doi: 10.56294/saludcyt2023445




The influence of cultural competence on healthcare outcomes


Influencia de las competencias culturales en los resultados de la atención sanitaria


Harita Nair M1  *, Apurvakumar Pandya2  *, Suphiya Parveen3  *


1College of Nursing, Teerthanker Mahaveer University. Moradabad, Uttar Pradesh, India.

2Department of Parul Institute of Public Health, Parul University. PO Limda, Tal. Gujarat, India.

3Department of Genetics, School of Sciences, JAIN (Deemed-to-be University). Karnataka, India.


Cite as: Nair M H, Pandya A, Parveen S. Influencia de las competencias culturales en los resultados de la atención sanitaria. Salud, Ciencia y Tecnología. 2023;3(S1):445.


Submitted: 16-05-2023                       Revised: 10-06-2023                                       Accepted: 01-08-2023                       Published: 02-08-2023


Editor: Dr. William Castillo-González   


Associate Editor: Fasi Ahamad Shaik  




Background: the demand to improve nurses’ Cultural Competence (CC) was recently introduced to light by the growing cultural variety in healthcare in European nations. It is possible to enhance culturally competent treatment by evaluating CC and identifying pertinent influencing variables. The purpose of this research was to use the Cultural Competence Assessment (CCA) scale to measure the CC of nurses and nursing students working in acute care settings and to identify influencing variables.

Methods: the design was cross-sectional. Data was collected in March 2021 from nurses and nursing students enrolled in their last year of education and employed in acute care facilities. The research participants’ general features and degrees of general CC were shown using descriptive analysis. The influencing aspects of CC were examined using a multiple linear regression analysis.

Results: the cultural proficiency of the nurses ranged from moderate to excellent. Age, educational attainment, cultural diversity training (CDT), and self-perceptions of CC all had a significant impact on the level.

Conclusions: all healthcare professionals, including nurses who interact with patients frequently, need to be prepared to offer CC healthcare for patients from a variety of cultural backgrounds. Delivering CC care involves the implementation of effective interventions, such as educational training, which may help to eliminate healthcare inequities and enhance patient outcomes.


Keywords: Cultural Competence (CC); Cultural Competence Assessment (CCA) scale; Cultural Diversity Training (CDT); Nursing; Healthcare.




Antecedentes: la demanda de mejorar la competencia cultural (CC) de las enfermeras ha salido a la luz recientemente debido a la creciente variedad cultural de la asistencia sanitaria en los países europeos. Es posible mejorar el tratamiento culturalmente competente evaluando la CC e identificando las variables influyentes pertinentes. El objetivo de esta investigación era utilizar la escala de Evaluación de la Competencia Cultural (ECC) para medir la CC de enfermeras y estudiantes de enfermería que trabajan en entornos de cuidados intensivos e identificar las variables influyentes.

Métodos: el diseño fue transversal. Los datos se recogieron en marzo de 2021 de enfermeras y estudiantes de enfermería matriculados en su último año de formación y empleados en centros de cuidados intensivos. Las características generales de los participantes en la investigación y los grados de CC general se mostraron mediante un análisis descriptivo. Los aspectos que influyen en la CC se examinaron mediante un análisis de regresión lineal múltiple.

Resultados: la competencia cultural de las enfermeras osciló entre moderada y excelente. La edad, el nivel de estudios, la formación en diversidad cultural (FDC) y la autopercepción del CC influyeron significativamente en el nivel.

Conclusiones: todos los profesionales sanitarios, incluidas las enfermeras que interactúan frecuentemente con los pacientes, deben estar preparados para ofrecer atención sanitaria CC a pacientes de diversos orígenes culturales. La prestación de cuidados de CC implica la aplicación de intervenciones eficaces, como la formación educativa, que pueden contribuir a eliminar las desigualdades en la atención sanitaria y mejorar los resultados de los pacientes.


Palabras clave: Competencia Cultural (CC); Escala de Evaluación de la Competencia Cultural (ECC); Formación en Diversidad Cultural (FDC); Enfermería; Atención Sanitaria.





The capacity to engage in cross-cultural relationships effectively and properly in both personal and professional contexts level is referred to as CC. CC describes a collection of cognitive, emotional, behavioral, and linguistic skills that promote comfortable and fruitful interactions with people from different cultural backgrounds. Since culture provides important economic and social benefits, culture has intrinsic worth. With improved education and health, greater tolerance, and more opportunities for social engagement, culture enhances the value of daily life and increases satisfaction with life for both individuals and communities.(1) Healthcare is the practice of enhancing an individual's physical and emotional well-being through defect detection, treatment, and amelioration. Health care is provided by specialists in the medical area and related professions. The World Health Organization defines a healthcare structure includes all groups, people, and actions whose main objective is to advance, rebuild, or protect health. It covers actions that affect the factors that affect health as well as more direct actions that enhance health.(2) Healthcare professionals can obtain correct medical information when there is good interaction. It also promotes open communication so that any misconceptions between patients and their medical professionals may be resolved and confidence can be developed. The goal of CC is to create and deliver programs that are specially tailored to meet the requirements of every person, kid, and community.(3)

Training in CC allows service providers to comprehend the values of the community they are serving better to provide better outcomes. Cultural sensitivity helps the patient, the healthcare system, and the clinician.(4) The term CC in the environment of healthcare refers to the ability of a system to offer services in a way that takes into account the social, cultural, and language requirements of patients as well as their different values, beliefs, and behaviors. The greatest objective have a health care system and staff that can treat every patient to the best of their abilities, despite their ethnic background, culture, or degree of English proficiency.(5)

CC is developing more essentials for achieving equitable health care delivery, In addition to the organizational level of the business and the specific health care provider. Pre-service and on-the-job educational courses, in addition to being essential to health professional authorization, now contain CC in several nations. The best ways to attain CC, however, are not universally agreed upon and defined.(6) CC training is being offered by healthcare organizations to create healthcare professionals who can manage patients from various cultural backgrounds more successfully and with ease. The term CC denotes the accomplishment of a certain goal, such as fostering inclusivity. This strategy instills false confidence in decision-makers and healthcare professionals and ignores the fact that our knowledge of cultural barriers is always expanding and evolving.(7) Five interventions to improve CC were identified by CC healthcare industry systems, CC education for medical professionals, the utilization of interpreters to ensure that individuals from different cultures may communicate effectively, CC medical resources that teach workers from various cultures, and the distribution of culturally appropriate health learning materials are just a few examples of initiatives to attract and constant employees from different backgrounds.(8) The purpose of this investigation aimed to employ the CCA scale to evaluate the CC of nurses and nursing students in acute care settings in Austria and to find influencing factors.

Shepherd(9) examined the fundamental ideas, assumptions, and most importantly, the evidence supporting the value of cultural awareness (CA) training and its derivatives, using a critically necessary critical lens. In many industries, CA training for health workers is becoming standard practice. Ratna(10) determined the elements of successful communication in a hospital situation are analyzed. The healthcare systems and their patients have to collaborate in a way that benefits both patients. If the patient or the healthcare practitioner does not fully understand the information given, the delivery of treatment is put in danger.

Novacek et al.(11) examined that it is necessary to adequately measure and provide therapies for COVID-19's effects on Black Americans' mental health. Greene-Moton et al.(12) provided cultural humility that was discussed in the study and gained popularity in a variety of professions, including nursing, public health, community psychology, and social work. Applying the idea of cultural humility to the professions of health care and medicine more than 20 years ago, sparked an enthralling and ongoing discussion over whether it is more important to practice cultural humility than to become competent in the cultures of people with whom we work and interact. Wright(13) examined how the area of applied behavior analysis (ABA) should incorporate culturally modest techniques, especially through using self-reflection, to reduce inequalities and enhance. The purpose of ABA is to improve individual standards and lifestyles throughout a variety of professional fields for many different racial and ethnic communities. The range of specialists employed by the ABA business is not well known. Several modern, well-known behavioral treatments do not adequately account for cultural differences, and access to ABA intervention is uneven. Washington(14) proposed that CC should be a national priority for university computer departments. The culture often starts in undergraduate computer programs, where industry demographics are represented. Marcelin et al.(15) assisted in determining and decreasing unconscious disadvantage and fostering an atmosphere of equality in the healthcare sector, particularly in the area of transmissible diseases. Patients from underrepresented groups in the US may be negatively affected by unintentional cognitive biases brought on by cultural stereotypes, which in turn lead to persistent health inequalities. Lee et al.(16) examined how anxiety, sadness, somatic symptoms, and sleep problems were related to racial bias that was self-reported against Asians and Asian Americans living in the US. Evaluating the social support's ability to act as a moderator. Additionally, participants were asked to give a thorough description of a specific instance of discrimination that had happened during the event. Kaihlanen et al.(17) looked at nurses' perceptions of the usefulness and substance of CC training, which emphasizes increasing cultural self-awareness. CC is undoubtedly crucial to the quality of healthcare, and a fuller comprehension of the numerous educational methods and tactics designed to increase CC is necessary. Givler et al.(18) referred to palliative care and pain evaluation. Patients' treatment for pain has improved mainly as a consequence of health professionals and teams becoming informed about cultural differences. They are also more equipped to help the patients' survivors deal with the process of aging.

McGregor et al.(19) examined the state of CC education in the healthcare industry, the advantages of keeping an emphasis on training healthcare providers in a variety of settings, as well as efforts in both policy and practice to ensure that current and aspiring healthcare professionals are prepared to satisfy the medical requirements of various ethnic and racial groups. Harrison et al.(20) assessed CC in community healthcare practitioners' approaches to patient involvement while dealing with patients from ethnic minorities. High-quality healthcare has been linked to effective patient involvement. There is a lack of data on how to effectively engage customers from ethnic minorities. Flynn et al.(21) examined Latina and non-Latino White American women in the United States were evaluated to see whether provider CC lessened the emotional and behavioral effects of unpleasant healthcare experiences. Patients who have experienced negative healthcare experiences suffer psychologically and behaviorally, especially those who belong to underrepresented racial and socioeconomic groups. Using a paradigm that integrates cultural, psychological, and behavioral aspects of health. Chae et al.(22) provided the way nurses' assessments of their own CC changed after taking a CC instruction program. To guarantee that everyone receives high-quality healthcare, the CC education program for health workers was created. Handtke et al.(23) addressed whether migrant workers' health is impacted by stakeholder views of language and CC among health professionals and migrants, particularly in Malaysia where an official interpreting program is still lacking. Interventions that increase the efficacy and accessibility of health care for persons from ethnic minorities are known as culturally competent interventions. To get to an agreement on the crucial components of an online CC program for Korean public health professionals (PHWs), Chae et al.(24) gave educational topic categories priority. The panelists were tasked with evaluating the importance and urgency of the numerous topic areas covered in the classroom, as well as the effectiveness of the teaching-learning strategies, and with expressing their opinions on the ideal frequency, duration, and population. Ratna(25) featured a qualitative design that was founded on critical realism, based on interviews with educators. To guarantee that social and healthcare personnel are efficient and highly skilled, competent instructors are required. However, there isn't nearly enough data to support the notion that educators' competencies in this area need to be improved. A culturally competent healthcare organization seeks to understand the culture of the population served, recognizes the impact of cultural differences, fosters internal learning opportunities to improve cultural knowledge among care teams, and modifies patient care to meet the patient’s unique needs. Figure 1 shows the cc healthcare organization process.


Figure 1. Culturally competent healthcare organization



The method employed proved to be a cross-sectional approach. Cross-sectional analyses were performed at hospitalization facilities. Participants’ demographic information and their reported degrees of cultural fluency was provided using statistical analysis. The factors influencing cultural competency were analyzed using a multiple linear regression model.


Data gathering and sampling techniques

The survey was sent to Austrian nurses and nursing students who had performed direct patient care in acute care settings during their last year of study. Since the majority of nurses in Austria work in acute care settings, they decided to conduct our study there to contact as few nurses as possible. The investigators introduced the objectives in an email request they sent to all Austrian urgent care institutions and colleges of science and technology. The email offer and link to the online survey were respectfully sent to the recipients whether nursing personnel or students. An alert was issued after two weeks. In March 2021, Lime Survey, a freely available software online statistics survey web tool, was used to gather information internet.  To tell as many nurses as possible about the research, we also posted information about it on Facebook. The questionnaire proved feasible to employ the German version of is already established Cultural Competence Assessment scale (CCA-G), in addition to collecting initial demographic information for these students and nurses. The number of decades the healthcare workers or Student effort, the probability they had participated in a range of educational programs and were international. A person with a migratory background is one whose parents were both born internationally. They further distinguished between immigrants of the first and second generations. The original migrants include both born internationally and the parents who had immigrated in addition. Nationals who were born in the destination country although the parents were foreigners are referred to as second-generation migrants.

In contrast, 77 % of respondents believed that healthcare education reflects patients' values and beliefs. The graph below demonstrates that 77 % of instructors feel that healthcare education taught in other countries does not provide possibilities for culturally diverse patient care. Approximately 80 % of respondents said that since nursing education is mostly influenced by Western culture, it distances students from their cultural roots. Figure 2 demonstrate the CC in the nursing curriculum.


Figure 2. Cultural Competence in the nursing curriculum



The initially verified CCA scale was utilized in its German translation to determine the degree of CC. In several languages, the self-reported CCA was professionally reproduced and psychometrically assessed. It has been established that the procedure is a workable and dependable method for assessing CC in healthcare. Schim and Miller's Cultural Competence Model served as the foundation for the truly original CCA scale, which was created in the United States. Determined to process the viable and reliable tool for evaluating CC in healthcare. The Schim and Miller-developed CC Model served as the foundation for the innovative CCA scale, which was created in the USA. This scale has 25 questions that are split into two distinct subsections cultural sensitivity and awareness and culturally competent behavior (CCB). The term CA refers to the professionals' understanding of the distinctions and affinities among various forms of cultural expression. CA, sensitivity to oneself and others, and behaviors that are influenced by interactions with culturally varied individuals are all examples of CC. The 14 items that make up the modified CCA-G are split into two subscales CA and CCB. Five questions that make up the CA subscale may be assessed on a five-point Likert scale with responses ranging from entirely agree to disagree. The five-point Likert scale can be used to evaluate the nine statements that compose the CCB subdivision, with reactions being from usually to certainly. Stronger scores represent stronger CC levels. A 5-point Likert scale through solutions that differ from being extremely inadequate and highly qualified may be used to score the supplementary topic on self-perceived CC. Stronger scores represent stronger CC levels.

The ability to understand and adapt to other cultures Five percent of nurses reported feeling inadequate. Nearly one-third of the nurses reported feeling culturally competent when delivering nursing care, whereas another third reported feeling neither culturally competent nor incompetent (figure 3).


Figure 3. Cultural competence assessment


Data analysis

The program for statistics IBM SPSS Statistics 26 is accustomed to examining the information. The research participants' general features and levels of overall CC concerning the two subscales were shown using descriptive analysis. Mean values and typical deviations were employed to describe ongoing information, whereas frequencies and percentages were used to represent essential components. Spearman's rank coefficient of correlation were utilized to calculate the association between CC and the continuous variables in the univariate analysis. It was determined how CC and categorical factors related using the “Mann-Whitney U test and the Kruskal-Wallis test”. Applying the Box-Tidwell approach, which includes an interaction term between the continuous independent variables and their natural logs in the regression equation, allowed us to determine the linearity of the continuous variable concerning the logit of the dependent variable. The Durbin-Watson information were used to determine the impartiality of the residuals. Outliers were found using studentized residual values. It has been shown that multicollinearity occurs when the variance inflation factors are less than four. The reliance of CC on impact factors discovered by univariate analysis was the dependent variable, and a multiple linear regression analysis were utilized to predict it after validating the assumptions for linear regression. As independent factors, we included immigrant background, educational level, age, multilingualism skill, CDT experience, and self-perceived CC. The threshold for statistical significance was set at p< 0,05. Cultural competence is a complicated process that evolves in systems and organizations along continuum involving people at all levels. Policymakers, administrators, practitioners, and the actual consumers themselves are all required to engage in the process on behalf of an agency. On this continuum, the Cross framework delineates six key positions, from cultural destructiveness to cultural competency or competency (figure 4).


Figure 4. Cultural Competence Continuum



The survey was completed by 915 total nurses and nursing students. The average age of them was 43, and 80,6 % of them were female. Over 10 years of experience were already the norm for the majority of the nurses. However, a small number of nurses are considered highly culturally inept or moderately culturally incompetent, and around one-third of the nurses are classified personally as either CC or incompetent. 48,4 % of the nurses said they were comfortable giving nursing care to people from different ethnic backgrounds. Table 1 gives a general breakdown of the characteristics of the participants.


Table 1. CDT, multilingualism, and backgrounds of migrants need an indent because they must be on par with the average age in years, and the percentage of females


Total sample N = 915

Average age expressed in years


Teaching (%)


·         Nurse


·         Nurse with further elaboration


·         Nursing student




              Master’s degree


              Bachelor’s degree


Female (%)


Professional Experience Years (%)


.>10 years


.<10 years


Multilingualism (%)


Migrant background (%)


·    2nd generation


·    1st generation                              


Cultural diversity training (%)


Self-perceived CC (%)


·         Very incompetent


·         Very competent


·         Somewhat competent


·         Neither competent nor incompetent


·         Somewhat incompetent



The CCA-G ratings for the nurses indicated an average overall degree of CC. According to the comments, the nurses exhibited a high degree of intercultural awareness. "I believe that everyone, regardless of their cultural heritage, must be regarded with respect" had the greatest awareness rating. The nurses demonstrated a moderate degree of CCBs, according to the responses gathered for the cultural behavior subscale. "I gladly accept feedback from clients on how I relate to people from different cultures" received the highest rating, and "I have access to textbooks and other materials that help me learn more about people from different cultures" received the lowest rating (table 2).


Table 2: The CCA-G's cultural competence item indicates

CC items

Mean (SD)



That different societies have various definitions for what health care entails


Several cultural groups place great importance on their spiritual and religious beliefs




Individuals share their desires for healthcare programs


Customer comments on how I interact with individuals from other cultures


For new individuals at work or school, I ask them about their cultural requirements



The Influences on cultural competency

The influence of maturity, level of education, immigrant background, multilingualism, different cultural backgrounds education, as well as self-perceived CC on nurses' perceptions of CC was investigated using an analysis of variance.

The consistency, variable independence, homoscedasticity, uncommon points, and residual normality conditions were all fulfilled. Age, educational attainment, access to historical diversity education, and self-perceived CC are 4 of the characteristics that affected CC, according to the findings of the multiple regression study. Several factors had an impact on CC that was statistically significant, p< ,0000, F = 18,971, R2 = 1,09, table 3. The findings of the regression investigation indicate that nursing students that finished their higher education or possessed a college degree, completed part in a variety of training courses, and felt they were slightly or extremely culturally competent related to having greater levels of CC.


Table 3. Elements that Influence CC

Independent variables


Std. Error




Self-perceived cultural competence












Multilingual ability






Cultural diversity training experience












Migrant background






Educational level









Evaluating the CC of nurses is of the highest importance in countries like Austria which are seeing rapid increases in the number of people belonging to different ethnic and cultural groups and, as a result, have a greater need for individuals that work in the healthcare field to be able to communicate effectively with patients from such backgrounds. The study offers the initial observations about the levels of CC Austrian nurses and nursing students who work in hospitals and clinics maintain. The total degree of CC of the participants varied from medium to high, and the participants displayed substantial amounts of CA as well as a moderate level of culturally competent action. Our findings are similar to those of studies conducted in Italy and Slovakia, two states close by, where the same instrument was used to evaluate nurses' CC. High-level culturally conscious nurses are often able to identify both cultural differences and similarities, as well as to show respect for and an open mind toward such differences. For one to be considered CC, these skills are necessary. Performing cultural evaluations in work environments, adapting therapies to accommodate cultural standards, questioning patients about their needs and preferences for therapy, and looking for extra data and assets are a few instances in that CC may be demonstrated. The study's recommendations include nurses exhibiting a moderate degree of CCB suggesting that Austrian nurses still face limitations in their ability to identify and respond to cultural demands when people regularly participate. Nurses' self-perceived degrees of CC was higher than what nurses in Slovakia and Italy indicated. In comparison, just 66,7 % of those polled in Austria considered themselves to be either somewhat or extremely CC, though just 62 % of nurses in Slovakia and 44 % of nurses in Italy felt the same way about themselves. If these figures contrast with reports from countries such as the US, that CC has proved addressed and promoted in nursing efforts for several years, it would seem that the self-perceived cultural competence in European nations is typically significantly lacking.


Influencing factors for CC

According to the outcomes of a multiple regression study, the degree of CC among nurses was significantly influenced by factors such as age, educational attainment, prior exposure to CDT, and self-perceived CC. Following the results of the analysis of the data, over fifty percent of the nurses who have participated in culturally diverse educational programs or activities had CCA-G scores that were higher. The results of the analysis indicate that nurses conduct CCB more often the more training they receive, in line with the CC Model. The CC Model is supported by our findings, which show that nurses exhibit CCB more often the more training they get. The outcomes are consistent with such of numerous additional research projects that were done in the past discovered that prior diversity training affected levels of CC, thus suggesting that training in CC may be beneficial for nurses while caring for patients that come from a variety of cultural backgrounds. Programs for teaching CC must be founded on acknowledged educational ideas and theories that describe how CC improves. Organizations in the healthcare industry should take action to address the issues posed by cultural diversity and to guarantee nursing personnel receives excellent quality ongoing education in CC. This suggests that modifications need to be made not just to the organizational aspects but also to the level of CC possessed by the nurses to ensure that all patients get care of equally high quality. The size of the sample, as well as the fact that it included both practicing nurses and nursing students from a variety of Austrian locations, are two of the study's strongest points. However, the method of convenience sampling used to include those participating in the study restricts the generality of the general results. An additional restriction is presented by the longitudinal design. To better understand the CA of nurses in all Austrian medical facilities, longitudinal studies should be conducted. Even though they only make up 7 % of our sample, the inclusion of nursing students may have had some impact on our findings. The invited nursing students who had completed their final semester and had a lot of prior nursing care practice. It would have been beneficial to include further information about some of the factors that play a significant role, such as the number of years of professional experience or the ability to speak several languages. Even slightly different research findings could have been obtained by adding a finer subcategory for years of employment or testing participants' proficiency in other languages.



The demand for healthcare that is culturally sensitive is evolving across Europe, particularly in Austria, as a result of continuous demographic shifts. According to the results of the research, the level of CC possessed by the nurses varied anything from medium to high. It was common to find higher levels of CC among older nurses with a bachelor's degree or that had completed extra education, had taken part in a variety of training courses, and self-identified as being moderately or highly CC. In acute care settings in Austria, effective interventions need to be put in place to promote the availability of healthcare that is CC. These interventions might take the form of educational events or programs that have been established to fit the needs of nurses. It is regarded as required to do further study is determine how other pertinent factors affect CC.



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Conceptualization: Harita Nair M, Apurvakumar Pandya, Suphiya Parveen.

Methodology: Harita Nair M, Apurvakumar Pandya, Suphiya Parveen.

Drafting - original draft: Harita Nair M, Apurvakumar Pandya, Suphiya Parveen.

Writing - proofreading and editing: Harita Nair M, Apurvakumar Pandya, Suphiya Parveen.