ICC
group (mean age = 25.6, SD = 6.5).
Independent Variable
The independent variable included two components:
the integration of cultural content into the undergraduate
nursing curriculum (ICC), and a 5-week clinical immer-
sion in international nursing (ICC Plus).
ICC. Southern Oregon is limited in culturally diverse
populations, thus limiting students’ exposure to culturally
diverse clients within this region. Therefore, the faculty
May 2005, Vol. 44, No. 5
JNE0505CAFFREY.indd 235
CAFFREY ET AL.
made a concerted effort to incorporate cultural concepts
into course materials. This included obtaining a Fund for
the Improvement of Higher Education (FIPSE) 3-year
North American Mobility Grant for an international ex-
change program involving two schools each in Canada,
Mexico, and the United States. In addition, new faculty
members with experiences in international and cross-cul-
tural nursing were hired. Student learning experiences
with Hispanic populations were expanded. More content
in the form of multicultural case studies was introduced
into the ongoing courses.
ICC Plus. This experience was a partnership with Pueb-
lo Partisans, a Canadian and U.S. nongovernmental orga-
nization, recognized by the Guatemalan government as
providing international assistance in the areas of health,
agriculture, literacy, and economic development. The goal
of the 5-week, 200-hour experience was the preparation of
nursing professionals who were capable of collaborating
with and supporting a culture to promote its own health.
The 7 students participating in ICC Plus during the last
term of their senior year worked with community-directed
initiatives for health promotion and illness prevention
across the lifespan and with general medical clinics.
Students worked in teams of 2 or 3. The clinics were
large, with 40 to 60 clients on average. Some clients
walked for up to 3 hours to reach the clinic and waited
all day just to see a nurse or other health care provider.
Experienced health professionals, including Guatemalan
health professionals, worked with students in the clinics.
Students were also exposed to and, in certain clinical set-
tings, worked with traditional healers.
Instrument
The Caffrey Cultural Competence in Healthcare Scale
(CCCHS) was developed based on the cultural competencies
we expected from our students on completion of our bac-
calaureate nursing program. It was initially developed to
evaluate the outcomes of the FIPSE grant. The model used
in constructing the items was a rating scale of respondents’
self-perceived knowledge, self-awareness, and comfort with
skills of cultural competence. The statements were generic
in that they did not test knowledge, skills, or attitudes re-
lated to any specific cultural group. A sample item is, “In
general, how would you evaluate your comfort level in car-
ing for clients from a culture other than your own?”
The scale contained 28 items requesting a self-rating
on a Likert scale, with 1 = not comfortable (or not knowl-
edgeable or not aware) and 5 = very comfortable (or very
knowledgeable or very aware) in relation to concepts ap-
propriate to cultural competence. An overall CCCHS score
was computed by averaging the 28 items. Items included
the following categories:
● Knowledge about health care beliefs and practices of
a cultural group other than their own.
● Knowledge of and comfort with the cultural assess-
ment process.
● Comfort with their ability to work with a translator,
clients’ family members, or folk healers.
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4/22/2005 8:11:18 AM
 IMPROVING CULTURAL COMPETENCE

group of our FIPSE project

partner in West Virginia.
The university Institution-
al Review Board approved
the research.
Preliminary testing of
the CCCHS' reliability
and validity for detecting
change was obtained from
students involved in the
FIPSE grant. Fourteen
total matched scores were
analyzed by the paired
samples t test. Twenty-two
of the 28 items showed sig-
nificant improvement be-
tween pretest and posttest,
based on a .05 level of sig-
nificance. Cronbach’s al-
pha was .94 on the pretest
(N = 14) and .90 on the
posttest (N = 14). Based
Figure 1. Comparison of changes in mean cultural competence scores of students in the ICC group on these preliminary re-
(coursework only) and students in the ICC Plus group (coursework plus immersion experience in sults, it appeared that
Guatemala). Values plotted are mean ± standard error of the mean. the CCCHS was reliable
and sensitive in detecting
improvement in students’
self-assessment of their culturally competent attitudes,
TABLE 1
knowledge, and skills following the international experi-
Number of Items Falling into Each Effect Size ences they had during their nursing program. Therefore,
Category for the ICC and ICC Plus Groups we used the CCCHS in this study to evaluate the overall
Number of Items effectiveness of our nursing education program on stu-
ICC Plus dents’ development of perceived cultural competence and
Effect Size Category ICC Group Group to further evaluate the outcomes of the Guatemala immer-
sion experience.
Very large effect (⭓ 1.00) 0 21
In this study, Cronbach’s alpha was .93 on the pretest
Large effect (.66 to .99) 1 2 (N = 44) and .97 on the posttest (N = 32). Using an inde-
Moderate effect (.36 to .65) 8 3 pendent samples t test, pretest mean scores on the overall
Small effect (.10 to .35) 12 2
CCCHS of the 7 students in the ICC Plus group (mean
= 3.19, SD = .41) and the 25 students in the ICC group
No effect (–.09 to .09) 1 0 (mean = 3.41, SD = .58) were not significantly different (p
Negative effect (⭐ –.10) 6 0 = .28). Similarly, the pretest mean scores of the two groups
Total number of items 28 28 did not differ on any of the CCCHS items.

● Knowledge of another cultural group’s practices
around death and dying, organ donation, and pregnancy
and childbirth.
● Awareness of one’s own limitations related to cul-
tural competence.
● Willingness and ability to work as a team member
with or supervise diverse staff.
● Awareness of national policies affecting culturally
Procedure
The pretest CCCHS was administered to 44 new juniors
upon entry to the program. Students were asked to identify
a number they would recognize at the end of the program,
so each student’s pretest and posttest could be matched.
The researchers had no access to student-identifying infor-
mation. By the end of the senior year, 32 of the original 44
students could be matched with their pretest scores.

diverse populations and perceived ability to advocate on RESULTS

their behalf.
The scale was reviewed by a consultant who is an ex- At the posttest, just before graduation, the mean
pert in the culture and nursing arena, and preliminary CCCHS of the ICC group was 3.60 (SD = .59) and the mean
psychometric evaluation was performed with a student for the ICC Plus group was 4.42 (SD = .48). An F test for

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 CAFFREY ET AL.

TABLE 2
Comparison of Pretest and Posttest Cultural Competence Means and Effect Sizes for Selected CCCHS Items
ICC Group (n = 25) ICC Plus Group (n = 7)
Pretest Posttest Pretest-to- Effect Pretest Posttest Pretest-to- Effect
CCCHS Item Mean (SD) Mean (SD) Posttest r Size Mean (SD) Mean (SD) Posttest r Size
Two items with largest effect
size for the ICC Plus group
22. Ability to provide culturally 3.52 (.82) 3.64 (.76) .31 .13 2.86 (.69) 4.86 (.38) .55 3.46**
competent care.
24. Comfort supervising diverse 3.52 (1.19) 3.80 (.87) .47 .25 2.57 (1.27) 4.43 (.79) .88 2.69**
staff.
Two items with largest effect
size for the ICC group
19. Awareness of own cultural 3.24 (.93) 4.04 (.84) .42 .84** 3.43 (.79) 4.57 (.79) .08 1.07*
competence limitations.
4. Knowledge regarding risk 2.64 (.95) 3.28 (.84) .39 .64** 2.43 (.79) 4.71 (.49) –.50 2.05**
factors of another cultural
group.
Two items with largest negative
effect size for the ICC group
25. Interest in working with 4.52 (.51) 4.04 (.79) .36 –.62** 4.43 (.79) 4.86 (.34) .80 .80
diverse staff.
10. Comfort working with a 4.48 (.59) 4.08 (.86) .17 –.42* 4.43 (.53) 4.86 (.38) –.47 .54
translator.

* p < .05; ** p < .01. Significance of paired t test for pretest-to-posttest change in mean scores.
Note: Bolded values indicate reversed scores from junior to senior year.
Complete table of information for all items is available from the first author upon request.
CCCHS = Caffrey Cultural Competence in Healthcare Scale.

the groups ⫻ time interaction from a 2 ⫻ 2 repeated mea-
sures analysis of variance (ANOVA) was used to compare
the ICC and ICC Plus groups in terms of their change in
overall CCCHS scores from pretest to posttest. Improve-
ment in cultural competence on the overall CCCHS score,
while demonstrated by students in both the ICC and ICC
Plus groups, was significantly greater for students in the
ICC Plus group (F[1, 30] = 21.2, p < .001) (Figure 1).
Effect Sizes
Effect sizes were then computed for each group by di-
viding the mean change score (posttest minus pretest) by
the standard deviation of the change scores (Lipsey, 1990).
The advantage of an effect size is that it presents mean
change in standard deviation or z-score units. We drew on
guidelines from Cohen (1988), who considered effect size
values of .20, .50, and .80 as small, medium, and large,
respectively, and we categorized effect size values into six
categories as shown in Table 1.
Effect Sizes for Overall CCCHS Scores. Simply inte-
grating cultural content in the curriculum (ICC group, n
= 25) improved students’ cultural competence by .19 raw
score points (on a scale of 1 to 5; SD of change = .46). This
raw score change corresponded to an effect size of .41 SD,
which is considered a small-to-moderate effect size. How-
ever, adding the international immersion experience (ICC
Plus group, n = 7) improved students’ perceived cultural
competence by 1.23 raw score points (on a scale of 1 to 5;
SD of change = .59). This corresponded to an effect size of
2.07 SD, which is very large. Using these actual changes
between the ICC and ICC Plus groups to estimate the ef-
fect size for the difference between change scores for the
two groups (effect size = 2.13) and using an alpha of .01
for a one-tailed test to compare the two groups with n =
25 (ICC group) and n = 7 (ICC Plus group), the power is
89%. Conventionally, an 80% level of power is considered
adequate.
Effect Sizes for Item-Level Change. Because of the study’s
exploratory nature, we also analyzed data at the item lev-
el to show more clearly where change on the CCCHS was
occurring and not occurring. As shown in Table 1, for the
ICC group, no item had a very large effect size value, and
only 1 item had a large effect size value (.84). Nearly three
fourths of the items showed either moderate or small ef-
fect sizes, with a negative effect size (⭐ –.10) for 6 items,
indicating lower posttest than pretest scores. In stark con-
trast to the ICC group, the ICC Plus group had very large
effect size values (1.00 to 3.46) for 21, or three fourths,

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 IMPROVING CULTURAL COMPETENCE

dents improved, 11 showed

no change, and 4 worsened
on perceived cultural com-
petence. For the 25 stu-
dents in the ICC group, 11
improved, 10 showed no
change, and 4 worsened.
For the 7 students in the
ICC Plus group, 6 im-
proved, and 1 showed no
change.

DISCUSSION

Overall, students in the

Figure 2. Scatterplot of overall Caffrey Cultural Competence in Healthcare Scale (CCCHS) pretest
and posttest scores for students in the ICC and ICC Plus groups. The solid line ± 2 standard errors of
measurement indicates no change.
of the items; all of these improvements in perceived cul-
tural competence were statistically significant at p < .05.
Of the effect size values for the remaining 7 items, two
were large, three were moderate, and two were small; no
item had a negative effect size value for this group. For
illustration purposes, we have listed selected individual
CCCHS items in Table 2 to show the 2 items with the larg-
est effect size for the ICC Plus group, the 2 items with the
largest effect size for the ICC group, and the 2 items with
the largest negative effect size (i.e., items where perceived
cultural competence worsened) for the ICC group.
Pretest to Posttest Change for Individual Students
Because change at the individual student level is im-
portant for educators, we also inspected change scores
on the overall CCCHS to determine what percentage of
students improved, worsened, or showed no change. Un-
less the change exceeded two standard errors of measure-
ment, the pretest to posttest difference was considered “no
change.” The standard error of measurement was .15 on
the scale of 1 to 5, and was estimated by multiplying the
SD of the pretest (.55) by the square root of 1 minus the
reliability of the pretest [公1 – .93)]. Thus, we considered a
pretest-to-posttest change of at least 2 ⫻ .15 (.30) as more
than simply measurement error.
As shown in Figure 2, a scatterplot of pretest and
posttest CCCHS scores of all 32 students, 17 total stu-
ICC group demonstrated
moderate improvement in
perceived culturally com-
petent attitudes, knowl-
edge, and skills over the 2
years in the nursing pro-
gram. However, students
in the ICC Plus group
gained much more than
their classmates in their
perceived cultural compe-
tence as a result of the im-
mersion program.
The item showing the
greatest improvement for
students in the ICC Plus
group was, “Overall, how would you evaluate your abilities
to provide culturally competent care in the clinical setting
to clients from a culture other than your own?” The effect
size value for this item was 3.46 for students in the ICC
Plus group, whereas the improvement of students in the
ICC group on this item was negligible (effect size = .13). In
contrast, the item with the largest effect size value for stu-
dents in the ICC group was, “How aware do you think you
are regarding your own limitations in providing cultur-
ally competent care to a member of a cultural group other
than your own?” (effect size = .84). For students in the
ICC Plus group, this item had an effect size value of 1.07.
Perceived knowledge regarding risk factors of another cul-
tural group ranked second for students in the ICC group.
It would appear that the experiences gained by students
in the ICC Plus group enhanced their perceived abilities
to provide culturally competent care along with diverse
staff, while students in the ICC group became more aware
of their limitations and reliance on knowledge gained from
classroom content.
The 2 items with the largest negative effect size for stu-
dents in the ICC group (Table 2) are representative of the
6 items for which students’ scores reversed from pretest to
posttest. These items all had received high pretest values
(4.08 to 4.52 on a scale of 1 to 5). These reversals indicate
a high self-evaluation at the beginning of the program, but
perhaps reflect a more realistic view of students’ level of

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comfort with these items as they progressed in the nurs-
ing program. It may also reflect students’ lack of experi-
ence with culturally diverse clients, staff, and translators
as, for students in the ICC Plus group, these items showed
small to large gains.
LIMITATIONS
Some concerns need to be addressed in examining
the results of this study. First is whether self-perceived
cultural competence has any relationship to actual prac-
tice. This is an ongoing concern of researchers who are
attempting to study this phenomenon. This study does not
answer the question but only examines students’ perceived
knowledge, self-awareness, and comfort with the skills of
cultural competence. How these translate into practice is
unknown.
Second are concerns about the small sample. However,
the very large effect size values obtained indicate the scale
was sensitive enough to give valid results with this small
sample.
A third concern is whether the self-selection, and then
final selection by faculty, of students in the ICC Plus group
biased the results. As noted previously, no differences ex-
isted in the pretest scores of the two groups. In fact, stu-
dents in the ICC Plus group scored somewhat lower on the
pretest. The ages of students in the two groups were also
comparable.
One factor that may well have influenced the study re-
sults was recognition by students in the ICC group of what
experiences they had missed, when students in the ICC
Plus group returned from abroad and shared their expe-
riences. This may have made students in the ICC group
less confident in their perceived knowledge and skills re-
garding their own cultural competence. Administering the
posttest to students in the ICC group prior to the return
of the students in the ICC Plus group would help decrease
this contamination, although not completely, because the
students in the ICC Plus group were still communicating
with their classmates through e-mail.
In addition, although we were not aware of any other,
unmeasured factors that could have resulted in the im-
provement in posttest scores for students in the ICC Plus
group, this is always a possibility.
CONCLUSIONS
The following communication from one of the students
in the ICC Plus group provides insight into the personal
and professional implications of the Guatemala immer-
sion experience (L. Rushton, personal communication, No-
vember 19, 2002):
It was in Guatemala that I finally felt like I was apply-
ing my nursing knowledge. This was my reflective practice
clinical experience, the time that I needed to more fully
embrace the responsibilities and knowledge of nursing.
We were practicing nursing on a basic level without the
modern equipment that makes life easier in this country
May 2005, Vol. 44, No. 5
JNE0505CAFFREY.indd 239
CAFFREY ET AL.
[United States]. Testing supplies were a luxury in Guate-
mala, so a clear picture of the patient’s signs and symptoms
was necessary for treatment. My senses were heightened:
I listened, looked, touched, smelled, and intuited. Nursing
knowledge gained in the classroom was being applied in a
clinical setting full of families with various ailments. My
confidence grew as I recognized patient symptoms related
to certain illnesses. Using the knowledge of other nursing
students was equally as exciting. We were peers sharing
information in an attempt to uncover the unknown. The
experience was invaluable in building confidence.
It is clear in the above statement that the experience
played a critical role in the students developing confidence
in nursing skills. More important, the results of this study
are consistent with those of St Clair and McKenry (1999)
regarding the importance of an international experience
in the development of cultural competence. Although cul-
tural awareness may develop when students interact with
culturally diverse groups in the clinical practice setting,
St. Clair and McKenry (1999) found there was no change
in students’ ethnocentrism if the experience did not in-
clude immersion into the cultural groups’ daily reality.
Ms. Rushton described the effect of this experience on her
current practice as an RN:
In many ways, not speaking the language highlighted
important issues regarding cultural differences and com-
munication problems that can exist between nurse and
patient. Even though there were cultural brokers [indi-
viduals who are both bilingual and knowledgeable about
the culture] assisting with translation in Guatemala, we
were forced to find new ways of reaching the patient. It
was critical that we explain our hands-on nursing assess-
ment in an effort to [show] respect and avoid violating
social norms.
At the same time, we were learning how to create a
trusting relationship with a people [who] we did not fully
understand culturally and [who] appeared fearful of us at
times. This task may have been as simple as making eye
contact with a mother and smiling. However, more often, it
entailed an array of tactics to reveal the real problem that
brought the patient to the clinic.
I speak of this because it has been very useful to me in
my practice today. Patients are aware of how busy nurses
are. It is impossible not to notice the pace of a nurse, or
hear the beepers and phones ringing when the nurse is at
the patient’s bedside. Additionally, being hospitalized is
traumatic, and fear is common. I have the gift of words in
this country to assist in making a human connection with
my patients. I learned in the clinical setting in Guatemala
that a few extra seconds or minutes focused on the patient
produces a relationship of mutual respect and trust. There
is an art to providing undivided attention to a patient in
the midst of a busy nursing environment.
Ms. Rushton described the “art” of nursing. According
to Bernal (1998), “Delivering culturally competent care is
no more and no less than delivering quality holistic care to
anyone regardless of ethnic or racial background, place of
birth or national origin” (p. 7). Bernal went on to say, “An-
239
4/22/2005 8:11:20 AM
 IMPROVING CULTURAL COMPETENCE
other way to look at this issue is, if we, as nurses, become
more sensitive to these differences, we will deliver more
holistic, relevant care to everyone” (p. 7).
CONCLUSION
Questions remain regarding the level of cultural com-
petence that should be expected from students at gradua-
tion. The Wells (2000) model can be useful in helping edu-
cators make this decision. For those students who do not
participate in an immersion experience with another cul-
ture, perhaps the cognitive level of cultural competence is
the best that can be expected. This would include baseline
knowledge about cultural health care needs and practices
of diverse populations and an awareness of their own limi-
tations in providing culturally competent care.
However, cultural competence is an ongoing process
requiring more than formal knowledge. Values and at-
titudes are the foundation for a commitment to provid-
ing culturally competent care, and their development
requires experiences with culturally diverse individuals
and communities. For those nursing education programs
that are committed to promoting cultural competence in
their students, support for an immersion clinical experi-
ence in another country can result in dramatic affective
JNE0505CAFFREY.indd 240
changes in students’ values and attitudes, which affect
their cultural competence, as evidenced by the results of
this study.
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