Cultural humility among nursing students in a multicultural setting

Abstract

BACKGROUND:

Given the importance of cultural diversity in healthcare, the shift from “cultural competence” to “cultural humility” has become crucial. This transition is particularly relevant for nursing students in multiethnic regions, such as Southeastern Anatolia, Turkey, where diverse cultural interactions can significantly impact their professional development and practice.

OBJECTIVE:

This study was conducted to determine the cultural humility levels of nursing students.

METHODS:

This descriptive study was carried out with nursing students in two universities in the Southeastern Anatolia region, where the immigrant population is dense, in Turkey.

RESULTS:

In this study, the total mean score of the Cultural Humility Scale of the students participating in the research was 70.03±16.01. A significant difference was found between the Cultural Humility scale mean scores of the students and their gender, nationality, native language, experience of going abroad, desire to live in another country, and enjoying spending time with people from different cultures (p < 0.05). Significant positive correlations were determined between the average scores provided by the students on a 0–10 scale, indicating the importance they placed on cultural diversity in nursing education, and both the total score of the Cultural Humility Scale and the mean score of its sub-dimensions (p < 0.01, r = 0.273)

CONCLUSION:

This study found that the cultural humility level of nursing students living and studying with people from various cultures is sometimes exhibited.

Keywords

Cross-cultural interactions cultural awareness healthcare education multicultural training nursing education transcultural nursing care

1 Introduction

The values, lifestyles, and rules of each culture that live together may differ from those of other cultures [1]. Considering the migration trends in the world, the probability of encountering individuals from different cultures increases for all professionals working in the service sector. In an increasingly diverse and multicultural world, healthcare providers have also begun to recognize cultural differences and their impact on health, focusing on culturally competent care [2, 3]. The Southeastern Anatolia Region of Turkey [4] is known for its rich cultural diversity, which can be attributed to the increasing migration movements and numerous ethnic origins, cultures, and languages in the area. Considering the complexity of multiculturalism, the concept of cultural competence comes to the fore [4, 5]. Although cultural competence is a strategy to address health inequalities, “cultural humility” reshapes the discourse on health inequalities by extending the traditional understanding of race and ethnicity to different origins, genders, sexual orientations, and abilities [6, 7]. Since it is impossible to master or become competent in a culture, cultural humility is a more realistic value and a better approach to inclusive care [8, 9].

Cultural humility was first developed to shape medical education in 1998. It was defined as mutually contributing to recognizing and resolving power imbalances in the culture of others while respectfully understanding one’s culture [10 –12]. In their conceptual analysis of cultural humility, Foronda et al. developed a framework to capture the essence of cultural humility’s qualities, antecedents, and consequences [13]. This framework reveals that in a world of diversity and power imbalances, cultural humility is a process of openness, self-awareness, being egoless, and incorporating self-reflection and criticism after willingly interacting with different individuals [13].

In the literature, “cultural competence” is viewed as a goal centered on learning about other cultures, whereas “cultural humility” represents an ongoing and lifelong learning process [14 –18]. Unlike cultural competence, cultural humility lacks a definitive endpoint [17, 18]. The broader cultural environment increasingly shapes the perspectives and norms of students and faculty. Elevating cultural humility among nursing students necessitates targeted education and heightened awareness, achievable by first identifying knowledge gaps and the present status of students. Cultivating cultural humility involves the simultaneous consideration of multiple factors. Integrating this aspect into the nursing curriculum offers a pivotal opportunity for students to evolve into professionals capable of providing authentic, culturally competent care [14 , 32].

Cultivating cultural humility is a cornerstone in the ethical framework of the nursing profession [19]. Recognizing the significance of determining cultural humility levels for fostering corresponding skills in the education process, numerous studies have focused on enhancing the cultural humility of nursing students [19 –22]. However, in the Turkish context, studies have yet to be identified to assess the cultural humility levels of nursing students. This study aims to evaluate the cultural humility levels of nursing students in a city in Southeastern Anatolia, Turkey, characterized by a high immigrant population and the coexistence of individuals from diverse cultural backgrounds. The findings seek to contribute to the preparation of future nurses, enabling them to deliver culturally competent care and advocate for health equality [23].

2 Methods

2.1 Study design

A descriptive cross-sectional design was used.

2.2 Setting and sample

The research was conducted between March and June 2022 with undergraduate nursing students at a private university and a state university in the same city within the Southeastern Anatolia region of Turkey, which currently hosts different cultures and has a dense immigrant population. The study population consisted of all undergraduate nursing students enrolled in both universities in the 2021/2022 academic year (n:1495). The Southeastern Anatolia Region borders many different countries. Additionally, the region exhibits a multicultural structure where individuals from various ethnic origins, such as Turkish, Kurdish, Arab, and others, along with Muslim and Christian communities, coexist harmoniously. Due to its geographical location, it has hosted many civilizations throughout history. For this reason, it is a unique region where societies from different cultures have always lived together throughout history.

In this research, the study of Kuşçi and Oğuz Duran (2022) using the Cultural Humility Scale (CHS) on education faculty graduates was taken as a reference [14]. Using the G. Power-3.1.9.2 program, a t-test was envisaged to evaluate the risk factors affecting students’ CHS score averages and to calculate the difference between two averages in independent groups in statistical analysis. In this context, the number of students in the study was determined to be 698 when the effect size was 0.3, the alpha value was 0.05, and the theoretical power was 90%. 750 nursing students were invited to the study using the simple random sampling method, considering there would be losses in filling out the online questionnaire. The study resulted in the participation of nursing students (n = 733).

2.3 Data collection

After obtaining the necessary permissions, the online link of the questionnaire was distributed to all participants via WhatsApp during the data collection phase. Participants then completed the questionnaire through Google Forms, which is a secure online platform for gathering information.

2.4 Measurements

The questionnaire consisted of two parts: (1) the student descriptive information form and (2) the Cultural Humility Scale.

2.4.1 Student descriptive information form

The researchers created this form due to the literature review[15, 16]. It consists of 17 questions in which students’ sociodemographic characteristics and knowledge of transcultural nursing are questioned.

2.4.2 Cultural humility scale (CHS)

This 5-point Likert-type scale, which was developed by Foronda, Porter, and Phitwong (2020) [17], consists of 19 items ranging from 1 (never) to 5 (all the time) and three sub-dimensions: Context for the difference in perspective (7 items), Self-attributes (4 items) and Outcomes of cultural humility (8 items). There is no reverse item in the scale, and a score between 19 and 95 can be obtained. Those who score “19–38” are rarely considered to have cultural humility; those who score “39–75” are sometimes considered to have cultural humility; those who score “76–85” are usually considered to have cultural humility; and those who score “86–95” are deemed to have cultural humility all the time. The Cronbach’s alpha coefficient for the context for the difference in perspective sub-dimension of the scale was 0.86, 0.58 for the self-attributes sub-dimension, and 0.85 for the outcomes of cultural humility sub-dimension, and the Cronbach alpha coefficient for the whole scale was 0.85. The Turkish validity and reliability preliminary study of the scale was carried out by Kuşci and Oğuz Duran in 2022. In the present study, Cronbach’s alpha coefficient for the Turkish version of the Cultural Humility Scale (CHS) was 0.82. The sub-dimension of Context for Difference in Perspective had a coefficient of 0.74, the Self-attributes sub-dimension of 0.54, and the Outcomes of Cultural Humility sub-dimension had a coefficient of 0.78 (22). Furthermore, the Cronbach’s alpha coefficient was calculated as 0.96 when considering the entire scale. The sub-dimensions also exhibited high internal consistency, with Context for Difference in Perspective at 0.92, Self-attributes at 0.86, and Outcomes of Cultural Humility at 0.95.

2.5 Data analysis

The research data were analyzed using the Statistical Package for Social Sciences (SPSS, Version 22.0, IBM Corporation, Armonk, NY, USA) [18]. Data were presented using mean and standard deviation values for continuous variables, while frequencies and percentages were reported for categorical variables.

In this study, the selection and application of statistical tests required evaluating whether continuous and dependent variables showed a normal distribution. This evaluation process employed the normality test, histogram tables, skewness and kurtosis values, and the Q-Q plot graph. The skewness and kurtosis values for the continuous variables were between –1 and+1, supporting the assumption of normal distribution [19]. The Kolmogorov-Smirnov test (for n > 50) yielded a p-value of 0.001, and the points on the Q-Q plot graph were found to be on the 45-degree line. Moreover, the histogram graph associated with the scales exhibited bell-curve characteristics. These findings suggest that the data meet the normal distribution assumption, making it appropriate to use parametric tests. The Independent Samples t-test was employed to compare two categorical variables.

The Pearson correlation test was employed for the correlation analysis, and correlation coefficients (r) were reported. This coefficient, which ranges between –1 and 1, signifies the strength of a relationship. The interpretation of correlation coefficients was as follows: if r > 0.6, the relationship was considered strong; if r was between 0.3 and 0.6, it was considered moderate; and if r < 0.3, the relationship was considered weak [20]. The threshold for statistical significance was set at p < 0.05.

2.6 Ethical considerations

We received research ethics committee approval from the Hasan Kalyoncu University Institutional Ethical Review Board (Date: 18/03/2022, number: 2022/28). The study was conducted according to the principles of the Declaration of Helsinki. Before the study, the students were informed about the aim of the study, and their written and verbal consent was received online in line with the principle of voluntary participation. The students completed the questionnaires anonymously.

3 Results

This study was completed with 733 nursing students studying in a multicultural city. 75.7% of the students participating in the study were female, 94.8% were Turkish nationals, 90.2% were native Turkish speakers, 61.8% were studying in a state university, and 37.7% were in their first year. 81.3% did not take a course on transcultural healthcare. It was determined that 69.2% of the students had friends from different cultures, 93.6% enjoyed spending time with individuals from different cultures, 42% cared for patients from different cultures, and 55.5% had difficulties caring for patients from different cultures. 89.6% of the students had never traveled abroad before, 13% had a family history of immigration, 74.4% wanted to live overseas, and according to the CHS scores, 49.2% of the participants were sometimes culturally modest. The students were asked to rate the importance of cultural diversity in nursing care between 0–10 (with an open-ended question), and the mean was calculated as 7.91±2.19 (Table 1).

Table 1
Descriptive characteristics of the nursing students (n = 733)

Descriptive Characteristics n %

Gender

Female 555 75.7

Male 178 24.3

Nationality

Turkish 695 94.8

Other 38 5.2

Native Language

Turkish 661 90.2

Other 72 9.8

University

State University 453 61.8

Private university 280 38.2

Year/Grade

1st grade students 276 37.7

2nd grade students 213 29.1

3rd grade students 213 29.1

4th grade students 31 4.2

Received education about transcultural healthcare

Yes 137 18.7

No 596 81.3

Fluency in languages other than native language

Yes 189 25.8

No 544 74.2

Presence of friends from different cultures

Yes 507 69.2

No 226 30.8

Enjoying spending time with people from different cultures

Yes 686 93.6

No 47 6.4

Experience of caring for patients from different cultures

Yes 308 42.0

No 425 58.0

Status of traveling abroad before

Yes 76 10.4

No 657 89.6

Presence of a family history of immigration

Yes 95 13.0

No 638 87.0

Desire to live abroad

Yes 545 74.4

No 188 25.6

According to CHS, students

rarely has cultural humility 45 6.1

sometimes has culturally humility 361 49.2

usually has culturally humility 216 29.5

has cultural humility all the time 111 15.1

Mean + SD Min Max

Age: 21.13±1.46 18 32

The Importance of Cultural Diversity in Nursing Care: 7.91±2.19 1 10

Context for difference in perspective 24.53±6.53 7 35

Self-attributes 14.74±3.63 4 20

Outcomes of cultural humility 30.75±7.49 8 40

CHS Total Score 70.03±16.01 19 95

Descriptive Characteristics	n	%
Gender
Female	555	75.7
Male	178	24.3
Nationality
Turkish	695	94.8
Other	38	5.2
Native Language
Turkish	661	90.2
Other	72	9.8
University
State University	453	61.8
Private university	280	38.2
Year/Grade
1st grade students	276	37.7
2nd grade students	213	29.1
3rd grade students	213	29.1
4th grade students	31	4.2
Received education about transcultural healthcare
Yes	137	18.7
No	596	81.3
Fluency in languages other than native language
Yes	189	25.8
No	544	74.2
Presence of friends from different cultures
Yes	507	69.2
No	226	30.8
Enjoying spending time with people from different cultures
Yes	686	93.6
No	47	6.4
Experience of caring for patients from different cultures
Yes	308	42.0
No	425	58.0
Status of traveling abroad before
Yes	76	10.4
No	657	89.6
Presence of a family history of immigration
Yes	95	13.0
No	638	87.0
Desire to live abroad
Yes	545	74.4
No	188	25.6
According to CHS, students
rarely has cultural humility	45	6.1
sometimes has culturally humility	361	49.2
usually has culturally humility	216	29.5
has cultural humility all the time	111	15.1
	Mean + SD	Min	Max
Age:	21.13±1.46	18	32
The Importance of Cultural Diversity in Nursing Care:	7.91±2.19	1	10
Context for difference in perspective	24.53±6.53	7	35
Self-attributes	14.74±3.63	4	20
Outcomes of cultural humility	30.75±7.49	8	40
CHS Total Score	70.03±16.01	19	95

The total mean score of the CHS of the students participating in the research was 70.03±16.01. The Context for the difference in perspective sub-dimension score was 24.53±6.53. In contrast, the Self-attributes sub-dimension score was 14.74±3.63, and the Outcomes of the cultural humility sub-dimension score was 30.75±7.49 (Table 2).

Table 2

Comparison of Cultural Humility Scale Score by demographic characteristics of students

Demographic Characteristics	Total CHS Score	Context for difference in perspective	Self-attributes	Outcomes of cultural humility
Gender FemaleMale U, p	71.49±15.3265.46±17.284.429,.000^**	25.060±6.3922.87±6.693.919,.000^**	15.01±3.4313.92±4.093.492, 0.001	31.42±7.1528.65±8.144.334,.000^**
Age ≤20 >20 t, p	71.07±14.7469.99±16.410.830, 0.407	24.68±6.3724.59±6.600.186, 0.853	14.87±3.3414.79±3.690.275, 0.783	31.50±6.8930.60±7.651.485, 0.124
NationalityT.R.Othert, p	70.72±15.6257.39±18.064.758,.000^**	27.82±6.4119.15±6.395.034,.000^**	14.90±3.5711.94±3.664.653,.000^**	30.99±7.2826.28±9.642.794, 0.004^*
University PrivateStatet, p	69.67±16.2370.24±15.900.471, 0.637	24.36±6.7024.63±6.430.542, 0.588	14.70±3.5714.77±3.670.266, 0.791	30.60±7.4530.83±7.520.406, 0.684
Native LanguageTurkishOthert, p	70.62±15.5764.61±18.882.679, 0.007^*	24.74±6.4422.56±7.052.657, 0.008^*	14.87±3.5413.59±4.252.427, 0.015^*	31.00±7.2628.44±9.111.191, 0.046^*
Received education about transculturalhealthcareYesNot, p	69.76±16.0370.09±16.020213, 0.831	24.37±6.4124.56±6.560.315, 0.753	14.78±3.4414.73±3.680.140, 0.888	30.60±7.6330.78±7.460.250, 0.177
Experience of traveling abroad beforeYesNot, p	70.49±5.8265.97±17.202.339, 0.020^*	24.72±7.1422.84±6.432.387, 0.017^*	14.84±3.6013.93±3.792.068, 0.039^*	30.93±7.4129.19±8.051.912, 0.056
Desire to live abroadYesNot, p	71.01±15.9967.17±15.802.852, 0.004^*	24.91±6.5723.41±6.312.727, 0.007^*	14.99±3.6514.03±3.503.131, 0.002^*	31.10±7.3829.71±7.272.196,0.028^*
Enjoying spending time with people from different culturesYesNot, p	70.64±15.6561.04±18.553.511,.000^**	24.71±6.4721.85±6.872.586, 0.010^*	14.88±3.5612.80±4.133.341, 0.001^**	31.04±7.3226.38±8.573.755,.000^**
Experience of caring for patients from different culturesYesNot, p	69.96±15.6670.07±16.280.090, 0.928	24.45±6.3224.58±6.690.268, 0.788	14.79±3.6314.71±3.630.315, 0.857	30.71±7.4130.77±7.550.111, 0.912

^*p < 0.05 ^**p < 0.01.

This study found a significant difference in gender, nationality, spoken native language, desire to live abroad, and enjoy spending time with people from different cultures. The CHS level of the female students was higher than that of the male students (p < .000). The CHS mean scores of the Turkish citizens were higher than the participant’s citizens, and the number of those whose native language is Turkish was higher than that of the other students (p = 0.000, p = 0.007, respectively). No statistically significant difference was found between the CHS mean scores of the students and the other descriptive characteristics (Table 2).

The present study made significant observations regarding the Cultural Humility Scale (CHS) total scores and its sub-dimensions. It was found that students who had traveled abroad had higher scores in the CHS total scale and in the sub-dimensions of Context for Difference in Perspective and Self-attributes (p = 0.020, p = 0.017, p = 0.039, respectively). Similarly, students who expressed a desire to live abroad exhibited higher scores in the CHS total scale and its sub-dimensions than students who did not have such aspirations (p = 0.004, p = 0.007, p = 0.002, and p = 0.028, respectively) (Table 2).

A significant difference between enjoying time with people from different cultures and cultural humility was found. The total CHS mean score of the students who enjoyed spending time with people from other cultures was higher than those who did not enjoy spending time with people from different cultures (t = 3.511, p < 0.00). According to these results, the Context for differences in perspective, Self-attributes, and Outcomes of cultural humility sub-dimension scores of the students who enjoy spending time with people from different cultures were higher than those of the other students (p < 0.05). (Table 2).

It was determined that there was a weak but significant positive correlation between the 0–10 point averages of the students regarding the importance of cultural diversity in nursing education and the total scores of the Cultural Humility Scale and its sub-dimensions (r = 0.273, r = 0.299, r = 0.238, r = 0.209; p < 0.01). It was determined that as the scores given by the students regarding the importance of cultural diversity in nursing education increased, their level of cultural humility increased(Table 3).

Table 3

The Relationship between the Average Scores Given to the Importance of Cultural Diversity in Nursing Education and the Cultural Humility Scale average scores

	Average Scores Given the Importance of Cultural Diversity in Nursing Education	Total CHS Score	Context for difference in perspective	Self-attributes	Outcomes of cultural humility
Average Scores Given the Importance of Cultural Diversity in Nursing Education	1
Total CHS Score	,273^**	1
Context for difference in perspective	,299^**	,879^**	1
Self-attributes	,238^**	,907^**	,701^**	1
Outcomes of cultural humility	,209^**	,931^**	,667^**	,843^**	1

^**p < 0,001 Pearson correlation Test.

A weak yet statistically significant positive correlation was identified between the 0–10 point averages of the students regarding the importance of cultural diversity in nursing education and the total scores of the Cultural Humility Scale and its sub-dimensions (r = 0.273, r = 0.299, r = 0.238, r = 0.209; p < 0.01). According to the rules of interpretation proposed by Mukaka (2012), these correlation coefficients (r = 0.273, r = 0.299, r = 0.238, r = 0.209) fall into the ‘weak’ category [20]. However, considering the significance level of this ‘weak’ correlation (p < 0.01), it demonstrates a marked increase in the students’ level of cultural humility as the importance attributed to cultural diversity in nursing education increases. Consequently, these findings support the notion that students’ importance of cultural diversity may positively influence their levels of cultural humility.

4 Discussion

This study, aimed at assessing the cultural humility levels of nursing students, found that students demonstrate a significant engagement with cultural humility across various dimensions. This engagement is particularly pronounced in environments with diverse cultural interactions, such as those encountered in the Southeastern Anatolia region of Turkey. As the diversity of the patient and caregiver population increases, healthcare providers need to care for patients with different cultural perspectives and values [21]. As in this sample, today’s developments and migrations reveal the necessity of people from other cultures to live together [22, 23]. It has been shown that nursing students need cultural skills, such as transcultural awareness, sensitivity, humility, and some technical and clinical skills, to have a successful professional working life after graduation [24]. Nurses must consider and try to understand the situation of people receiving assistance within their cultural context. Studies indicate that approaches based on cultural humility provide more positive and successful results for people who receive assistance [5 , 26]. That they were educated in a city in the Southeastern Anatolia Region, which contains the different cultures of Turkey and has the highest immigrant population, is thought to have contributed to this situation.

Within the scope of the research, the factors related to the student’s cultural humility were evaluated. For example, most of the students participating in our study were women, and it was found that the women’s cultural humility levels were higher than the men’s. Similar to this study, in the survey of university students by Gonzales (2017), it was concluded that women could empathize culturally better than men [27].

Based on the data in Table 1, most students indicated having friends from diverse cultural backgrounds and enjoying the company of people from different cultures. Additionally, it was observed that a significant proportion of them expressed the desire to work abroad. The students who wished to live abroad exhibited notably higher cultural humility. A similar observation was noted in another study where individuals desiring to live abroad exhibited a heightened level of transcultural effectiveness [28]. These interactions, especially with individuals from different cultures, present an opportunity for self-reflection on personal practices and value systems, which can foster cultural competence. This awareness and understanding of diverse ways of practicing nursing might advance nursing practices across cultures [29]. Since the experience of going abroad allows students to see different cultures and to live and compare in a different culture, it is natural for those who have this experience to have a high level of cultural humility. The literature found that students who went abroad with study abroad programs had a better understanding of cultural differences [30, 31]. In a study conducted as a field study, the level of transcultural effectiveness was found to be higher for those who have friends from foreign countries [28]. In this study, the literature supports the high level of cultural humility of the students who had friends from different cultures and enjoyed spending time with people from different cultures.

Most of the students did not receive training in transcultural care; however, it was observed that the cultural humility levels of the students who gave high scores to the importance of cultural diversity in nursing education increased. In developing countries, such as Turkey, a great effort is needed to raise awareness of the importance of transcultural nursing education and to prepare a standard quality education program [32, 33]. Gungor et al.’s study determined that the level of transcultural effectiveness, behavioral flexibility, comfort in communication, and management level in communication of students receiving transcultural healthcare education were significantly higher [15]. It is stated in the literature that students who would like to receive transcultural education have a higher awareness and desire to learn about this subject [21]. The prejudiced and hostile approach of nurses and other health staff who need to be well-educated or equipped to provide healthcare to individuals, families, or communities from different cultures may adversely affect the quality of healthcare [34, 35].

4.1 Limitations of the study

This study comes with certain limitations that should be noted. First, being conducted in nursing schools of a public and a private university located in a refugee-dense area, there is a likelihood that students primarily considered refugees when responding to questions about patients from various cultural backgrounds. Second, a lower representation of final-year students and those from private universities in the survey could limit the comprehensiveness of our evaluation. The lower participation rate observed in this study can be attributed to the university’s internship system, which typically involves full-time clinical rotations for final-year students. Finally, while our simple random sampling method provided a naturally occurring distribution of students across different years, it might not precisely represent the overall student distribution in nursing education. These limitations, such as the study setting and sample representation, could restrict the generalizability of our findings.

5 Conclusion

The study’s findings indicate that nursing students’ cultural humility, as measured by the Cultural Humility Scale, falls within the range indicating a ‘sometimes’ to ‘usually’ engagement with cultural humility principles. This suggests the students’ varying but generally positive levels of cultural humility. It was found that the female students, those with experience going abroad, those who wanted to live in another country, and those who enjoyed spending time with people from different cultures had higher levels of cultural humility. Most of the students did not take courses on transcultural nursing; however, it was seen that the cultural humility levels of the students who believed in the importance of cultural diversity in nursing education were higher. Elements of cultural humility must be taught and applied in classroom and clinical settings for nursing students to become nurse professionals and provide transcultural nursing care. Establishing ground rules reinforced throughout the educational process can help create an environment that encourages support, cooperation, openness, and respect. Applying the characteristics of cultural humility will promote a more inclusive and psychologically safe learning environment, thereby increasing the potential to improve learning outcomes and encourage minority students’ success in nursing.

Ethical considerations

Informed consent

Written and verbal informed consent was obtained from all participants.

Footnotes

Acknowledgments

We want to thank the students who participated in this study.

Conflict of interest

There is no conflict of interest among the authors.

Funding

This project did not receive any funding.

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