Turkish validity and reliability of the individual cultural values scale on nurses

Abstract

Background

Nurses need to understand their own cultures in order to care for patients in ways that are based on the cultural structure of the patient, which means to the patient’s cultural values and beliefs.

Aim

This study was conducted in Turkey, and the aim of the study was to test the Turkish validity and reliability of the Individual Cultural Values Scale (CVSCALE) for nurses.

Methods

This research was a methodological study. The sample of the research was composed of 256 nurses. The reliability and validity analyses were performed such as additivity, Cronbach’s alpha, response bias, language, content, and construct validity. Ethical approval was obtained for the research.

Results

The content validity index of the scale was .91. As a result of confirmatory factor analysis, it was determined that the model had a good fit, and five dimensions of the scale were confirmed. The internal consistencies of subscales, except those for power distance and masculinity, were very reliable. The test–retest correlations were found to be very high for the CVSCALE.

Conclusion

The Turkish form of the Individual Cultural Values Scale that was conducted on nurses had acceptable levels of validity and reliability. Measuring culture at the individual level is important for transcultural nursing, and it will contribute to the creation of nursing policies in Turkey.

Keywords

cultural values nursing reliability Turkey validity

Introduction

The concept of culture has been studied by researchers from different areas of expertise and there are many different definitions about it. The concept of culture is derived from the Latin verb “colere” which means tending and cultivation (Kroeber and Kluckhohn, 1952).

According to Hofstede (1993), culture is the collective programming of the mind that separates a group of people from others. Hofstede (1993) stated that culture is not directly accessible by observation; however, culture can be understood based on verbal expressions and behaviors, and it is a useful structure for predicting other observable/measurable verbal and non-verbal behaviors (Hofstede, 1993). Hofstede (2011) identified four basic dimensions with regard to differences in cultures. The dimensions were power distance, uncertainty avoidance, individualism, and masculinity (Beugelsdijk and Welzel, 2018; Hofstede, 2011; Maleki and De Jong, 2014; Yoo et al., 2011). Later, the long-term versus short-term orientation dimension was added, making five dimensions (Hofstede, 2011; Maleki and De Jong, 2014; Tekeş et al., 2019). In the 2000s, Hofstede accepted indulgence versus restraint which is one of Minkov’s three dimensions as the sixth dimension (Hofstede, 2011; Hofstede et al., 2010; Maleki and De Jong, 2014).

According to Hofstede (1993), power distance can be defined as the degree of inequality among people that is considered normal within the population of a country; if the society is relatively equal, there is low power distance, and if the society is extremely unequal, there is high power distance. Uncertainty avoidance can be defined as the degree to which a country prefers structured over unstructured situations. Structured situations are those in which there are clear rules about how a person behaves. These rules can be written, but they can also be unwritten and imposed by tradition (Hofstede, 1993). Individualism refers to the weaknesses or strengths of the links between individuals in the society, and it is basically related to how an individual defines himself or herself. The opposite of individualism is collectivism, which is essentially low individualism. Masculinity versus femininity refers to the roles attributed to men and women in a society and the basic beliefs of society about different sexes. In masculine societies, there are some values that include the importance of showing off, of performing, of achieving something visible, of making money etc. In feminine societies, the dominant values are not showing off, putting relationships with people before money, minding the quality of life and the preservation of the environment, helping others etc (Hofstede, 1993). Long-term versus short-term orientation is related to whether people choose to focus on the past and present or the future. While long-term orientation includes values that consider the future, such as thrift and persistence, short-term orientation includes values that focus on the past and present, like respect for tradition and fulfillment of social obligations (Hofstede, 1993, 2011). Indulgence versus restraint is related to the gratification versus control of basic human desires about enjoying life (Hofstede, 2011). In nursing profession, the dimensions of culture can be used to evaluate patients during care and provide optimal care to patients.

According to Hofstede’s national culture model (Hofstede, 2011), it can be said that Turkey has high power distance, a low tolerance of uncertainty, a collectivist structure, somewhat feminine attributes, and relatively long-term oriented focus and indulgence (Insights, 2020). In addition, and especially in organizations, it can be said that Turkey has extremely masculine attributes and is short-term oriented. In nursing profession, each of the dimensions of culture can be used to evaluate patients during care and provide optimal care to patients.

Nursing and culture

The concept of culture, which has been examined by researchers from different disciplines, has been started to be explored in the nursing profession with the foundation of transcultural nursing. The foundations of transcultural nursing, which handles approaches to cultural issues in nursing, were laid in the mid-1950s. The first theory developed in the field of transcultural nursing is the “Culture Care Diversity and Universality” theory developed by Leininger in 1960. This theory, known as the Leininger’s sunrise model, focuses on exploring different and universal cultures and providing comparative care. This model includes technological, religious and philosophical, cultural values and lifestyle, political and legal, economic and social factors. In 1969, the International Council of Nurses began to use cultural content in nursing (Değer, 2018; Leininger and McFarland, 2005; Şahin et al., 2009). This refers to the acceptance of culture as an important component in the nursing profession. In addition, it means that nurses need to provide cultural care in multicultural societies, and care patients by respecting their cultural values and beliefs.

In recent years, the kind of care provided by knowing the cultural structure of individuals has gained importance in nursing. The American Nurses Association refers to three interactions in the patient–nurse relationship: the culture of the individual (patient), the culture of the nurse, and the culture of the environment. In these interactions, the culture of the patient, the environment, as well as the nurses’ own traditions, beliefs, and values are important parts in the transcultural relationship. Individuals as physical, ecological, sociopolitical, and cultural beings are continuously interacting with their environments (Değer, 2018; Şahin et al., 2009). Moreover, culture is transferred and learned from social environments, not from genes (Arrindell, 1998). Therefore, the environment is an integral part of the culture. Nurses’ self-understanding may serve as the starting point for gaining a cultural understanding of the patient (Değer, 2018; Şahin et al., 2009). In this context, measuring the cultural values of the nurse at an individual level which facilitates nurses to understand their own culture or creating awareness about this issue in nurses will cause a decrease in cultural conflicts in the process of providing care to the patient and contribute to transcultural nursing care.

Yoo et al. (2011) developed the Individual Cultural Values Scale to measure Hofstede’s national cultural dimensions at the individual level. In Turkey, there has not been any study or implementation of measurement tool regarding nurses’ individual cultural values. Furthermore, Turkey, which contains different cultures and traditions in its heterogeneous population, has received a great number of immigrants in recent years. Therefore, measuring culture at the individual level is important. This study was conducted to test the validity and reliability of the Individual Cultural Values Scale (CVSCALE) on Turkish nurses.

Methodology

Design and participants

This research is a methodological study regarding the language adaptation, validity, and reliability of the Turkish version of the Individual CVSCALE. The research data were collected from nurses working in a regional hospital between August 2018 and March 2019. In past studies that focus on the scale, it was suggested that the sample volume should be 5–10 times the total number of scale items (Hair et al., 2014). For this reason, and taking into consideration the number of items on this study’s scale (26 items), it was determined that the minimum number for the sample should be 130 and the maximum should be 260. The universe of the research was composed of nurses (N = 400) working in a regional hospital, and the sample of the research was composed of 256 nurses (9.8 times the number of scale items) who agreed to voluntarily participate in the study.

Instruments

The research data were collected with the Information Form for Nurses and the Individual CVSCALE. The researchers created The Information Form for Nurses in accordance with literature, and it consists of sociodemographic characteristics, including age, sex, marital status, education level, and working conditions. The CVSCALE, which was developed by Yoo et al. (2011) to determine the individual cultural values of employees and was based on “Hofstede National Cultural Values,” includes a 26-item survey. The instrument’s dimensions were power distance, uncertainty avoidance, collectivism, masculinity, and long-term orientation. Power distance dimension measures the degree to which individuals accept whether power is equally distributed or not. Uncertainty avoidance dimension measures the some extent to which individuals are disturbed by uncertainty. Collectivism dimension measures the degree to which individuals prefer to act as a group. Masculinity dimension measures whether individuals adopt male-specific values or not. Long-term orientation measures the degree to which individuals prefer to focus on their future efforts. The scale was a 7-point Likert type. The dimension scores range from 1 to 7. Higher scores indicate that individuals have high power distance and uncertainty avoidance, a collectivist structure, masculine attributes, and long-term oriented focus. In the original study, the internal consistencies of the CVSCALE’s dimensions for Americans were .90, .88, .85, .84, and .79; in Koreans, the internal consistencies of the CVSCALE’s dimensions were .79, .79, .89, .84, and .78, representing power distance, uncertainty avoidance, collectivism, masculinity, and long-term orientation, respectively (Yoo et al., 2011).

Data analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), V15 (SPSS Inc., Chicago, IL, United States). The analysis of data was carried out using numbers and percentages to define demographic characteristics. The reliability of the scale was assessed by standard error, additivity, Cronbach’s alpha reliability coefficient, the item subscales total score correlation, response bias, and test–retest method; the validity was performed by language, content, and construct (confirmatory factor analysis (CFA) and exploratory factor analysis (EFA)) validity. For content validity, the content validity index was determined by Davis technique (Davis, 1992). Davis (1992) technique grades expert opinions into four levels: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant. Then, for each item, the content validity index for items (I-CVI) is computed as the number of experts giving a rating of either three or four, divided by the total number of experts. The content validity of the overall scale (S-CVI) was calculated the average of the I-CVIs for all items on the scale (S-CVI/Ave) (Davis, 1992; Polit and Beck, 2006).

Results

Study sample characteristics

The mean age of the nurses was 38.23 years (SD = 7.84). Most of the nurses (93.4%) were women, married (71.5%), and had a baccalaureate degree in nursing (62.5%). The majority (77%) worked as clinical nurses for more than 40 h in a week (76.2%), with both day and night shifts (80.5%). Most of the nurses (57.8%) evaluated their working conditions as a “medium.” The mean professional nursing experience of the nurses was 16.41 years (SD = 8.92), and the mean number of years working at the current hospital was 4.68 years (SD = 5.87).

Descriptive statistics

The scores of the power distance of nurses (M = 2.89, SD = 1.04) were low. The scores of uncertainty avoidance and collectivism of nurses (M = 5.88, SD = 1.23 and M = 5.19, SD = 1.37, respectively) were high. The scores measuring the masculinity of nurses (M = 3.08, SD = 1.49) were low. The scores measuring the long-term orientation of nurses (M = 5.62, SD = .87) were high.

Validity results for Turkish version of Individual Cultural Values Scale

Language testing: In the translation of scale items into Turkish, researchers considered appropriate sentence structures and replacements for foreign items in order to match the culture. In the first stage, five experts, who know Turkish and English well, separately translated the CVSCALE. Then, the researchers examined these translations, and the Turkish version of the CVSCALE was formed. The scale was then re-translated into English, after which someone who knows English well compared the original version with the final version. Cognitive questioning was performed on ten individuals, representing the target group of the final version of the scale. The ten individuals provided no negative feedback regarding the intelligibility of the items. Preliminary data were not included in the study.

Content validity: The Turkish version of the scale was presented to seven different faculty members (six in the Nursing department, of which three are in the Nursing Management department of a different university, and one faculty member in the Social Work department) to determine content validity. These faculty members conceptually evaluated each item and graded them from 1 to 4. As a result of the experts’ opinions, the S-CVI was found to be .91 for the 26 items, and the final form of the scale was created in accordance with the recommendations of the experts.

Construct validity

Confirmatory factor analysis: First, in order to test the CVSCALE’s suitability to the theoretical structure developed by Yoo et al. (2011), a CFA was done. In order to evaluate the compliance of the data with the model, fit indices (x²/df, RMSEA, GFI, AGFI, CFI, NFI, and NNFI) were measured. CFA results of the CVSCALE were given in Table 1.

Table 1.

Fit indices for the Turkish version of the Cultural Values Scale.

Fit indices	CVSCALE
x²/df	664.79/289 = 2.30
RMSEA (root mean square error of approximation)	.071
GFI (goodness-of-fit index)	.83
AGFI (adjusted-goodness-of-fit index)	.80
CFI (comparative fit index)	.94
NFI (normed fit index)	.90
NNFI (non-normed fit index)	.93

The results for the fit indices were x²/df: 2.30, RMSEA: .071, GFI: .83, AGFI: .80, CFI: .94, NFI: .90, and NNFI: .93 (Table 1). It was found that x²/df, RMSEA, CFI, NFI, and NNFI indices had acceptable values; however, GFI and AGFI were below acceptable values. The CFA results confirmed that the scale consisted of five factors: power distance (1, 2, 3, 4, 5), uncertainty avoidance (6, 7, 8, 9, 10), collectivism (11, 12, 13, 14, 15, 16), masculinity (17, 18, 19, 20), and long-term orientation (21, 22, 23, 24, 25, 26), as seen in Figure 1. Maximum likelihood estimations were above the acceptable limit of .45, measuring between .52 and 1.56. CVSCALE t values were found to be significant at p < .05 level. The factor loadings of the CVSCALE model ranged from .27 to .67 in the first factor, .77 to .90 in the second factor, .74 to .93 in the third factor, .52 to .70 in the fourth factor, and .58 to .80 in the fifth factor.

Figure 1

. Path diagram for the Cultural Values Scale.

The convergent validity of the measurement model was assessed by the average variance extracted (AVE) and composite reliability (CR). AVE and CR values were shown in Table 2.

Table 2.

AVE and CR values of the CVSCALE.

Subscales	AVE	CR
Power distance	.25	.60
Uncertainty avoidance	.71	.92
Collectivism	.69	.93
Masculinity	.50	.79
Long-term orientation	.46	.83

Note: AVE: average variance extracted; CR: composite reliability.

Exploratory factor analysis: Kaiser–Meyer–Olkin (KMO) was used to assess the suitability of the data set for factor analysis, and Bartlett’s test of sphericity was used to test whether the variables correlated with each other. For the CVSCALE, the KMO measure of sampling adequacy was .83, and Bartlett’s test of sphericity was found to be significant (x²: 3522.646, p < .000).

A factor analysis, using principal component analysis and the varimax rotation method, was performed on the 26 items. In this research, factors whose eigenvalue exceeded 1 were evaluated. In the principal component analysis of the 26-item scale, five factors that explained 61.48% of the total variance were obtained. The largest factor that emerged after varimax rotation was the first factor, which explained 26.93% of the variance. The second factor explained 12.17% of the variance. The third factor explained 9.77% of the variance, the fourth factor explained 6.82% of the variance, and the fifth factor explained 5.77%.

Reliability results for Turkish version of Individual Cultural Values Scale

The mean, standard error, and standard deviation values of nurses’ responses to the 26 items in the scale were calculated. These results indicated that the mean of item scores was changed between 6.05 and 1.98.

In this research, the additivity characteristics of the scale were evaluated using Tukey’s additivity test. It was found that the non-additivity value of the CVSCALE was significant (F: 31.696; p < .000).

Cronbach’s alpha reliability coefficient of the CVSCALE was .83. Additionally, Cronbach’s alpha reliability coefficient was .55 for power distance, .91 for uncertainty avoidance, .92 for collectivism, .76 for masculinity, and .82 for long-term orientation. As a result of the item analysis that was conducted to determine the internal consistency of the scale, the total score correlations of item subscales were found to be .57–.64 for the power distance; .80–.90 for the uncertainty avoidance; .80–.90 for collectivism; .68–.82 for masculinity; and .70–.77 for long-term orientation (Table 3).

Table 3.

Reliability coefficients and item subscales total score correlations for the Turkish version of the Cultural Values Scale.

Subscale	Item	Item subscales total correlations	p	Cronbach’s alpha reliability coefficient	Cronbach’s alpha if item deleted
Power distance	Item 1	.64	.000	.55	.45
	Item 2	.60			.50
	Item 3	.57			.48
	Item 4	.58			.54
	Item 5	.62			.51
Uncertainty avoidance	Item 6	.85	.000	.91	.89
	Item 7	.86			.88
	Item 8	.88			.88
	Item 9	.80			.91
	Item 10	.90			.87
Collectivism	Item 11	.80	.000	.92	.92
	Item 12	.86			.90
	Item 13	.90			.90
	Item 14	.89			.90
	Item 15	.85			.90
	Item 16	.80			.92
Masculinity	Item 17	.68	.000	.76	.77
	Item 18	.78			.69
	Item 19	.82			.65
	Item 20	.77			.72
Long-term orientation	Item 21	.72	.000	.82	.80
	Item 22	.77			.78
	Item 23	.74			.79
	Item 24	.70			.80
	Item 25	.71			.81
	Item 26	.74			.79

According to the Pearson correlation analysis, which examined the relationship between the mean scores of test–retest scores applied at 4-week intervals, it was determined that there was a strong relationship between the first and the second application in overall subscales (power distance r = .88, p = .000; avoidance of uncertainty r = .90, p = .000; collectivism r = .93, p = .000; masculinity r = .88, p = .000; and long-term orientation r = .92, p = .000 in a sample size of 60 nurses).

In the study, whether the responses of the individuals to the items of the scale were equal was assessed with Hotelling’s T² test. As a result of the test, the Hotelling’s T² test value of the CVSCALE was found to be significant (Hotelling T²: 2043.345, p = .000).

Discussion

In this study, researchers examined nurses’ individual cultural values, and it was determined that they had low power distance and tolerance of uncertainty, a collectivist structure, long-term orientation, and feminine values. When these results were compared with the wider results of Turkish culture according to the Hofstede national culture model, power distance, masculinity, and long-term orientation results were not similar. The low power distance assessment and adoption of feminine values may be partially attributable to the characteristics of the sample group, specifically the fact that 72.7% of participants were subordinates and 93.4% were female employees. In addition, seven basic values that are altruism, aesthetics, equality, freedom, human dignity, justice and truth, and realism are mentioned in the nursing profession (Shaw and Degazon, 2008). Feminine values, which are the dominant values of equality, solidarity, focusing on quality of life, and maintaining and protecting other individuals, are similar in many respects to the values of the nursing profession. That is, this result may be due to the similarity between feminine values and the values of the nursing profession. Moreover, it can be said that due to the socioeconomic situation in Turkey, nurses are worried about the future; therefore, they are more likely to have a long-term orientation.

In this research, the CVSCALE was adapted to Turkish and used to test psychometric properties with 256 nurses. The content validity index of the scale was above .80 (Almanasreh et al., 2019; Esin, 2014), indicating that the scale had good content validity.

In the CFA of the scale, x²/df, RMSEA, GFI, AGFI, CFI, NFI, and NNFI fit indices were assessed to determine the compliance of the data with the model. In the confirmatory factor analysis, the x²/df value was less than 5, the RMSEA was less than .8, and fit indices (GFI, AGFI, CFI, NFI, and NNFI) were greater than .90, indicating acceptable values for the model fit (Çokluk et al., 2010). In this study, and as a result of the CFA, it was determined that the fit indices, excluding GFI and AGFI, had acceptable values. Furthermore, the results from the CFA of the data on the 26 items of the instrument supported the five-factor model and indicated that the items in each subscale adequately represented their factor. In the original study, the results of fit indices obtained from the CFA had acceptable values (Yoo et al., 2011). The results indicated a sufficient model fit between the original model and the data of this sample.

The average variance extracted (AVE) and the composite reliability (CR) are estimated to determine whether the observed items of the dimensions were strongly correlated between themselves. AVE values greater than acceptable value .50 and CR greater than acceptable value .70 indicate an adequate convergent validity. CR between .6 and .7 may be acceptable (Hair et al., 2014). In this study, the CR values of the scale were greater than acceptable values and this result is an evidence of the convergent validity of the scale. However, the AVE values of the scale were less than .50 in power distance and long-term orientation dimensions.

For the CVSCALE, KMO values were above .50, and the result of Bartlett’s test of sphericity was determined to be significant (p < .05). These results indicated that the data set was suitable for factor analysis. As a result of the EFA, five factors, which explained 61.48% of the total variance, were obtained. In the literature, factors that were revealed from the EFA were needed to explain 40–60% of the total variance (Tavşancıl, 2005). In this context, it can be said that the scale results were above the acceptable values. In the original study, the total variance, which was explained by five factors, was found to be 49% for Americans and 40.7% for Koreans (Yoo et al., 2011).

In this study, the additivity test was performed to determine reliability of the scale. The result of Tukey’s additivity test indicated that the non-additivity value of the CVSCALE was significant (p < .05). This result means that the CVSCALE has an additivity characteristic, that is, the scale provides more precise estimates of population effects and it means data can be collected from this scale (Myers et al., 2013).

In the literature, Cronbach’s alpha reliability coefficient value ≥.70 is considered acceptable (Kline, 2011; Taber, 2018). In the research, it can be said that the internal consistencies of subscales, excepting power distance and masculinity, are very reliable. In this study, power distance and masculinity subscales may have been affected by the characteristics of the sample group, specifically the fact that 72.7% were subordinate and 93.4% were female employees. Yoo et al. (2011) found that Americans and Koreans showed .91 and .79 reliability alpha, respectively, for power distance; .88 and .79, respectively, for uncertainty avoidance; .85 and .89, respectively, for collectivism; .79 and .78, respectively, for long-term orientation; and .84 and .84, respectively, for masculinity. To some extent, the findings of this research were consistent with the original study by Yoo et al. (2011).

The item subscales and total score correlations, which provide information about the reliability of the scale items, need to be above .30 (Esin, 2014). In this study, the reliability scores of the subscales were acceptable, and all items measured the same property in the subscales.

The test–retest correlations were found to be very high for the CVSCALE, and the significant relationship between the two measurements indicated the stability of the scale over time (Esin, 2014).

The format of the scale may have had an unwanted impact on survey participants’ responses. Therefore, Hotelling’s T² test was performed, which evaluated whether the responses of the individuals to the items of the scale were equal or not, and it was determined to be significant (p < .05). According to this result, it can be stated that the CVSCALE does not have response bias.

Conclusion

The Turkish form of the CVSCALE that was conducted on nurses had acceptable levels of validity and reliability. It was confirmed that this measurement tool, based on the Hofstede national culture model, can be used to measure culture at the individual level. Furthermore, this study is the first to demonstrate the validity and reliability of the Turkish version of the CVSCALE with a sample of nurses. Further studies are suggested to evaluate the psychometric properties of the Individual Cultural Values Scale in different cultures. Nurses need to understand their own cultures in order to care for patients in ways that are based on the cultural structure of the patient. Therefore, this instrument will contribute to transcultural nursing care and the creation of nursing policies in Turkey.

Key points for policy, practice and/or research

• This article provides a valid and reliable tool in which the individual cultural values of the nurses can be measured.

• In nursing profession, cultural studies are generally focused on patient culture. However, this research focused on cultural values of nurses.

• Nurses need to understand their own cultures in order to care for patients in ways that are based on the cultural structure of the patient. Therefore, this instrument will contribute to transcultural nursing care and the creation of nursing policies in Turkey.

Footnotes

Acknowledgements

We thank Boonghee Yoo, Naveen Donthu, and Tomasz Lenartowicz for their permission to translate and adapt the CVSCALE to Turkish. We are grateful to all experts for their contributions in the process of research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

, who developed the CVSCALE, granted permission via email for the adaptation of this instrument to Turkish. The Manisa Celal Bayar University Local Ethics Committee granted ethical approval for the research (approval number: 20.478.486). In addition, written permission was obtained from the nurses who agreed to participate in the study with the “Informed Volunteer Consent Form.”

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Nurcan Bilgin

Adalet Kutlu

Nurcan Bilgin got a doctorate degree from Health Sciences Institute, Manisa Celal Bayar University in 2020. She works a research assistant at Manisa Celal Bayar University and leads nursing management lessons. Before entering academia, she worked at Cardiovascular Surgical Intensive Care Unit and Surgical Intensive Care Unit.

Adalet Kutlu got a doctorate degree Surgical Nursing from Health Sciences Institute, Ege University. Also, she graduated in Management and Organization Master Program. She is an Associate Professor at Manisa Celal Bayar University, and leads nursing management and surgical nursing lessons. Before entering academia, she worked at Emergency Nursing and Cardiovascular Surgical Intensive Care Unit. Interest subject of her; nursing management, surgical nursing, quality of life, complementary therapies, homeopathy.

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