Psychometric evaluation of the Cultural Capacity Scale Arabic version for nursing students
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Contemporary Nurse
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Psychometric evaluation of the Cultural Capacity
Scale Arabic version for nursing students
Jonas Preposi Cruz, Paolo C. Colet, Meshrif Ahmed Bashtawi, Jennifer H.
Mesde & Charlie P. Cruz
To cite this article: Jonas Preposi Cruz, Paolo C. Colet, Meshrif Ahmed Bashtawi, Jennifer H.
Mesde & Charlie P. Cruz (2016): Psychometric evaluation of the Cultural Capacity Scale Arabic
version for nursing students, Contemporary Nurse, DOI: 10.1080/10376178.2016.1255153
To link to this article: http://dx.doi.org/10.1080/10376178.2016.1255153
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3. 2015). This could be attributed to the lack of valid instruments that can accurately measure this
variable.
The need for an assessment tool to accurately assess the cultural competence of Saudi
nursing students is warranted. The establishment of a valid and reliable tool will facilitate
the conduct of related studies, which will enrich the literature regarding the cultural competence
of nursing students. Furthermore, it will be used to assess the individual needs of the Saudi
nursing students; thus, appropriate intervention can be implemented to improve the cultural
competence.
Background
Saudi Arabia is one of the top five destinations for migrants across the world. As of mid-2013,
approximately 32.4% of the 29,994,272 population of the kingdom was composed of expatriates
(De Bel-Air, 2014). With the growing number of migrants in the kingdom, its population diversity
correspondingly rises. Therefore, it is anticipated that patients from various cultural backgrounds
will seek medical services within the country. Each individual has his or her own beliefs, norms
and practices, which affect their lifestyle and health. Furthermore, patients from varied cultures
experience specific health needs that warrant culturally sensitive care. This poses a challenge
to the healthcare team members. In order to meet the demands of these culturally diverse patients,
healthcare workers must necessarily be equipped with basic competence and sensitivity in provid-
ing them quality patient care.
Assessment of cultural competence among the nurses has been the subject of several studies in
the past (Almutairi et al., 2014; Chae, Park, Kang, & Lee, 2012; Mareno & Hart, 2014). This sig-
nifies the paramount importance attributed to the cultural competence of nurses in providing
patient care. Culturally competent care involves knowledge, attitudes, and skills that sustain
caring for individuals across varied languages and cultures (Seeleman, Suurmond, & Stronks,
2009). Nurses are expected to provide the same quality of care to all patients, regardless of
their religious or cultural backgrounds. As culture greatly influences an individual’s perception
of health, health behavior, and compliance and response to treatment, nurses are expected to
enhance their cross-cultural approach (Gözüm, Tuzcu, & Kirca, 2015). Culturally competent
care has been shown to have a positive impact on the quality of care and patient satisfaction. It
allows nurse–patient concession, improves patient compliance, mutual exchange of information,
and improved communication (Castro & Ruiz, 2009).
Several instruments are available to measure the cultural competence of nursing students
and professional nurses, most of which are self-administered and self-reported (Loftin,
Hartin, Branson, & Reyes, 2013). One such measure is the Cultural Capacity Scale (CCS;
Perng & Watson, 2012). In the study of Perng and Watson (2012), a 41-item scale called the
Nurse Cultural Competence Scale (NCCS) was developed through rigorous literature search.
Originally, the NCCS includes four domains, namely cultural awareness, cultural knowledge,
cultural sensitivity, and cultural skill. The items of the NCCS were entered in a Mokken
scaling analysis to confirm its construct validity. As a result, 20 of the 41 items form a
strong Mokken scale, which was called the CCS. The CCS differs from other cultural compe-
tence assessment tools on the characteristic of unidimensionality and a hierarchy of items. In
terms of unidimentionality, the CCS reflects the scalability of items along the scale. The
items included in the CCS reflect the individual’s abilities which can be externally performed
during nursing practice. In terms of hierarchy, the ordering of the items of the CCS were
from lowest to highest levels of difficulty, which indicates that respondents more readily
endorse items related to their own skills before teaching colleagues about cultural aspects of
care. From the results of such a hierarchical scale, one can accurately assess one’s cultural
2 J.P. Cruz et al.
4. competence level and provide appropriate interventions for improvements (Perng & Watson,
2012). Although the CCS is concise, it covers multiple domains of cultural competence such
as cultural knowledge, sensitivity, and skills. This scale can measure the levels of and individual
differences in the cultural competence of nursing students and professional nurses, which can
form the basis for planning and implementing educational programs specific to their individual
needs (Perng & Watson, 2012).
Study aim
This study was conducted to evaluate the psychometric properties of the Cultural Capacity Scale
Arabic version (CCS-A) for nursing students.
Methods
Design and sample
This study used a descriptive, cross-sectional design in evaluating the psychometric properties of
the CCS-A among a convenience sample of 200 Bachelor of Science in Nursing (BSN) students
in Saudi Arabia. The study was conducted in the nursing department of a government-run univer-
sity situated in the central province of Riyadh, Saudi Arabia. The university has separate cam-
puses for male and female students. Saudi Arabia is the only Muslim country in the world that
still does not have coed schooling in all education levels. The sample size was estimated based
on a criterion for performing exploratory factor analysis (EFA), with a ratio of 10 participants
for every item on the scale (Costello & Osborne, 2005; Hair, Anderson, Tatham, & Black,
1998). Only those participants who fulfilled the following criteria were included in the study:
(1) a male or female Saudi nursing student in the university mentioned, (2) full-time student,
(3) registered in second to fourth year level, and (4) voluntarily indicated his/her intention to par-
ticipate in the study. First-year Nursing Program students were excluded due to their lack of clini-
cal or community exposure.
Ethical consideration
Ethical approval was granted by the research committee of the College of Applied Medical
Sciences of the university. Written informed consent was solicited from each respondent before
they were presented with the questionnaire and a blank white envelope. Confidentiality was
assured throughout the research process. Permission for translation and the use of the instrument
were granted by the copyright holder of the scale via email.
Instruments
A two-part, self-administered questionnaire was utilized for data collection from the respondents.
Respondents’ demographics
Part 1 was the respondents’ demographic sheet, which elicited the respondents’ characteristics
and cultural background. Data gathered in this section included: (1) gender, (2) age, (3) academic
level, (4) length of hospital and/or community exposure, (5) prior diversity training, (6) experi-
ence of caring for patients of other races or ethnicity in the past 12 months, (7) whether residing
in an environment characterized by diverse race/ethnicity, and (8) whether they had encountered
any special population group during training over the past 12 months.
Contemporary Nurse 3
5. Cultural capacity scale
The CCS, a 20-item scale, measures the cultural competence of the respondents. The scale employs
a 5-point Likert scale, with options ranging from strongly disagree (1) to strongly agree (5), with
possible scores from 20 to 100. A higher score signifies higher cultural competence. The CCS
form a strong Mokken scale (H = 0.67). The 20 items formed a reliable (rho = 0.97) and statistically
significant scale (p < .001). The scale is also negatively skewed (skewness = −0.42), which indi-
cates that the item scores fall on the higher side of the scale (Perng & Watson, 2012).
Translation and cross-cultural adaptation of the CCS
The cross-cultural adaptation and translation of the CCS to CCS-Awas guided by a cross-cultural
adaptation process (Beaton, Bombardier, Guillemin, & Ferraz, 2000; Gjersing, Caplehorn, &
Clausen, 2010).
A literature search was done to assess the conceptual and item equivalence of the original to
the intended setting. The result of the rigorous literature search was presented and discussed with
three Saudi experts on the subject. After approval from the experts was gained, the CCS English
version was independently translated by two bilingual Saudi nationals. The first translator is a
nurse with sound knowledge of the concept of cultural competence, while the second translator
has specialized in foreign languages. Both translations were presented to another bilingual Saudi
national who synthesized them into one final version. Thereafter, the synthesized translation
version was independently back-translated by two bilingual translators fluent in English and
excellent in Arabic. These two translators were unaware of the concept under study. The two
back-translated versions were synthesized by a third translator to produce a single back-translated
version. The translated version and the back-translated version were then presented to a five-
member panel of experts. The panel examined the semantic, idiomatic, experiential, and concep-
tual equivalence of the tool. Thereafter, the CCS-A was examined for Item-level Content Validity
Index (I-CVI) and the Scale-level Content Validity Index using the averaging calculation method
(S-CVI/Ave) (Polit & Beck, 2006). The results of the I-CVI and S-CVI are presented later in this
paper. No revisions have been suggested to the translated version of the scale.
The pre-final CCS-A was subjected to pre-testing in 30 nursing students who were not part of
the study. The first author distributed the questionnaire to the male respondents and the female
researcher to the female respondents. The respondents were requested to answer the questionnaire
and give their comments on the paper attached regarding the difficult-to-comprehend words or
sentences. The results after pre-testing reported neither language problem nor any difficulty
answering the questionnaire. The respondents took about 5–15 minutes to complete the question-
naire. The CCS-A was then subjected to psychometric evaluation.
Data collection
Data collection was conducted from 27 September 2015 to 5 November 2015. Data gathering was
initiated by the researchers during the first-hour classes of the respondents in the morning. The
assigned instructors of the respondents were not present during the data collection time. Adequate
information, such as the aim of the study, their expected participation, the time needed for partici-
pation, their right to refuse participation or discontinue their participation for any reason without any
consequences to their part, and their right to leave any part of the questionnaire unanswered if they
feel uncomfortable answering it, were explained to the respondents. The students were also
instructed not to write their names or anything that will identify them in the questionnaire. These
were done to protect the students from possible coercion. Approximately 5–15 minutes were pro-
vided for answering the questionnaires. The respondents were asked to personally seal the answered
4 J.P. Cruz et al.
6. questionnaire in the envelope provided and return it to the researchers. Two weeks after the first data
collection, the CCS-A was redistributed to the respondents, and the same procedure was repeated.
Statistical analysis
All statistical analyses were performed using the SPSS version 21.0. The characteristics of the
respondents were analyzed using descriptive statistics. Scale reliability was established by com-
puting the Cronbach’s α coefficient of the scale (internal consistency reliability) and the intra-
class correlation (ICC) of the test–retest scores (stability reliability).
Content validity was examined using the I-CVI and S-CVI/Ave. The item–total correlation
(ITC) was calculated to establish the internal construct validity. An EFA using the principal
factor analysis (PCA) with varimax rotation was performed. Factors with an Eigen value
greater than 1 and factor loading of greater than 0.40 were determined for construct validity
(DeVellis, 2003). Before performing the PCA, the Kaiser–Meyer–Olkin (KMO) and Barlett’s
test of sphericity were calculated.
Testing of the theoretical relationship was performed by independent samples t-test. p-values
less than .05 were considered significant.
Results
From the 221 questionnaires distributed, 200 were returned giving a 90.5% response rate. The
majority of the respondents were females (52.5%) and had less than or equal to 360 hours of clini-
cal exposure (54.5%). The mean age of the respondents was 20.89 ± 1.33. Nearly half of the
respondents (45.5%) were in the final year of the nursing program (see Table 1).
Reliability assessment of the CCS-A
The reliability of the scale was established by the Cronbach’s α and ICC coefficient computation.
The CCS-A exhibited acceptable internal consistency with a computed Cronbach’s α value of
0.96 for the entire scale. The computed ICC of the two-week test–retest scores was 0.88.
Validity assessment of the CCS-A
The content validity of the CCS-A was examined by a five-member panel of experts. Both the
item-level and scale-level CVI were calculated based on the responses of the experts. The com-
puted I-CVIs for the CCS-A was 1 and the computed S-CVI/Ave was 1.
Table 1. Demographic characteristics of the respondents (N = 200).
Characteristics Mean ± SD / n (%)
Age 20.89 ± 1.33
Gender Male 95 (47.5%)
Female 105 (52.5%)
Academic level 2nd year 52 (26.0%)
3rd year 57 (28.5%)
4th year 91 (45.5%)
Clinical exposure ≤360 hours 109 (54.5%)
>360 hours 91 (45.5%)
Contemporary Nurse 5
7. EFA, employing PCA method and varimax rotation, was performed for the 20 items of the
CCS-A (see Table 2). A KMO index of 0.940 was computed and the Bartlett’s test of sphericity
was significant (p < .001). The computed ITC ranged from 0.460 to 0.796. All the 20 items loaded
in a single factor that reached a cumulative contribution rate of 57.4%. The factor loading of the
20 items ranged from 0.495 to 0.828.
Comparisons on cultural competence of the respondents by their cultural background are
shown in Table 3. Nursing students with prior diversity training (t = 6.83, p < .001), who had
earlier experience of caring for patients from other races or ethnic groups (t = 11.97, p < .001),
who resided in an environment with diverse people (t = 7.12, p < .001) and who had encountered
individuals belonging to special population groups (t = 9.23, p < .001) exhibited significantly
higher cultural competence.
Discussions
This study was conducted to evaluate the psychometric properties of the CCS-A in a sample of
Saudi nursing students. As reflected, the CCS-A revealed acceptable reliability and validity thus
supporting its sound psychometric properties.
The results suggest that the CCS-A had satisfactory internal consistency as observed by the
computed Cronbach’s α value being higher than the acceptable one, which is 0.70 (Nunnally
& Bernstein, 1994). This signifies that the 20 items in the scale were intercorrelated with each
other. This further implies that the items in CCS-A were coherent and that the scale is a suitable
instrument that can provide accurate measurement for Saudi and other Arabic-speaking nursing
students. This finding is comparable with the alpha value reported in earlier validation studies
of the original version (Perng & Watson, 2012) and the Turkish version of the scale (Gözüm
et al., 2015). Furthermore, the ICC value exceeded the acceptable one, which is 0.80 (Vincent,
1999). This means that there was a consistent measurement of cultural competence among the
Saudi nursing students in the first and second period of assessment using the scale. This suggests
that the scale is capable of measuring cultural competence of the Saudi nursing students consist-
ently overtime, thus supporting its stability reliability. With these findings, the CCS-A’s reliability
was strongly supported.
As reported, the I-CVIs and S-CVI/Ave of the scale were within the acceptable values, thus
supporting its excellent content validity (Polit & Beck, 2006). In this study, the responses of the
five experts in all the items on the scale ranged from 3 (quite relevant) to 4 (highly relevant) which
resulted in I-CVIs of 1 and S-CVI/Ave of 1. For a scale to be considered of excellent content val-
idity, all the items of I-CVI should be 1, if there were 3–5 experts evaluating the scale. S-CVI/Ave
higher than 0.90 implies excellent scale-level content validity and thus supports excellent content
validity (Polit & Beck, 2006). The content validity assessment of the CCS-A was performed to
support its quality, relevance and appropriateness to Saudi nursing students. The findings
imply that all the items in the scale were conceptually relevant and culturally appropriate to
Saudi Arabia, specifically to nursing practice and education. Thus, the scale was feasible for
further use.
EFA was performed to examine the patterns or relationships of the items within the instru-
ment. EFA was also used to identify the items that were not suitable in the scale (Tabachnick
& Fidell, 2007). In this study, all the corrected ITCs were within 0.30 to 0.80 and did not
cause ≥ 10% drop in the computed alpha of the scale if deleted; hence, all the items were retained.
Moreover, the computed KMO value and the Barlett’s test of sphericity supported the sample size
adequacy and appropriateness of the factor model, respectively. The PCA and varimax rotation
revealed a single factors of the CCS-A, with a cumulative contribution rate of 57.4%, which indi-
cates good construct validity (Tabachnick & Fidell, 2007). The single factor revealed by the
6 J.P. Cruz et al.
8. Table 2. Item mean, factor loadings, corrected item–total correlations and Cronbach’s α if item deleted for the CCS-A (N = 200).
Items Mean ± SD
Factor
loading
Corrected item–
total correlation
Cronbach’s α if
item is deleted
1. I can teach and guide other nursing colleagues about the differences and similarities of
diverse cultures
3.34 ± 1.18 0.777 0.751 0.957
2. I can teach and guide other nursing colleagues about planning nursing interventions for
clients from diverse cultural backgrounds
3.30 ± 1.09 0.812 0.781 0.957
3. I can use examples to illustrate communication skills with clients of diverse cultural
backgrounds
3.36 ± 1.12 0.818 0.789 0.956
4. I can teach and guide other nursing colleagues about the communication skills for clients
from diverse cultural backgrounds
3.35 ± 1.16 0.684 0.646 0.958
5. I can explain the influences of cultural factors on one’s beliefs/behavior towards health/
illness to clients from diverse ethnic groups
3.18 ± 1.11 0.813 0.780 0.957
6. To me collecting information on each client’s beliefs/behavior about health/illness is very
easy
3.29 ± 1.15 0.652 0.624 0.959
7. I can teach and guide other nursing colleagues about the cultural knowledge of health and
illness
3.34 ± 1.15 0.793 0.770 0.957
8. I can teach and guide other nursing colleagues to display appropriate behavior, when they
implement nursing care for clients from diverse cultural groups
3.12 ± 1.17 0.816 0.794 0.956
9. I am familiar in health- or illness-related cultural knowledge or theory 3.11 ± 1.07 0.828 0.796 0.956
10. I can explain the influence of culture on a client’s beliefs/behavior about health/illness 3.24 ± 1.12 0.768 0.735 0.957
11. I can list the methods or ways of collecting health-, illness-, and cultural-related information 3.31 ± 1.10 0.822 0.793 0.956
12. I can compare the health or illness beliefs among clients with diverse cultural background 3.31 ± 1.08 0.816 0.785 0.957
13. I can easily identify the care needs of clients with diverse cultural backgrounds 3.36 ± 1.09 0.770 0.734 0.957
14. When implementing nursing activities, I can fulfill the needs of clients from diverse cultural
backgrounds
3.20 ± 1.17 0.563 0.532 0.960
15. I can explain the possible relationships between the health/illness beliefs and culture of the
clients
3.26 ± 1.08 0.803 0.768 0.957
16. I can establish nursing goals according to each client’s cultural background 3.00 ± 1.18 0.495 0.460 0.961
17. I usually actively strive to understand the beliefs of different cultural groups 3.27 ± 1.18 0.743 0.712 0.957
18. When caring for clients from different cultural backgrounds, my behavioral response
usually will not differ much from the client’s cultural norms
3.16 ± 1.18 0.752 0.726 0.957
19. I can use communication skills with clients of different cultural backgrounds 3.21 ± 1.16 0.781 0.755 0.957
20. I usually discuss differences between the client’s health beliefs/behavior and nursing
knowledge with each client
3.15 ± 1.12 0.749 0.719 0.957
ContemporaryNurse7
9. findings supports the characteristic of the CCS-A as being unidimentional. This finding is congru-
ent with previous studies that reported the validity and reliability of the scale (Gözüm et al., 2015;
Perng & Watson, 2012). Although the scale contains items from three domains of cultural com-
petence (cultural knowledge, sensitivity and skills), all the items pertain to activities that can be
accomplished by nursing students during their clinical practice, such as explanation of knowledge
on cultural aspect of care, utilization of communication skills, offering care and teaching others
regarding the clients from various cultural backgrounds (Perng & Watson, 2012).
Construct validity of the scale was further supported by testing of the theoretical relationships of
the CCS-A. As presented in an earlier study, the cultural background of the nursing students has an
impact on their cultural competence (Cruz, Estacio, Bagtang, & Colet, 2016). It was reported that
nurses having friends or neighbors from other cultures and who had prior experience of attending on
patients from other countries and patients belonging to special population groups have higher cul-
tural sensitivity than those who lack similar experiences (Gözüm et al., 2015). This is also evident
from the findings of this study. Moreover, diversity training and education were shown to be effec-
tive in improving the cultural competence of the nursing students (Cerezo, Galceran, Soriano, &
Moral, 2014; Noble, Nuszen, Rom, & Noble, 2014). Based on this finding, it was expected that
nursing students who received diversity training in the past will have higher cultural competence
than those who did not receive it. This study found similar results among the Saudi nursing students.
The congruence of the results of this study to the expected theoretical relationship signifies excellent
validity of the CCS-A as the measuring instrument.
Limitations
Although this study offers valuable findings that can contribute to the existing knowledge about
this topic, some limitations are acknowledged. The use of the convenience sampling technique
limits the generalizability of the results. Confirmatory factor analysis was not conducted in this
study. Other methods of assessing construct validity, such as convergent and divergent validity
tests, were not performed. Also, the study did not present either the cultural competence of the
Saudi nursing students or the factors that might influence it.
Conclusions
The CCS-A manifested acceptable internal consistency and stability reliability as well as excellent
content and construct validity. These findings support its sound psychometric properties.
Table 3. Differences in cultural competence by cultural background of the respondents (N = 200).
Cultural background n (%)
Cultural competence
Mean ± SD t p
Prior diversity training Yes 63 (31.5%) 75.75 ± 16.96 6.83 .000
No 137 (68.5%) 59.77 ± 14.58
Taken care of a patient from other race or ethnic group
in the past 12 months
Yes 124 (62.0%) 73.43 ± 12.37 11.97 .000
No 76 (38.0%) 50.74 ± 13.99
Living in an environment with people with diverse
race/ethnicity
Yes 42 (21.0%) 79.69 ± 16.00 7.12 .000
No 158 (79.0%) 60.85 ± 15.03
Encountered special population groups as patients
within the healthcare environment in the past 12
months
Yes 94 (47.0%) 74.70 ± 14.50 9.23 .000
No 106 (53.0%) 56.03 ± 14.08
8 J.P. Cruz et al.
10. Therefore, the CCS-A is a valid and reliable tool that can be used to assess the cultural compe-
tence of nursing students in relation to clinical practice.
Relevance to practice
Nurses and nursing students are expected to provide culturally sensitive care to their patients
during their tour of duties. Providing nursing care that is culturally competent and congruent
can improve quality of care, health outcomes and patient satisfaction (Ahmann, 2002; Castro
& Ruiz, 2009). Also, through culturally sensitive and unbiased care, cultural competence is
seen as an essential foundation for reducing, if not totally eradicating, health disparities in
health care facilities (Taylor & Lurie, 2004). However, previous studies have reported that
many nurses are incapable and uncomfortable in providing culturally appropriate and sensitive
care to patients, which compromise the quality of nursing care (McHenry, 2007). Because of
this, the importance of ensuring the development of cultural competence among nurses and
nursing students is underscored. Adequate training should be provided to ensure the development
of their cultural competence. An essential part of preparing nursing students to assume their future
role as nurses is to equip them with necessary knowledge, skills and values in rendering culturally
competent care. Nursing students must learn the cultural aspect of care and develop cultural com-
petence in order to work effectively in a culturally diverse environment. In order to achieve this,
nursing managers and educators need to have a valid and reliable tool that can accurately assess
one’s cultural competence. The establishment of the validity and reliability of the CCS-A provides
an effective means of assessing the cultural competence of nurses and nursing students in Saudi
Arabia and other Arabic-speaking countries. Accurate assessment of cultural competence assists
in identifying the individual needs of each nurse and student, and thereafter appropriate planning
and intervention will be done. Lastly, the CCS-A can be utilized to conduct future studies on
related subjects in the Arab region and will also facilitate cross-cultural comparisons.
Acknowledgement
This study received a non-financial assistance from Shaqra University, Saudi Arabia.
ORCID
Jonas Preposi Cruz http://orcid.org/0000-0002-3758-1414
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Contemporary Nurse
ISSN: 1037-6178 (Print) 1839-3535 (Online) Journal homepage: http://www.tandfonline.com/loi/rcnj20
Psychometric evaluation of the Cultural Capacity
Scale Arabic version for nursing students
Jonas Preposi Cruz, Paolo C. Colet, Meshrif Ahmed Bashtawi, Jennifer H.
Mesde & Charlie P. Cruz
To cite this article: Jonas Preposi Cruz, Paolo C. Colet, Meshrif Ahmed Bashtawi, Jennifer H.
Mesde & Charlie P. Cruz (2016): Psychometric evaluation of the Cultural Capacity Scale Arabic
version for nursing students, Contemporary Nurse, DOI: 10.1080/10376178.2016.1255153
To link to this article: http://dx.doi.org/10.1080/10376178.2016.1255153
Accepted author version posted online: 31
Oct 2016.
Published online: 10 Nov 2016.
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