healthcare

Article
A Preliminary Study on the Cultural Competence of Nurse
Practitioners and Its Affecting Factors
Tsui-Ting Liu 1 , Miao-Yen Chen 2 , Yu-Mei Chang 3 and Mei-Hsiang Lin 2, *

1 Department of Nursing, Taipei Veterans General Hospital, National Taipei University of Nursing and Health
Science, Taipei 112303, Taiwan; [email protected]
2 School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei 112303, Taiwan;
[email protected]
3 Department of Nursing, Asia Eastern University of Science and Technology, New Taipei City 22061, Taiwan;
[email protected]
* Correspondence: [email protected]

Abstract: Cultural competence refers to a healthcare provider’s ability to consider cultural factors
that affect an individual’s health and attitudes toward disease and disability. Nurse practitioners
(NPs) are increasingly important in healthcare, practicing culturally competent care strategies to
improve the quality of patient care. The aim of this study was to explore cultural competence and its
related factors among NPs. A cross sectional study design with a structured questionnaire survey
was used. Purposive sampling was employed, for which 86 NPs were recruited from a medical
center in northern Taiwan. A T-test, one-way ANOVA, and Pearson’s product-moment correlation
coefficient were used for data analysis. The results were as follows: (1) overall, the total score for
cultural competence was above-average, with a score of 3.75; (2) years of experience as a NP was
found to have a statistically significant correlation with overall clinical competence, with r = 0.23,
p < 0.05; (3) there were significant differences in clinical awareness and cultural sensitivity related





 to the clinical ladder system (t = −2.42, p = 0.01; t = −2.04, p = 0.04). The findings of this study can
Citation: Liu, T.-T.; Chen, M.-Y.; provide information for directors of medical institutions to design an in-service educational program
Chang, Y.-M.; Lin, M.-H. A for NPs to enhance their cultural competence and nursing quality.
Preliminary Study on the Cultural
Competence of Nurse Practitioners Keywords: cultural competence; nurse practitioners; nursing education
and Its Affecting Factors. Healthcare
2022, 10, 678. https://doi.org/
10.3390/healthcare10040678

Academic Editor: Jose Granero-Molina 1. Introduction

Received: 9 March 2022

Nursing philosophy is the foundation of nurse practitioner (NP) training [1]. NPs
Accepted: 1 April 2022
have come into existence because of their demand in the health care system, and their
Published: 3 April 2022
role and areas of practice vary according to the health care needs and legal and medical
systems in different countries or districts [2,3]. NPs provide medical care equivalent to
Publisher’s Note: MDPI stays neutral
that of physicians and facilitate access to healthcare [4]. Currently, in Taiwan, there are
with regard to jurisdictional claims in
approximately 7000 NPs, the majority of whom practice in various acute care settings [3–5].
published maps and institutional affil-
The NP scope of practice includes the two following major parts: direct patient care and
iations.
indirect patient care. The top three direct patient care activities include performing a
physical assessment, discussing the treatment plan with physicians, and taking patient
history. The top three indirect patient care activities are charting, coordinating patient care,
Copyright: © 2022 by the authors.
and assisting with paperwork related to medical interventions [5].
Licensee MDPI, Basel, Switzerland. Taiwan has been driving the internationalization of medical services since 1995. How-
This article is an open access article ever, many foreign nationals have experienced problems and disparities in healthcare
distributed under the terms and services when seeking medical treatments [5]. These disparities arise from multifarious
conditions of the Creative Commons causes, which include the issue of language barriers, but more often concern the problem
Attribution (CC BY) license (https:// of cultural differences [6]. Leininger [7] suggested that professional health care providers
creativecommons.org/licenses/by/ should adapt to the changes in social structure and improve their cultural congruence to
4.0/). provide healthcare services that can cater to the patients’ cultural needs. Cross et al. [8]

Healthcare 2022, 10, 678. https://doi.org/10.3390/healthcare10040678 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, 678 2 of 10

define cultural competence as “a set of congruent behaviors, attitudes, and policies that
come together in a system, agency, or amongst professionals and enable that system, agency
or those professionals to work effectively in cross-cultural situations”. Cultural competence
in nursing focuses largely on the ability to compare and contrast the healthcare beliefs,
values, and cultural lifestyles of different individuals, and to provide them with culturally
appropriate and beneficial care [9]. There are many advantages in the provision of culturally
appropriate care. For example, it empowers patients and makes them feel respected and
more compliant with treatment plans, in turn improving their prognosis [10]. Many studies
highlighted that NPs provide medical care equivalent to that of physicians and facilitate
access to healthcare [11–13]. Igrarshi et al. [4], interviewed NPs in Japan and discovered
that NPs can improve the quality of healthcare by proposing practical solutions to prob-
lems faced by patients and medical organizations. Nursing practitioners in Taiwan were
developed in the context of a shortage in medical practitioners resulting from the change
in the medical context after the establishment of National Health Insurance in 1995 [5].
Their primary responsibility is to cooperate with medical practitioners and offer complete
and continuous medical and nursing care to patients. Apart from possessing considerable
knowledge and experience about a specific group of diseases to provide patients of that
group with higher quality nursing services, they are also in charge of education, consulta-
tion, research, policy amendments, and administrative management [14–16]. During the
provision of healthcare services, if NPs can take into consideration the differences in lan-
guages, health perception, lifestyles, and cultural diversity among patients and respect each
patient’s native cultural beliefs and behavior, they can not only improve their healthcare
quality and the patients’ satisfaction, but also eliminate the existing inequality in healthcare
services [17].
Cultural competence is not an innate characteristic, and instead requires learning [12,15,16].
Campinha-Bacote [18] proposed in a study that cultural competence is composed of five
aspects, including cultural awareness, cultural knowledge, cultural skills, cultural en-
counter, and cultural desire. This definition has been acknowledged by various empirical
studies, especially in the field of nursing research [19,20]. Liang et al. [21] conducted an
investigation into the multicultural competence of nursing staff in Taiwan and catego-
rized cultural competence into four aspects, which include cultural awareness, cultural
knowledge, cultural sensitivity, and cultural skills. The research results showed that the
nursing staff’s cultural knowledge and skills were yet to be improved. Cultural awareness
refers to the ability to realize in a meaningful manner that one’s own cultural viewpoints
are different from those of others and to scrutinize one’s own professional and cultural
values, in order to know more about any personal understandings and bias towards foreign
cultures. When we grasp an understanding of how our fixed cultural values and beliefs
affect our interactions with patients, our cultural sensitivity becomes sharpened. On the
other hand, cultural knowledge refers to the ability to seek and obtain knowledge related to
different cultural groups, including their health beliefs, health-seeking behavior, perception
about illness and morality, and the treatments that they deem effective. Cultural sensitivity
is the ability to sympathize with, trust, respect, and accept the beliefs and values of different
cases, and to give weight to the patient’s culture and its influence on their health-seeking
behavior. Cultural skills stand for the ability to leverage tools and resources to develop
communication skills, gather information about the subject’s cultural background, and
conduct a cultural assessment accordingly for the purpose of fulfilling the needs arising
from the patient’s background [15,21].
Clinical practice must rely on multicultural practice and learning to help NPs rein-
force their critical thinking and understand the variances among cases and medical teams
in an intricate cultural context. Thus, they can learn to respect cultural differences and
broaden their cultural horizon, in turn fulfilling the expectations of each case and medical
team [16,21]. In Taiwan, the differences in dialects, living regions, religious beliefs, and cul-
tural backgrounds influence the health patterns and perception of individuals [21]. Building
a nurse-patient relationship with effective communication and trust is the key to improving
Healthcare 2022, 10, 678 3 of 10

healthcare quality. Therefore, the ability to accept patients’ cultures and overcome language
barriers should be prioritized urgently. When NPs conduct health assessments during their
first encounter with patients, any failure in considering their cultural diversity, lifestyles,
and health perception because of language differences, miscommunication, or cultural
insensitivity will hinder their provision of culturally appropriate healthcare services [15,16].
Culture is the motive behind individuals’ behavior during the process of playing
roles in ever-developing social backgrounds [18]. It has a rather high level of specificity.
A reflection on the content of in-service education currently provided in clinical medical
institutions reveals a lack of culture-related topics [22]. Nevertheless, it is clinically common
to encounter patients that are new habitants or old-aged people accompanied by foreign
caretakers, who request to carry with them a lucky charm obtained from a Chinese temple
before surgeries, or whose family members demand to perform religious rituals in the
ward as required by the condition of the patient. Countless healthcare behaviors of ethnic
or cultural diversity can be found in the medical context. The research suggests that
in order to provide culturally competent care, NPs should consider every possible non-
medical problem that can occur in each case, such as how their background knowledge
related to dietary or living styles could affect the patient’s health [23]. Furthermore, due
to the high degree of specificity and individuality of cultures, NPs cannot design nursing
programs according to uniform standards when interacting with patients from different
cultures. Hence, our research aimed to investigate the question, “What is NP’s capacity for
multicultural care in clinical practice in Taiwan?” To answer this question, this study aims
at exploring the status quo of NPs’ cultural competence and its affecting factors to obtain
domestic data from Taiwan. The results provide a reference for the directors of medical
institutions to design in-service education schemes for NPs that can enhance their cultural
competence and the quality of their healthcare services.

2. Materials and Methods

2.1. Design and Sample
This study employed a cross-sectional design. A purposive sample is one in which
characteristics are defined for a purpose that is relevant to the study [24]. This study
purposely examines the cultural competence and its related factors among NPs, because
we do not know what competencies NPs perform or how effective they are in their work
in clinical practice in Taiwan. Thus, purposive sampling was utilized to collect data. A
total of 86 NPs who had completed the nurse practitioners training program, and had at
least one-year’s practical experience as a clinical NP were recruited from a medical center
located in the north of Taiwan. The sample size was estimated using the G*power statistical
software package version 3.1.2 (http://www.gpower.hhu.de/, accessed on 13 March 2022).
A sample size of at least 82 has 80% power to detect a medium effect size of 0.3. An alpha
level of 0.05 was used. A total of 90 questionnaires were issued. After sample collection
and blank and invalid questionnaires were removed (the same answer for all tests), 86 valid
samples were recovered for data analysis. The valid response rate was 95.55%.

2.2. Measurements
2.2.1. Demographic Data Questionnaire
The demographic characteristics questionnaire included gender, age, marital status, ed-
ucation level, seniority, clinical ladder system, years of experience as an NP, service division,
attended courses related to cultural diversity and experience of studying abroad [21].

2.2.2. Nurses’ Multicultural Caring Competence Scale (NMCCS)

The NMCCS was used to assess NPs’ cultural competence. A total of 29 items were
grouped into the following four domains: cultural awareness, cultural knowledge, cultural
sensitivity, and cultural skills. The NMCCS was devised by Liang et al. [21]. It divides
cultural competence into four aspects, with a total of 29 questions (seven on cultural
awareness, eight on cultural knowledge, three on cultural sensitivity, and 11 on cultural
Healthcare 2022, 10, 678 4 of 10

skills). Cronbach’s alpha for the overall scale and the four subscales are between 0.91 and
0.97, showing the comprehensive psychometric properties [21]. In addition, the authors
of the original scale constructed the scale based on Taiwanese nursing staff, who had
a similar culture to the participants in this study, so this study used NMCCS. The four
domains were scored on a 5-point Likert scale, from 1 being “strongly disagree” to 5 being
“strongly agree”. The higher the score, the higher the level of cultural competence in the
corresponding aspect based on the participant’s self-assessment [21]. The original scale
was designed to measure the cultural competence of general nursing staff, but as this study
targets nurse practitioners, some options on basic attributes have been amended, and their
content validity was tested by five nursing educators, nursing experts, and experienced
NPs. The content validity index (CVI) was 0.98. On the other hand, the overall Cronbach’s
α of this scale was 0.93.

2.3. Data Analysis

SPSS for Windows 20.0 software (SPSS, Inc., Chicago, IL, USA) was used for data
analysis. The frequency, percentage, mean, SD, t-test, one-way ANOVA, Pearson product
correlation, and multiple regression were utilized. The p value for the significance level
was less than 0.05.

2.4. Ethical Considerations

The study was approved by the institutional review board of Taipei Veterans General
Hospital in Taiwan (Approval Code: 2017-02-003BC). The participants were informed that
the research process would not involve any risk or comorbidity. The study was conducted
after obtaining signed informed consent from each participant. Completed questionnaires
were placed into a questionnaire return box in each department to be retrieved by the
research assistant.

3. Results
3.1. Demographic Characteristics of the Participants
The study sample contained 86 participants, and 94.2%of them were females. The
mean age of all subjects was 43.48 years (SD = 5.54). The NPs’ mean seniority and years of
experience as an NP were 20.62 years (SD = 5.92), and 8.62 years (SD = 5.99), respectively.
Fifty-seven participants (66.3%) were married. The highest educational certification held
by the majority of participants was a bachelor’s degree, accounting for 70.9%. Sixty partici-
pants had a clinical ladder system that was above N3 (69.8%). In terms of service division,
37 participants (43%) were in surgery wards. A large proportion of the subjects (n = 82,
95.3%) had not attended courses related to cultural diversity. Seventy-five participants
(65.2%) had exercise habits. In terms of studying abroad, eight of them had experienced
studying abroad (9.3%) (Table 1).

Table 1. Demographic characteristics of the participants.

Variables n % Mean (SD)

Gender
Female 81 (94.2)
Male 5 (5.8)
Age 43.48 (5.54)
Marital status
Unmarried 29 (33.7)
Married 57 (66.3)
Education level
Bachelor’s degree 61 (70.9)
Master’s degree 25 (29.1)
Healthcare 2022, 10, 678 5 of 10

Table 1. Cont.

Variables n % Mean (SD)

Clinical Ladder System
≥N3 60 (69.8)
≤N2 26 (30.2)
seniority 20.62 (5.92)
Years of experience as a NPs 8.62 (5.99)
Service division
Internal medicine 26 (30.2)
Surgery 37 (43)
Obstetrics & Gynecology 9 (10.5)
Intensive care unit 14 (16.3)
Attended courses related to cultural diversity
no 82 (95.3)
Yes 4 (4.7)
Experience of studying abroad
Yes 8 (9.3)
no 78 (90.7)

3.2. The Distribution of the Cultural Competence

The NPs’ cultural competence was measured by the Nurses’ Multicultural Caring
Competence Scale (NMCCS) in this study. Four dimensions were scored. The mean score
of the overall cultural competence was 3.75 (SD = 0.41). According to the results, the mean
score in cultural awareness was 4.41 (SD = 0.42), with the highest score in “People from
different cultural backgrounds tend to differ in their values”. In terms of cultural sensitivity,
the mean score was 4.32 (SD = 0.45); the highest scoring statement was “I respect the
differences between the different ethnic cultures”. As for cultural skills, the mean score
was 3.42 (SD = 0.57); the statement with the highest score was “I can explain the possible
cultural relevance of the client’s beliefs or behavior of the health/disease”. Lastly, in terms
of cultural knowledge, the mean was 3.42 (SD = 0.62), with the highest score in “I can
explain the possible correlation between a patient’s health/illness beliefs or behavior and
his culture”. (Table 2).

Table 2. The distribution of cultural competence among participants.

Items M SD
Cultural awareness 4.41 0.42
A person’s beliefs or behaviors are influenced by its cultural background 4.47 0.50
People from different cultural backgrounds tend to differ in their values 4.50 0.56
Most people’s health/disease beliefs or behaviors are influenced by cultural background 4.48 0.52
Cultural knowledge 3.42 0.62
I can tell the specific health problems between different ethnic groups 3.55 0.83
I can collect knowledge and information about health/disease of different cultures 3.44 0.71
I can explain the possible cultural relevance of the client’s beliefs or behavior of the health/disease 3.57 0.71
I can compare the health/disease beliefs of different cultural background clients 3.47 0.74
I can understand the care needs of different cultural background cases 3.45 0.80
Cultural sensitivity 4.32 0.45
I respect the differences between the different ethnic cultures 4.43 0.56
I am keen to advatages in the health care methods of my clients and appreciate them 4.36 0.52
Cultural skill 3.42 0.57
I can use communication skills in clients of different cultural backgrounds 3.67 0.67
I can understand the nonverbal expressions of different cultural background cases 3.53 0.79
When performing nursing activities, I can meet the needs of different cultural background clients 3.52 0.66
I can explain the impact of culture on client’s health/disease beliefs or behavior 3.45 0.77
Before performing the nursing activities, I will collect the cultural background information related to the clients 3.52 0.66
Overall cultural competence 3.75 0.41
Healthcare 2022, 10, 678 6 of 10

3.3. Association between Participants’ Demographics and Variables and Cultural Competence Score
Pearson’s product correlation was computed to evaluate the relationship among age,
seniority, years of experience as an NP and overall cultural competence. The results showed
that years of experience as an NP was significantly statistically correlated with overall
cultural competence with r = 0.22, p < 0.05 (Table 3).

Table 3. Descriptive Statistics and associations between cultural competence and participants’ demographics.

Variables M SD 1. 2. 3. 4. 5. 6. 7. 8.
1. Age 43.48 5.54 1
2. seniority 20.62 5.92 0.89 ** 1
3. Years of experience as a NPs 8.62 5.99 0.44 ** 0.50 ** 1
4. Cultural awareness 4.41 0.42 0.09 0.09 0.02 1
5. Cultural knowledge 3.42 0.62 0.08 0.10 0.19 0.14 1
6. Cultural sensitivity 4.32 0.45 −0.03 −0.01 0.12 0.52 ** 0.23 * 1
7. Cultural skills 3.42 0.57 0.08 0.14 0.24 * 0.06 0.78 ** 0.14 1
8. Overall Cultural competence 3.75 0.41 0.10 0.14 0.23 * 0.40 ** 0.89 ** 0.41 ** 0.89 ** 1
* p < 0.05; ** p < 0.01. The results showed that there were significant differences in clinical awareness and cultural
sensitivity related to the clinical ladder system, with t = −2.43, p = 0.01; −2.03, t = −2.43, p < 0.04, respectively (Table 4).

Table 4. Differences among participants’ demographic variables and cultural competence score.

Cultural Awareness Cultural Knowledge Cultural Sensitivity Cultural Skills Overall Cultural Competence
Variables
Mean ±SD Mean ±SD Mean ±SD Mean ±SD Mean ±SD
Gender a
Male 4.37 0.37 3.42 0.33 4.60 0.43 3.45 0.38 3.78 0.25
Female 4.42 0.42 3.44 0.63 4.31 0.45 3.42 0.59 3.75 0.42
t −0.25 −0.00 1.36 0.11 0.15
p value 0.79 0.99 0.17 0.90 0.88
Marital status a
Unmarried 4.43 0.44 3.35 0.72 4.41 0.43 3.40 0.64 3.73 0.49
Married 4.43 0.41 3.46 0.56 4.28 0.46 3.43 0.54 3.77 0.36
t −0.53 −0.73 1.22 −0.26 −0.40
p value 0.59 0.46 0.22 0.78 0.69
Education level a
Bachelor’s degree 4.39 0.39 3.38 0.52 4.27 0.43 3.38 0.54 3.72 0.34
Master’s degree 4.46 0.48 3.54 0.81 4.45 0.49 3.52 0.65 3.85 0.53
t (p) value −0.64 −0.90 −1.61 −1.01 −1.35
p value 0.52 0.37 0.10 0.31 0.18
Clinical Ladder System a
≥N3 4.48 0.44 3.40 0.63 4.39 0.46 3.37 0.60 3.75 0.42
≤N2 4.26 0.34 3.48 0.60 4.17 0.41 3.53 0.50 3.76 0.38
t (p) value −2.43 0.52 −2.03 1.16 0.72
p value 0.01 0.60 0.04 0.24 0.94
Attended courses
related to cultural
diversity a
No 4.41 0.42 3.41 0.60 4.32 0.45 3.42 0.57 3.75 0.40
Yes 4.42 0.42 3.59 0.95 4.33 0.60 3.47 0.66 3.82 0.64
t (p) value −0.04 −0.54 −0.01 −0.18 −0.33
p value 0.96 0.58 0.98 0.85 0.73
experience of
studying abroad a
No 4.39 0.42 3.41 0.62 4.31 0.46 3.41 0.57 3.74 0.40
Yes 4.60 0.43 3.50 0.65 4.45 0.43 3.54 0.67 3.88 0.49
t (p) value −1.32 −0.34 −0.83 −0.61 −0.89
p value 0.18 0.73 0.40 0.54 0.37
Service division b
Internal medicine 4.41 0.46 3.52 0.60 4.33 0.40 3.55 0.58 3.83 0.40
Surgery 4.38 0.39 3.33 0.65 4.30 0.52 3.30 0.60 3.67 0.42
Obstetrics & Gynecology 4.52 0.50 3.54 0.64 4.37 0.48 3.54 0.43 3.85 0.36
Critical care units 4.44 0.41 3.41 0.56 4.35 0.38 3.41 0.57 3.76 0.42
F (p) value 0.29 0.56 0.07 1.04 0.95
p value 0.83 0.64 0.97 0.37 0.42
a t test; b One way ANOVA.
Healthcare 2022, 10, 678 7 of 10

4. Discussion
The nurse practitioners sampled in this study scored an average of 3.75 (SD = 0.41)
in their overall cultural competence, which was an above-average performance. Among
the four related aspects, cultural awareness received the highest score, while cultural skills
had the lowest. This result is consistent with the finding of Dobrowolska et al. [25] and
Liang et al. [21], which reported that nurses had acquired a certain level of cultural aware-
ness and sensitivity, but their cultural knowledge and skills were yet to be improved. The
finding of this study shows that the NPs’ seniority correlated significantly and positively
with their cultural skills, and their cultural competence was similar to the study by Juan,
Zhuang, Yong, and Rong [26], which reported that years of work experience would directly
affect the nurses’ self-efficacy for cultural competence. Significant differences were found
between the NPs’ positions in the clinical ladder system and their cultural awareness and
sensitivity. This finding is consistent with that of a previous study [27].
The results of this study showed a lack of statistical significance between cultural com-
petence and the variables of gender, marital status, education level, attended courses related
to cultural diversity, experience of study abroad and one’s service division. This finding is
contradictory with a number of previous studies [10,21,28,29]. A possible explanation for
this is the high homogeneity among the nurse practitioners in this study. Their cultural
competence was unaffected by their differences in personal background attributes, learning,
and work experiences. Such results could be regarded as a positive phenomenon. Many
academic papers have proposed several factors that affect the cultural competence of nurses,
including participation in multicultural nursing, ethnic minority background, exchange
study, frequency of interacting with culturally different people in the workplace or daily
life, education level, experience of caring for multiple ethnic groups [10,28,30], cultural
diversity training [29], identical religious beliefs with patients [29], language skills [28,31],
cross-cultural communication skills [32,33], clinical experience in foreign countries [34],
and ethnocentrism [33]. Additionally, according to Purnell [35], the major influences that
shape peoples’ worldview and the degree to which they identify with and adhere to their
cultural group of origin are called the primary and secondary characteristics of culture.
Among them, marital status is one of the secondary characteristics. A somewhat different
finding emerged in the present study. The result of this study showed that there was not a
significant difference between cultural competence and marital status. Nevertheless, the
finding was contradictory with a study by Khodaveisi et al. [36], which reported significant
differences between cultural competence and marital status. Possible explanations for this
finding are the differences between the questionnaires used in the studies and the popu-
lations it studied. Furthermore, the years of work experience, professional titles, income,
ethnicity, and employment status will also exert a direct impact on the nurses’ self-efficacy
for cultural competence [26]. In addition, despite the fact that only 4.7% of the NPs in this
study had participated in a multicultural curriculum, they had high self-assessment scores
in cultural awareness and sensitivity, and an above-average overall cultural competence.
This showed that the NPs’ cultural competence might be attributed to quotidian life and
work experience. Unfortunately, data about previous work experience was not collected in
this study. In comparison, the NPs’ self-assessment scores in cultural knowledge and skills
were relatively low. This perhaps indicated their deficiency in educational training that can
remind them how to acquire more cultural knowledge and skills. Therefore, to tackle this
existing issue, consideration should be given to promoting in-service education.
In recent years, many nursing universities have begun to pay more attention to devel-
oping students’ cultural competence, and hence, have started establishing courses related to
cross-cultural nursing in the university curriculum [28,37]. As illustrated from the previous
study, the NPs who were more culturally competent had received cultural competence
training, had the experience of performing nursing work in different cities, and could
communicate in the patients’ language were able to derive higher patient satisfaction [22].
Another study also showed that NPs’ participation in conferences that emphasized cultural
awareness had positive effects on their cultural knowledge and competence. Attending
Healthcare 2022, 10, 678 8 of 10

workshops that build cultural competence with cultural skills is also beneficial to enhanc-
ing nurse–patient communication and cooperation. Improving NPs’ cultural competence
can improve their communication with patients and lead to better health outcomes for
them [27]. As the research targets of this study were NPs that joined the profession at an
earlier time, most of them did not participate in a multicultural curriculum when they
were receiving standard nursing education. After entering the workforce, their in-service
education was also short of training that could aid them in improving their cultural compe-
tence. In addition, several studies have reported on the importance of mutual education
among NPs and other medical professionals such as general physicians and other health
care professionals [38,39]. Therefore, this study urges education and training units in
hospitals and related societies to face the fact that multicultural ethnic groups have been
increasing in number. More learning opportunities and course options should be provided
for NPs to improve their cultural competence and consequently provide patients with a
more culturally appropriate assessment, nursing service and care.
Chinese has been designated as the official language of Taiwan, in which Minnan
and Hakka are two major dialects. As English is not our official language, it is unlikely
that everyone can speak fluently with an English-speaking foreign national. All of the
participants in this study had received post-secondary education or above, half of whom
had obtained a verification for English language proficiency, had studied Western medicine,
and wrote medical records in English at work. In fact, they had all acquired a certain degree
of English proficiency. However, some academic papers pointed out that nursing education
was not the main source for developing cultural competence [40]. The emphasis of nursing
education regarding cultural knowledge and skills should be placed on developing the
ability to explore and seek knowledge actively, instead of teaching concrete knowledge
and skills about cultural diversity [28]. As a result, when NPs encounter non-English-
speaking patients from foreign countries, what they need to know is how to search for
reliable resources and appliances to assist them in understanding the patient’s needs. The
development of multicultural knowledge is a continuous process [18]. If institutions can
take advantage of in-service education and incorporate more multicultural courses to
help NPs gain cultural knowledge, NPs can definitively harness their cultural skills more
efficiently and consequently produce a more culturally appropriate healthcare service.
This study had several limitations. Firstly, this study was restricted to one medical
center in northern Taiwan and did not use a large sample. Consequently, the results may
not be generalizable to NPs employed in other hospitals. Additionally, purposive sampling
can cause low validity and reliability. Based on the results of this study, a larger sample size
is recommended to strengthen the significance of the findings. Moreover, generalizations
from a purposive sample to a wider population is possible only if the sample was randomly
drawn from that population, something which is suggested for further study.

5. Conclusions
This study investigated cultural competence among NPs. With reference to the results
of this study, the overall cultural competence of NPs was above-average, with the highest
score in cultural awareness, as well as significant differences between their clinical ladder
and their cultural awareness and skills. It is advised that related studies in the future should
extend the research area to other districts or regional hospitals to investigate whether NPs’
cultural competence is related to the regions to which they belong, urban–rural disparities,
or the nature of the hospitals for which they work. Finally, apart from an increase in the
number of participants, the researchers also suggest that future studies adopt a qualitative
research design and specify the affecting factors of NPs’ cultural competence and their
multicultural learning experience, in order to facilitate a further assessment of their needs
for in-service education about cross-cultural nursing.
Healthcare 2022, 10, 678 9 of 10

Author Contributions: Conceptualization, T.-T.L.; data curation, M.-Y.C. and Y.-M.C.; methodology,
T.-T.L. and M.-H.L.; resources, T.-T.L., M.-Y.C. and Y.-M.C.; supervision, M.-H.L.; writing—original
draft, T.-T.L.; writing—review and editing, M.-H.L. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved by the institutional review board
of Taipei Veterans General Hospital in Taiwan (Approval Code: 2017-02-003BC).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: All relevant datasets in this study are described in the manuscript.
Conflicts of Interest: The authors declare no conflict of interest.

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