Ličen and Prosen BMC Medical Education (2023) 23:819 BMC Medical Education

[Link]

RESEARCH Open Access

The development of cultural competences

in nursing students and their significance
in shaping the future work environment:
a pilot study
Sabina Ličen1* and Mirko Prosen1

Abstract
Background Working in a culturally diverse environment entails a moral and professional responsibility to provide
culturally competent care. This has been recognised as an important measure to reduce health inequalities,
improve the quality of care and increase patient satisfaction. The aim of this study was to assess the level of cultural
competence in nursing students a decade after the introduction of transcultural nursing content into the nursing
curriculum in Slovenia.
Methods A descriptive cross-sectional design with 180 s-year nursing students as a convenience sample was used.
Cultural competence was assessed using the Cultural Competence Assessment Tool (CCATool) via an online survey.
IBM SPSS facilitated statistical analysis, using descriptive statistics and inferential methods, including the chi-square
test. Non-parametric tests (Mann Whitney U, Kruskal-Wallis H and Wilcoxon signed-rank) were used for non-normally
distributed data (Shapiro-Wilk test, p < 0.05). The significance was set at p ≤ 0.05.
Results The results indicate that students demonstrate a high level of cultural competence, although there is
room for improvement in terms of cultural sensitivity, as determined by coding the CCATool. The results also show a
remarkable contrast between their self-assessed scores and the objective scores obtained from CCATool coding of the
statements in each subscale (p < 0.005). In addition, significant differences (p = 0.002) are found in subscale “Cultural
Knowledge” particularly between students who have lived abroad for more than 6 months and those who have not.
The latter group has a higher score in the CCATool, indicating greater cultural knowledge.
Conclusions The study suggests that the presence of transcultural elements in the Slovenian nursing curriculum is
associated with higher self-reported levels of cultural competence among nursing students, although the present
research design does not allow for causal interpretations. This competence is of immense importance in preparing
students for their future professional environment. However, it is crucial to further refine the nursing curriculum,
especially through greater integration of transcultural content in all health disciplines. In addition, the introduction

*Correspondence:
Sabina Ličen
[Link]@[Link]
Full list of author information is available at the end of the article

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Ličen and Prosen BMC Medical Education (2023) 23:819 Page 2 of 9

of innovative teaching and learning approaches can better prepare students to deal with the diverse cultural
experiences they will encounter in their nursing careers.
Keywords Cultural competence, Cultural competence Assessment Tool, Nursing students, Transcultural nursing,
Nursing curriculum

Introduction into account their values, beliefs, customs and tradi-

Globalisation processes, epidemiological conditions, tions, and incorporating them in the provision of care [8].
social conflicts and natural disasters often lead to Cultural competence is the ability to provide culturally
increased migration flows. According to the International sensitive and competent care to patients, families or com-
Organization for Migration [1], there were approximately munities by considering their values, beliefs, customs and
281 million international migrants worldwide in 2020, traditions and incorporating them in the provision of care
representing 3.6 per cent of the world’s population. This [8]. According to Papadopoulos, Tilki and Taylor’s 1998
number would most likely have increased to 283 mil- model, cultural competence involves providing effective
lion had it not been for COVID-19. Europe is currently healthcare while taking into account individuals’ cultural
the largest destination for international migrants, with a beliefs, behaviours and needs. It is seen as a continuous
total of 87 million migrants (30.9% of the international developmental process resulting from the integration of
migrant population). Due to the war in Ukraine, these knowledge and skills acquired throughout one’s personal
numbers are currently increasing rapidly. The resulting and professional life [9]. It is both a dynamic process and
increase in cultural diversity is a challenge for all social its outcome, which enables the provision of effective,
structures in any host country, and also has an impact safe, unbiased and quality care [4, 10]. A culturally com-
on the health system, especially on healthcare providers, petent healthcare professional is one who possesses the
who are obliged to provide quality care to patients of all virtue of courage to challenge accepted norms, practices
cultural backgrounds [2]. Working in a culturally diverse and even values that may harm, discriminate against or
environment places a moral and professional responsibil- disadvantage health service users in any way [10].
ity on all nursing students, nurses, their work organisa- The cultural competence of student nurses is of para-
tions, educational institutions, professional bodies and mount importance in providing effective and compas-
the health system to provide culturally competent care sionate care to diverse patient populations. Through
[3, 4]. While this has been recognised as an important education and exposure to different cultures, they
measure to reduce health inequalities, improve quality of develop a deep understanding and appreciation of the
care and increase patient satisfaction, it also means that beliefs, values and practises of others. This enables
future nurses need to be adequately prepared, and that them to provide patient-centred care, build trusting
the process of education and socialisation should begin at relationships and manage intercultural communication
undergraduate level, where the values and norms of the problems. By promoting cultural competence, nurs-
nursing profession are fundamentally shaped [3, 5]. ing students contribute to more inclusive and equitable
healthcare that respects and meets the unique needs of
Background each individual [11, 12].
Nurses not only represent the largest group of healthcare The two dimensions within the concept of cultural
professionals in the health system, but also spend most of competence – ‘sensitivity’ and ‘culture’ – can be studied
their working time providing direct care to patients [2]. together, as cultural sensibility represents an openness to
This means that they need to understand patients in the emotional impressions, receptivity, and sensitivity, which
context of their cultural background. Sufficient knowl- allows for personal reflection and influences human
edge about different cultures and traditions is also neces- behaviour when interacting with others [3]. As explained
sary to perform a comprehensive patient assessment [6]. by the authors, addressing cultural sensibility in nursing
Cultural competence has been at the centre of the debate curricula should represent the first step in helping stu-
in nursing for over half a century and is now an essen- dents understand the importance of culture and its role
tial element of nursing practice, as well as an indicator of in caring for patients from different cultures. To facilitate
the level of professionalism in nursing. While some argue training in cultural sensibility and to support the devel-
that the concept of cultural competence lacks clarity [7], opment of cultural competence in educational settings, it
the commonalities in the foundations of this concept is essential to assess students’ level of understanding and
remain the same despite certain problems with nomen- cultural awareness [3, 5].
clature. Cultural competence can be defined as the abil- Cultural sensitivity and cultural awareness are not the
ity to provide culturally sensitive and competent care to only attributes of cultural competence. Cultural skills,
patients and their families or communities with, taking cultural knowledge, cultural proficiency, and dynamism
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 3 of 9

are all concepts underlying cultural competence [4, 13]. in 2020 to a mandatory 90-hour course entitled ‘Trans-
Although the concept of cultural proficiency may seem cultural Nursing and Global Health’. In 2014, an addi-
less prominent in discussions of cultural competence, it tional lecture on transcultural nursing was added to the
is nevertheless a key component of clinical nursing and second-year undergraduate nursing curriculum as part
a cornerstone for the advancement of transcultural nurs- of the mandatory course ‘Sociology of Health and Illness’.
ing practice. Cultural proficiency refers to the acquisition Ever since, cultural competence has been widely pro-
and research-based knowledge transfer with therapeutic moted among both students and student mentors in the
approaches. It involves a proactive approach and reflects clinical setting. The aim of this study was to assess level
a commitment to change. Its focus is on behaviour, not of cultural competence of nursing students’ a decade
emotions, and it can be applied to organisational prac- after the introduction of transcultural nursing content in
tices as well as individual behaviours [4, 14]. Cultural the nursing curriculum in Slovenia.
proficiency is a transformational model and as such also
provides teachers and designers of study programmes Method
with important feedback on their success in student Research design
transformation during their education. To achieve the aim of the study, a cross-sectional study
Over the past two decades, several new concepts have was conducted on a convenience sample of undergradu-
emerged in the discipline of transcultural nursing which ate nursing students.
present cultural competence in a new light. One of these
concepts is culturally competent compassion. Papado- Research questions
poulos [10] believes that culturally competent nursing is The purpose of the study is to gain a comprehensive
undoubtedly compassionate nursing. She defines it as a understanding of the characteristics and experiences of
human quality of understanding the suffering of others the participants, thus improving the validity and applica-
and helping them in a culturally appropriate and accept- bility of the study’s findings. By collecting baseline data
able manner, which involves taking into consideration the on students’ previous experiences with cultural diversity
cultural background of both patients and carers, as well and exposure to transcultural care concepts, the study
as the context of care. Another, perhaps more challenging will provide a solid foundation for future comparisons
concept is cultural humility. It is defined as characteristic between students with varying levels of cultural knowl-
of respect, empathy, and self-reflection/self-criticism at edge. Understanding students’ cultural and demographic
the intrapersonal and interpersonal levels. At the intra- backgrounds is critical to interpreting study findings and
personal level, it involves an awareness of one’s limited offers insights into how variables, such as cultural experi-
ability to understand the patient’s worldview and cul- ences and personal background, define their level of cul-
tural characteristics, while at the interpersonal level, it tural competence.
involves an attitude of openness and respect towards the The research questions are as follows: (a) To what
patient’s worldview [15]. Despite these different perspec- extent do student nurses demonstrate cultural com-
tives, both cultural competence and cultural humility are petence? (b) What are the discrepancies between self-
effectively used to encourage self-reflection and promote assessed scores and objective scores obtained by coding
reflective practice in relation to patients’ cultural charac- statements on each subscale in CCATool? and (c) How do
teristics. Both concepts also emphasise the need to chal- demographic and other social characteristics of student
lenge the institutions and systems that allow for injustices nurses define their level of cultural competence and what
which lead to inequalities, and to show that we can work differences are observed between them?
together in this endeavour [16].
Curriculum interventions have been shown to contrib- Participants
ute to the development of cultural competence in nursing The sample was formed from 317 s-year undergraduate
students [17–19]; however, in Slovenia such interventions nursing students in the academic year 2021/2022 at one
were rarely introduced before 2013 [5]. Undergraduate of the nursing faculties in Slovenia. Invitations to par-
nursing education in Slovenia is in line with the Direc- ticipate in the survey were sent to students through the
tive on the Recognition of Professional Qualifications Office of Student Affairs, along with a detailed explana-
2005/36/ES and 2013/55/EU as well as the guidelines of tion of the purpose of the survey. The calculated sample
the Bologna Declaration. In Slovenia, at the University of size, based on a confidence level of 95% with a margin of
Primorska, Faculty of Health Sciences (UP FHS), the pro- error of 5%, was 174, which means that we achieve repre-
cess of changing the nursing curriculum by introducing sentativeness of the sample of nursing students (n = 180)
the topic of transcultural nursing began in 2013 with the among whom the survey was conducted.
development of a 25-hour elective course ‘Transcultural
Nursing’ at the postgraduate level [5], which was changed
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 4 of 9

The questionnaire concise and easy to understand. In addition, the internal

Data collection used the Cultural Competence Assess- consistency of each of the four subscales was assessed,
ment Tool (CCATool), which is based on Papadopoulos, yielding an acceptable level of reliability. The internal
Tilki, and Taylor’s 1998 model of cultural competence consistency of the individual subscales was satisfactory,
[20]. Permission to use the original CCATool ques- as evidenced by Cronbach’s alpha coefficients between
tionnaire for research purposes was obtained from the 0.79 and 0.85 [23].
copyright holder, Irene Papadopoulos. The original
questionnaire has demonstrated high reliability with a Data collection
Cronbach’s alpha coefficient greater than 0.7 [21]. The The questionnaire was distributed to students via email
CCATool includes four subscales: cultural awareness, in the form of an online survey by the researchers. Par-
cultural knowledge, cultural sensitivity, and cultural ticipation in the survey was voluntary, and students gave
skills. Each subscale of the questionnaire included ten their consent by clicking on the embedded link, indicat-
statements that participants rated on a 4-point Likert ing their agreement to participate, and starting the sur-
scale. The scale contained the following response options: vey. The online questionnaire, which was administered
5 - strongly agree, 4 - agree, 2 - disagree, and 1 - disagree via the open source application EnKlikAnketa (www.1ka.
at all. The scale did not include a neutral option, as it si), could be completed throughout the month of May
aimed to capture participants’ agreement or disagree- 2022. The questionnaire included a comprehensive expla-
ment with each statement. To facilitate self-assessment nation of the purpose of the survey and instructions on
of cultural awareness, knowledge, sensitivity, and skills, how to complete it. To maintain anonymity, a database
each section also included a visual analogue scale (VAS). was set up to store participants’ responses without per-
Four statements within the cultural sensitivity subscale sonal information. Only the lead researcher had access to
were reverse coded, meaning that higher scores indicated the data during the analysis phase.
lower levels of cultural sensitivity. In each subscale, par-
ticipants could achieve a maximum score of 10 points Data analysis
and a minimum score of 0 points. A perfect score of ten Data obtained from EnKlikAnketa ([Link]) were
in all four subscales was considered indicative of cultural exported for statistical analysis using IBM SPSS version
competence and meant that students possessed a high 26.0 (SPSS Inc, Chicago, IL, USA). Statistical methods
level of cultural competence. The CCATool can be used used in this study included basic descriptive statistics
for self-assessment by health professionals as well as for such as frequency, minimum, maximum, mean, median,
organizational assessment to identify strengths and areas and standard deviation. In addition, inferential statistics
for improvement in cultural competence. It provides were applied, particularly the chi-square test of indepen-
valuable insight into individual or collective readiness to dence. Given the non-normal distribution of the data
provide culturally congruent care and helps guide tar- (confirmed by the Shapiro-Wilk test, p < 0.05), non-para-
geted interventions and training programs to improve metric tests were used to determine statistically signifi-
cultural competence [9]. cant differences between groups. The Mann Whitney U
To ensure linguistic accuracy and cross-cultural valid- test and the Kruskal-Wallis H test were used for group
ity, a translation process was used for the questionnaire. comparisons, while the Wilcoxon signed-rank test was
First, the questionnaire was translated from English into used to compare two sets of results from the same partic-
Slovenian. The back-translation method described by Ili- ipants. A p-value of ≤ 0.05 was considered the threshold
escu [22] was used. Two experts, knowledgeable in the for statistical significance.
field and experienced in quantitative research methods,
worked together to produce the translated version. They Results
carefully reviewed the translation to ensure terminologi- Participants demographics
cal consistency. Subsequently, the Slovenian version of Table 1 shows that the majority of students were female.
the questionnaire was translated back into English and The age of the students ranged from 18 to 33 years
formed the basis for the comparison. Both versions of the (Mdn = 22.5; SD = 3.2). The sample was balanced in terms
questionnaire underwent a thorough validation process, of students’ place of residence, with an even distribution
assessing the validity and clarity of the questionnaire. As between urban and rural areas. More than half of the stu-
part of a pilot study, the questionnaire was administered dents identified themselves as religious. While most stu-
to a sample of 10 university faculty members in the fields dents had not lived in a country other than their country
of sociology, nursing, and transcultural nursing. The aim of birth, it is notable that 68% of students had relatives
was to assess the comprehensibility and face validity of abroad. Regarding interactions with people of other eth-
the questionnaire. The experts involved in the pilot study nic backgrounds, 75% of students reported having such
confirmed that all items of the questionnaire were clear, interactions more frequently, while 25% reported very
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 5 of 9

Table 1 Demographic characteristics of participants (n = 180) in cultural sensitivity, which received the lowest scores.
Variables n % Although a perfect score of ten on all four subscales indi-
Gender cates comprehensive cultural competence, the students
Male 34 18.9 scored 32 out of 40 based on CCATool coding.
Female 146 81.1
Each of the four subscales contained one or two state-
Country of birth
ments that respondents self-rated on a visual analogue
Slovenia 150 83.3
Other (Bosnia and Herzegovina, Croatia, Italy, Kosovo, 30 16.7
scale (VAS) ranging from 1 (lowest/negative) to 10 (high-
Macedonia, Moldova, Serbia) est/positive). The purpose of these statements was to
Have you lived in a foreign country for more than 6 compare students’ self-assessment based on VAS with
months? their final score on each subscale and to identify possible
Yes 33 18.4 discrepancies (see Table 3).
No 147 81.6 The results showed a remarkable discrepancy between
Do you have relatives living in a foreign country? 124 68.9 the subjective perception of cultural awareness and its
Yes 56 31.1
objective measurement, as participants scored higher
No
How would you define your religious beliefs?
on the rated statements than on the self-assessed state-
I am religious. 108 60.0
ment (p < 0.001) using VAS. Similar results were observed
I am an atheist. 43 23.9 for the subscales assessing cultural knowledge and cul-
I am an agnostic. 8 4.4 tural skills. In both cases, students scored higher on the
I do not wish to answer. 21 11.7 rated statements within each subscale than on the self-
Place of residence assessed statements (p = 0.002 and p < 0.001, respectively)
City 80 44.4 using VAS. However, for the subscale cultural sensitivity,
A suburb 24 13.4
the self-assessed values on the (VAS) were significantly
The countryside 76 42.2
higher than the values resulting from the statements
To what extent do you meet people from other ethnic
groups? assessed by the students on the scale (p < 0.001).
Daily 81 45.0
Several times a week 54 30.0 Factors associating cultural competence among nursing
Once a week 20 11.1 students
Once a month 13 7.3 To identify any statistically significant differences
A few times a year 12 6.6
between the groups, the Mann-Whitney U-test, the
Kruskal-Wallis H-test and the chi-square test for inde-
infrequent interactions, occurring either once a week or pendence were conducted (Table 4).
month or a few times a year. The results revealed intriguing patterns in relation to
several factors that associate the level of cultural com-
Level of cultural competence petence measured by the CCATool. Although there were
The cumulative score obtained using CCATool coding some differences in performance between female and
was high and above the calculated median for the CCA- male students, these differences did not reach statistical
Tool (Mdn = 32.0, SD = 7.9; 95% confidence interval [29.8, significance (p > 0.05). Similarly, students born outside
31.6], p < 0.01), as shown in Table 2. Slovenia, including Bosnia and Herzegovina, Croatia,
The findings indicate that the respondents display a Italy, Kosovo, Macedonia, Moldova and Serbia, showed
high level of cultural competence. Moreover, the results higher levels of cultural competence; however, these dif-
reveal strong cultural awareness among the partici- ferences were not statistically significant (p > 0.05). Nev-
pants. Additionally, the respondents demonstrated pro- ertheless, statistically significant differences (p < 0.05)
ficiency by providing correct answers on nine out of ten were found in the Cultural Knowledge subscale between
statements. However, there is scope for improvement students born in Slovenia and those born outside

Table 2 Descriptive statistics of cultural competence assessment

Variable n Mdn(IQR) M±SD 95% CI p value
Lower Upper
Cultural awareness 10 9.00(2) 8.75±1.615 8.50 8.99 < 0.001
Cultural knowledge 10 7.00(3) 7.27±1.726 6.95 7.59 < 0.001
Cultural sensitivity 10 6.00(2) 6.01±1.986 5.65 6.37 < 0.001
Cultural skills 10 10.00(2) 8.68±1.873 8.34 9.02 < 0.001
CCATool 40 32.00(29) 30.70±7.918 29.78 31.63 < 0.001
Note. n − number of statements; M − Mean; SD − Standard Deviation; Mdn − Median; IQR − Interquartile Range; 95% CI − 95% Confidence Interval
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 6 of 9

Table 3 Comparison between the VAS self-assessed scores and independence was conducted to examine the relation-
objective scores resulting from the coded statements on each ship between the level of cultural competence and a stay
subscale - Wilcoxon Signed-Rank Test abroad of more than 6 months. The results showed a sta-
Variable M±SD Mdn(IQR) Wilcoxon
tistically significant relationship (χ(2) = 50.550, p = 0.020)
Signed Ranks
test between these two variables, indicating that a stay abroad
Z p of more than 6 months is associated with higher levels of
I am highly aware of my 7.77±2.064 8(4) ‒4.797 < 0.001 cultural competence. However, when examining the rela-
own ethnic and cultural tionship between the level of cultural competence and
identity (VAS self-as- the presence of parents born in another country or rela-
sessed question). tives living abroad, there was no statistically significant
Cultural awareness 8.75±1.615 9.00(2) relationship (p > 0.05) between these variables.
subscale
I am very well informed 5.78±2.018 6(2) ‒5.747 < 0.001
about the culture and
Discussion
social situation of the Establishing a transcultural nursing curriculum in
majority of my clients health education, which is predominantly biomedically
(VAS self-assessed driven and rarely encourages enough self-reflection on
question). social and cultural curricular content and context of
Cultural knowledge 7.27±1.726 7.00(3)
care despite advocating for an inclusive approach, pres-
subscale
ents a challenge in many educational settings worldwide
I am very comfortable 6.81±2.342 7(4) ‒3.082b 0.002
working with people [24]. In this study, we examined the self-assessed levels
whose beliefs, values of cultural competence in undergraduate nursing stu-
and practices are differ- dents. This was done a decade after the first changes
ent from my own (VAS towards a more transculturally oriented nursing curric-
self-assessed question).
ulum were introduced at UP FHS. Tracking the impact
I am very confident of 8.36±1.745 9(3) ‒7.082b < 0.001
of curricular modifications on the development of cul-
my ability to establish
trust, show respect and tural competence in future healthcare professionals in a
empathy to all people rapidly changing social and cultural context of care has
whatever their culture. a significant bearing on future changes to the nursing
Cultural sensitivity 6.01±1.986 6.00(2) curriculum.
subscale Our study indicates that undergraduate nursing stu-
I am very able to 7.53±1.842 8(2) ‒5.179 < 0.001 dents demonstrated a positive development in their cul-
incorporate the clients
cultural beliefs into the
tural competence, as they score relatively high overall
care and treatment I pro- on the cultural competence assessment. Consistent with
vide (VAS self-assessed previous research on the cultural competence of nursing
question). students, it was found that individuals who receive more
I am very confident to 7.51±2.1622 8(4) ‒4.909 < 0.001 culturally related education show higher levels of cultural
challenge racism and competence and that the latter increases with students’
discrimination towards
clients, carers and staff
grade level, and that teachers show higher levels of cul-
(VAS self-assessed tural competence than students [17, 18]. A more detailed
question). analysis of the cultural competence assessment subscales
Cultural skills subscale 8.68±1.873 10.00(2) revealed that nursing students performed exception-
Note. M − Mean; SD − Standard Deviation; Mdn − Median; IQR − Interquartile ally well in the areas of cultural awareness and cultural
Range; b − Based on positive ranks
skills. Cultural awareness involves the conscious rec-
ognition of one’s own cultural background and helps to
Slovenia. In addition, students who described themselves avoid stereotyping and prejudice towards other cultural
as atheists showed higher levels of cultural competence groups. Cultural competence, on the other hand, refers to
than their religious peers, but again no statistically signif- the ability to obtain necessary information from patients
icant differences were found (p > 0.05). Interestingly, stu- through culturally appropriate health assessments [6].
dents who lived in suburban or rural areas showed higher The higher performance in these subscales may be attrib-
levels of cultural competence than students who lived uted to the nursing students’ exposure to a multicultural
in urban areas (Mdn = 31.00, SD = 7.412; Mdn = 31.00, and multilingual environment. The location of UP FHS
SD = 8.207 and Mdn = 30.00, SD = 7.873 respectively), in a bilingual area and the proximity to one of the larg-
although these differences were not statistically sig- est ports in this part of the Adriatic probably contribute
nificant (p > 0.05). In addition, the chi-square test for to this experience [19]. In addition to the elements of
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 7 of 9

Table 4 Comparison of the scores of the CCATool and its subscales based on student characteristics
Variables Awareness Knowledge Sensitivity Skills CCATool
M±SD M±SD M±SD M±SD M±SD
Mdn(IQR) Mdn(IQR) Mdn(IQR) Mdn(IQR) Mdn(IQR)
Gender
Male 8.41±2.239 6.59±1.709 5.95±1.914 8.27±2.567 29.23±6.406
9.00(2) 7.00(3) 6.00(2) 9.00(3) 30.00(7)
Female 8.82±1.123 7.42±1.765 6.02±2.035 8.77±1.687 31.03±4.846
9.00(2) 7.00(3) 6.00(2) 10.00(2) 32.00(5)
U test 1351.000 1002.500 1126.000 1017.000 1282.000
p value > 0.05 > 0.05 > 0.05 > 0.05 > 0.05
Place of birth
Born in Slovenia 8.85±1.138 7.19±1.733 5.92±1.968 8.70±1.693 30.66±4.812
9.00(2) 9.00(2) 6.00(2) 9.00(2) 31.0(6)
Born outside Slovenia 8.17±2.358 7.78±2.045 6.28±2.137 8.44±2.770 30.67±7.187
9.00(2) 8.00(4) 6.00(2) 10.00(2) 32.50(11)
U test 1011.000 1002.000 1024.000 908.500 1249.500
p value > 0.05 < 0.05 > 0.05 > 0.05 > 0.05
Religious beliefs
Religious students 8.79±1.192 7.37±1.680 6.25±2.021 8.76±1.735 31.17±4.862
9.00(2) 7.00(3) 6.00(2) 9.50(2) 32.00(5)
Atheist students 8.77±1.832 7.57±1.906 5.53±1.995 8.50±2.301 30.37±5.968
9.00(2) 7.00(2) 5.00(2) 10.00(3) 31.50(6)
U test 1527.500 1287.000 996.000 1124.000 1499.000
p value > 0.05 > 0.05 > 0.05 > 0.05 > 0.05
Meeting people from other ethnic groups
Daily 8.66±1.283 7.05±1.645 5.84±2.078 8.64±1.773 30.20±5.047
9.00(2) 7.00(2) 6.00(3) 10.00(3) 31.00(7)
Several times a week 9.07±0.829 7.33±1.886 5.95±2.136 8.70±1.911 31.05±5.129
9.00(2) 7.00(3) 6.00(2) 9.50(2) 32.00(6)
Once a week 8.70±1.567 7.90±1.853 6.70±1.889 9.20±1.135 32.50±18.722
9.50(3) 8.50(3) 6.50(3) 10.00(2) 33.00(7)
Once a month 9.99±1.069 8.00±2.000 6.25±1.389 9.25±1.165 32.50±4.106
9.00(2) 8.50(3) 6.00(2) 10.00(2) 32.50(14)
A few times a year 8.57±0.787 7.29±1.799 6.43±1.718 8.71±1.113 31.00±3.317
8.00(1) 7.00(1) 7.00(3) 9.00(2) 30.00(6)
χ2 4.831 2.472 1.781 1.575 3.258
p value > 0.05 > 0.05 > 0.05 > 0.05 > 0.05
Note. M − Mean; SD − Standard Deviation; Mdn − Median; IQR − Interquartile Range; U test − Mann Whitney test; χ2 − Kruskal-Wallis test

transcultural care already implemented in the nursing Sensitivity” which focused mainly on the development of
curriculum, supervised and guided clinical practice can appropriate communication skills, scores were low, indi-
provide an additional cultural immersion experience and cating students’ relatively low level of cultural compe-
contribute to a greater development of cultural compe- tence. Similar to Wang et al. [19], we can also assume that
tences when caring for patients from diverse cultural the main reason for lower scores on these two subscales
backgrounds [13, 18]. Moreover, in their first year of may be students limited direct exposure to transcultural
study, nursing students’ clinical practice, where the basis nursing content in the undergraduate nursing curricu-
for a culturally appropriate health assessment and skill lum. The currently available hours for theoretical con-
development is set, is mainly supervised by university- tent (less than 5 h in a three-year nursing programme)
employed clinical mentors. In the second and third years are definitely not sufficient to achieve a desirable level of
of study, clinical mentors are mainly nurses employed cultural competence, especially if we wish to stimulate its
at healthcare institutions, and university teachers only development also after graduation. As a consequence of
assume the role of practice supervisors and coordinators. the limited number of hours in the curriculum, the focus
Compared to a similar study conducted at UP FHS in on culturally sensitive communication was also very lim-
2018 [17], this study found that nursing students’ levels of ited. From this perspective, future nursing curriculum
cultural awareness and clinical skills were higher. On the should focus on transcultural components and rely on
other two subscales, “Cultural Knowledge” and “Cultural cross-curricular integration. Cross-curricular integration
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 8 of 9

is a holistic didactic approach that characterises both Conclusion

horizontal and vertical integration of knowledge, content This study sheds light on the cultural competence of
and learning skills, and encourages an independent and nursing students in Slovenia. It reveals a general strength
active acquisition of learning experiences. Such linking in this area, but also shows room for targeted educational
of disciplines builds on modern theories of teaching and strategies, especially in cultural sensitivity. A divergence
learning and puts learners in the role of active construc- was also found between the students’ self-assessed cul-
tors of their own knowledge. This can happen either at tural competence and the objective scores measured by
the content, conceptual or process level [25]. the CCATool. Furthermore, the study shows differences
Cultural competence is an essential skill that nurses in cultural competence that are influenced by demo-
must possess in order to provide culturally congruent graphic and social variables, such as the length of time
care. The results of our study show that undergraduate spent living abroad. Although the study does not mea-
nursing students have made positive progress in their sure changes in competence levels over time, its findings
cultural competence, as indicated by their relatively high serve as an important reference for decision-makers in
overall scores on the cultural competence assessment. By education and health policy. The data support the need
promoting cultural competence in nursing students, we for ongoing evaluations, curriculum updates that inte-
can better enable them to provide patient-centred care grate diverse cultural perspectives, and a commitment
that recognises and respects each individual’s cultural to promoting ongoing education in cultural competence
background and values. This in turn will contribute to to equip nursing students for effective practise after
more effective and inclusive healthcare [26]. It is critical graduation.
to continue to monitor and evaluate the impact of cur-
riculum changes on the development of cultural compe- Relevance to clinical practice
tence. This ongoing evaluation will inform future updates Increasing cultural diversity among healthcare users
to nursing curricula and ultimately shape the future work poses new demands and challenges for healthcare profes-
environment and ensure high quality, culturally sensitive sionals, especially nursing students, who will be working
care [27]. As nursing students develop their cultural com- in dynamic and globally connected work environments in
petence, they will be better able to improve the health the future. Understanding and developing cultural com-
and overall well-being of patients from diverse cultural petences are key factors in successfully addressing the
backgrounds, which is consistent with the fundamental diverse needs of patients and building trusting relation-
goal of culturally congruent care [28]. ships between patients and health professionals. Under-
It is important to acknowledge some limitations of this standing the development of cultural competences and
study that should be considered when interpreting its their importance to the future nursing work environment
results. First, data collection was based on a self-com- has important implications for education programmes
pleted questionnaire, which may lead to bias or limited and policies related to health. A comprehensive and
accuracy of responses [29]. In addition, the study focused well-rounded education that includes the acquisition of
on a specific cohort of nursing students from a single cultural competences will enable future healthcare pro-
faculty, primarily due to newly introduced changes in fessionals to work effectively and efficiently in a diverse
the nursing curriculum in Slovenia. To gain a compre- environment and improve the quality of patient care.
hensive understanding of the development of cultural
Acknowledgements
competence, future research should include a nation- Not applicable.
ally representative sample of nursing students to enable
comparisons and facilitate the formulation of curriculum Authors’ contributions
Study conception and design: SL, MP; Data collection: SL, MP; Data analysis
changes or policies on a broader level. Longitudinal and and interpretation: SL, MP; Drafting of the article: SL, MP; Critical revision of the
experimental studies would provide valuable insights article: SL, MP. Both authors read and approved the final manuscript.
into the development of cultural competence. For future
Funding
work, a test-retest study design should be considered This research received no specific grant from any funding agency in the
to assess changes more accurately in cultural compe- public, commercial, or not-for-profit sectors.
tence over time. In addition, conducting international
Data Availability
comparative studies in countries with similar nursing The datasets generated and/or analysed during the current study are not
education and curriculum structures would serve as a publicly available due institutional data sharing clause but are available from
benchmarking tool and ensure the pursuit of quality in the corresponding author on reasonable request.

higher education.
Ličen and Prosen BMC Medical Education (2023) 23:819 Page 9 of 9

Declarations 13. Dobrowolska B, Gutysz-Wojnicka A, Ozga D, Barkestad E, Benbenishty J,

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