The effect of the communication skills training on the sensitivity and cultural competence of the nurses in the pediatric wards: A quasi-experimental study

Abstract

BACKGROUND:

This study aimed to investigate the effect of the communicative training skills on the sensitivity and cultural competence of the nurses in the pediatric wards.

MATERIALS AND METHODS:

The participants included 54 nurses from the pediatric ward of Namazi Hospital affiliated with REDACTED. The sample members entered the study through voluntary registration in the in-service training system.

RESULTS:

The results showed that cultural sensitivity score was 44.22±11.78 before the intervention, 48.51±13.34 immediately after the intervention, and 55.55±20.20 one month after the intervention. Cultural sensitivity score significantly increased immediately and one month after communication skills training for nurses compared to before the intervention (P < 0.001). The results also showed that cultural competency score was 51.68±9.43 before the intervention and increased significantly immediately after the communication skills training and one month after the intervention (57.64±10.43 and 62.56±11.53, respectively), showing significant improvement (P < 0.001).

CONCLUSION:

The communication skills training promoted the nurses' cultural sensitivity and competence in childcare wards. Therefore, the implementation of the theoretical and practical methods of teaching communication skills is suggested to improve nurses' cultural competence and consequently, improve childcare quality in different cultures.

Introduction

Today, children are hospitalized for various reasons compared to the past two decades. Despite the growing trend of the short days of hospitalization and outpatient surgeries, many hospitalized children have more serious and complicated problems than in the past.[1] Child hospitalization can cause a lot of stress, first for the child and then for their parents.[2] This can lead to insomnia, uncertainty, anxiety, and feelings of helplessness in children, which in turn causes children not to cooperate and their negative emotions to increase.[3]

By using communication skills, nurses can significantly reduce the bitter experiences caused by the child's hospitalization.[4] Communication skills result in better health outcomes, including higher satisfaction, improved disease progression, increased self-confidence, increased respect for self and others, and reduced anxiety.[5]

Interfering factors in creating an effective relationship between the nurses and patients have been considered in various studies. In a study of the nurse's unfamiliarity with the local language, the large workload, the difference between the patient and the nurse, and the difference between the nurse and the patient's age were introduced as the causes of communication barriers.[6] Therefore, the interaction between the nurses, staff, and clients from different ethnicities and cultures is very important.[7]

Communication and culture are strongly interrelated. Through contact, culture is passed from one generation to the next. For providing culturally competent nursing care, making effective communication with clients with different ethnic and cultural backgrounds is very important.[8] Therefore, one of the essential aspects of providing care is cultural issues,[9] especially in Iran, where people of different ethnicities (Arab, Baluch, Gilaki, Kurdish, Lor, Mazani, Persian, Turkish, Turkmen, and Talesh) and other religions live together.[10] In addition, religious belief was deeply related to culture, and played a significant role, especially in times of crisis.[11]

The nurses who participated in Heidari et al.[7] study believed that language differences could be a barrier to communication between the nurses and patients. The way of communication with patients of different cultures is the private ward of education in bachelor's degree of nursing. The provision of cultural care in curriculum planning is low and formally not noticed. Heidari et al.[7] believe that due to the cultural differences between the nurse's place of study and the workplace, teaching the culture and cultural care is one of the essential subjects in nursing where the vacancy of cultural communication and nursing is seen.[7] Therefore, knowing the norms of cultural communication may prevent incorrect communication and its damages, which is one of the important and influential factors of cultural sensitivity among nurses[12]; through educating the nurses about culturally sensitive care, better improvement in the patient and family will be observed.[13]

The cultural sensitivity is one factor that affects the quality of nursing care[14] and is the key to cultural care. The cultural sensitivity prevents misunderstandings in nurse–child/parent communication and leads to parental honesty in sharing information and cultural needs.[15] As in Iran's hospitals, the ethnic, cultural, and climatic diversity and a number have led to the formation of cultural diversity in it. It affects the business interactions in the multicultural environment of hospitals.[12] The cultural sensitivity uses knowledge about ethnicities, religions, and differences and respects people from different cultures.[16]

Another factor affecting the quality of nursing care is cultural competence, which is an essential and vital component.[17] Cultural competence is understanding the clients' values, beliefs, and health practices[18] necessary for effective communication with patients and improving their health levels.[19] Employees should be trained in terms of cultural competence since it is one of the critical components in providing effective health care services to reduce health inequalities, challenge racism in health care, improve the patient's safety, satisfaction, and health consequences, and ensure that cultural competence is part of the curriculum.[20]

Iranian society has historically had a multiethnic–cultural, linguistic, and religious context. Consequently, nurses in clinical settings deal with people from different cultural backgrounds, it is necessary to pay attention to cultural issues.[19] The results of Valizadeh et al.[14] in Iran showed that despite the daily exposure of nurses to clients from different cultural groups, nurses working in the pediatric wards did not receive any training in cultural care and culturally sensitive care in university and in-service training programs.[14]

However, different teaching methods can be found in nursing curricula. Still, little information is available about the efficacy of various educational interventions in preparing nurses to care for culturally diverse patients.[21] Despite repeated searches, the researcher could not succeed in finding a study and research on the effect of the communication skills training on the sensitivity and cultural competence of pediatric nurses in Iran. Therefore, the present study aimed to determine the impact of the communication skills training on the sensitivity and cultural competence of the nurses in the pediatric wards of Namazi Hospital in 2021.

Material and Methods

Study design and setting

This is a quasi-experimental study that examined the effect of the communication skills training on cultural sensitivity and competence of the pediatric ward nurses of Namazi Hospital. The research community in this study included the nurses working in all the pediatric wards of Namazi Hospital.

Study participants and sampling

To determine the research sample size, the data of the study carried out by Bastami et al.[19] in 2016 entitled “cultural competence assessment of nurses in Ilam” were used. In this research, a = 0.05, power was 80%, and maximum absolute error was 10%. Based on the mentioned formula, the sample was a minimum 52. In this regard, 54 individuals entered the study. The sample included the nurses selected by non-random sampling method based on the registered volunteer samples in the in-service training system, as coordinated with the educational supervisor of Namazi Hospital.

Data collection tool and technique

This is a quasi-experimental study that examined the effect of the communication skills training on cultural sensitivity and competence of the pediatric ward nurses of Namazi Hospital. The research community in this study included the nurses working in all the pediatric wards of Namazi Hospital. After the approval of the Ethics Committee of the university and the National Ethics Committee, the researcher went to the research environment by obtaining a letter of introduction from the honorable research assistant of the university and making the necessary arrangements, and while introducing himself and stating the research objectives, he started the study.

The research community was made up of nurses from the children's ward of Namazi Hospital in Shiraz who met the conditions to enter the study. Then, through purpose-based non-random sampling, volunteer samples who agreed to participate in the study were included in the study.

At first, the nurses were introduced to the objectives of the study and the confidentiality of the information and the right of the nurses to withdraw from the study at any time were explained to them. Research instruments in this study included a demographic information questionnaire, multicultural sensitivity questionnaire, and inventory for Assessing the Process of Cultural Competence among Healthcare Professionals—revised:(IAPCC-r).

The demographic information questionnaire includes personal characteristics of age, gender, marital status, level of education and employment status, general service background (during their entire career), and service background in the children's wards and workplace. Several faculty nursing professors approved the validity of this questionnaire. This questionnaire was reviewed and approved by ten professors of the Faculty of Nursing, Pediatric Department, and after receiving suggestions and comments, the necessary corrections were made. One session of a 3-h workshop was held under the supervision of one of the professors of the psychiatric nursing department of the faculty. The theoretical and practical topics were presented simultaneously in the workshop. Theoretical topics included communication process in nursing, nurse skills in effective communication, therapeutic communication, cognitive errors in communication, intercultural communication, ethnicity, importance of culture at the bedside, cultural sensitivity, and cultural competence.

The multicultural sensitivity questionnaire was designed by Jibaja et al. in 1994. This is a standard questionnaire with 21 questions. It is scored based on a six-point Likert scale (7 = strongly disagree and 1 = strongly agree). The score range is 21–126, and a higher score indicates high cultural sensitivity. The validity and reliability of this instrument were confirmed by the study of Jibaja et al.[22] in 1994 with a Cronbach alpha of 0.89. Validity and reliability were evaluated in the thesis of Zialame et al.[12](2015). Ti determined the content validity, and the questionnaire and scale were distributed among 15 faculty members, and their opinions were applied. For determining reliability, the retest method was used. In the pilot study, a questionnaire was distributed among 15 nurses, and after two weeks, it was redistributed, and its correlation coefficient (r = 0.98) was determined to be very strong. Also, the reliability of the multicultural sensitivity questionnaire was determined 0.92 using the Cronbach alpha coefficient of the thesis by Zialame et al.[12](2015), and the reliability of the tools was confirmed.

The third questionnaire of the Campinha-Bacote scale is one of the most widely used tools for measuring cultural competence, which Campinha-Bacote designed to assess the cultural competence of students and employees in the medical profession. The tool consists of 25 questions scored on a 4-point Likert scale (4 = strongly agree and 1 = strongly disagree). The questionnaire evaluates seven sub-factors of cultural competence: cultural orientation, cultural awareness, cultural knowledge, cultural skill, and cultural encounter.[23] It should be noted that each subcomponent has five questions and each question has a minimum score of 1 and the maximum score of 4. Finally, the range of scores is 25 (the lowest score) to 100 (the highest score), where 25–50 indicate cultural incompetence, 51–74 cultural awareness, 75–90 cultural incompetence, and 91–100 a person's cultural proficiency. The reliability of this tool was determined by Kawashima et al.[24] in a thesis in Japan with a Cronbach alpha of 0.71. In the research of Khanbabayi Gol et al.[23](2017), the content validity of this questionnaire was confirmed by 10 faculty members, including 3 with Ph.D. degrees in Social Psychology, 3 with master's degrees in nursing education, and 4 with Ph.D. in nursing education. After receiving the offers and comments, necessary corrections were made. Also, the reliability of the internal consistency of the scale was evaluated in a 30-nursing student sample; the Cronbach alpha was 0.91.

To collect the data, after explaining the research objectives and providing complete and comprehensive information, the researcher obtained the participants' consent. They were assured that the information would remain confidential to the researcher. Also, they were given the demographic information questionnaires, the cultural sensitivity questionnaire of Jibaja, and the cultural competence questionnaire of the Campinha-Bacote. A 3-h workshop session was held under the supervision of one of the professors of the psychiatric nursing department of the faculty. In the workshop, the theoretical and practical topics were presented coincidentally [Table 1].

Table 1.

Communication skills topics

Theoretical and practical topics of communication skills
The riddle of communication, the factors influencing
Effective communication and communication, nurse communication skills, communication therapy, and communication goals
Ways to communicate with people with special needs, a guide to communication with angry clients, effective factors in interpersonal communication
Nursing assisting roles in therapeutic communication, the importance of learning communication skills in patient training, communication skills
Principles of patient training with scenario
Communication steps, responses that facilitate the effective communication process, communication skills development techniques
Recommendations for increasing the quality of active listening, effective communication disruptive responses, and effective communication barriers
Nurse-patient communication problems, cognitive errors in communication
Culture, ethnicity, the importance of culture in practice, cultural sensitivity, the importance of cultural competence in practice

Immediately and one month after the workshop, the ward nurses filled out the questionnaires and analyzed them. The data were analyzed using SPSS. 25. The significance level was 0.05. According to the average score of cultural sensitivity, the cultural sensitivity score has increased immediately and one month after the communication skills training compared to before the intervention. Also, the average cultural sensitivity score of the participants has increased one month after the intervention compared to immediately after the intervention, which shows the effectiveness of the intervention during the mentioned period. It is possible to say at what level it has increased, but the average scores obtained indicate the improvement of the cultural sensitivity scores during this period. And the score of cultural competence has increased, but it is still at the level of cultural awareness.

Ethical consideration

The study was concordant with all relevant principles of the Helsinki Declaration and was approved by the Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran (98/08-01-20311). Additionally, informed consent forms were obtained from all the participants.

Results

The findings showed that 54 nurses answered demographic questions in the study; 52 cases (96.3%) and 2 cases (3.7%) were female and male, respectively. Also, 22 cases were married (40.7%), all bachelors, and 32 were single (59.3%). The majority had planned and formal employment status (79.6%, 53.7% planned, and 25.9% formal). The participants' mean age was 30.79 ± 7.57, total work experience was 6.51 ± 4.68 years, and work experience in the children's ward was 5.50 ± 3 84 years [Table 2].

Table 2.

Frequency distribution of demographic variables of the pediatric ward nurses

Variable	Class	Relative frequency	Relative percent
Gender	Male	2	3.7
	Female	52	96.3
Education	Bachelor	54	100
	Master	0	0
	Ph.D.	0	0
Marital status	Single	32	59.3
	Married	22	40.7
Employment status	Agreement	3	5.6
	Contractual	4	7.4
	Formal	14	25.9
	Other	4	7.4
Children ward	Heart	2	3.7
	Kidney, neurology	7	12.9
	Infection	12	22.2
	Surgery	4	7.4
	Digestion	4	7.4
	Accidents	9	16.7
	Immunology	3	5.6
	Glands	3	5.6
	Orthopedic	5	9.25
	Dialysis	1	1.85
	Intensive care	4	7.4

The mean of cultural sensitivity was 44.22 ± 11.78 before the intervention, 48.51 ± 13.34 immediately after the intervention, and 55.55 ± 20.20 one month after the intervention. The score of cultural sensitivity after the communicative skills training and a month after that increased meaningfully (P < 0.001); it showed the efficacy of communicative skills training on the cultural sensitivity of children wards nurses [Table 3].

Table 3.

Determining and comparing the cultural sensitivity of the pediatric ward nurses before, immediately after, and one month after the communication skills training

	Mean±Standard deviation			P*
	Before the intervention	Immediately after the intervention	A month after the intervention
Cultural sensitivity	44.22±11.78	48.51±13.34	55.55±20.20	<0.001

*Friedman test

The mean of the nurses' cultural competency significantly changed after the communicative skills training compared to before the intervention (P < 0.001), and it shows the positive effect of training in the study. In all three time ranges, the mean of the nurses' cultural competency was 51–74, which shows the nurses' cultural awareness. Before the intervention, the mean of cultural competency was 51.68 ± 9.43, the lowest cultural awareness. Still, it increased after the communicative skills training to 57.64 ± 10.43 and 62.56 ± 11.53 a month after the intervention, but it was still in the range of cultural awareness [Table 4].

Table 4.

Determining and comparing the cultural competence of the pediatric ward nurses before, immediately after, and one month after the communication skills training

	Mean±Standard deviation			P*
	Before the intervention	Immediately after the intervention	A month after the intervention
Cultural competency	51.68±9.43	57.64±10.43	62.56±11.53	<0.001

*Friedman test

Discussion

This study showed that the communication skills training significantly increased the sensitivity score of the nurses in the pediatric wards. In other words, teaching communication skills has been effective in the nurses' cultural sensitivity in the pediatric wards of Namazi Hospital.

In a study by Valizadeh et al. (2017) in Tabriz, it was found that understanding the concept of care in terms of cultural sensitivity could help solve cultural exchange problems in the children's wards. Moreover, providing cultural facilities and interpreters to communicate with patients/families increased their satisfaction. Therefore, the present study results are in line with those of Valizadeh et al.[9]

In a study by Erkin et al. (2016), to determine the cultural sensitivity and related factors in the nurses of rural and urban hospitals in Turkey, the mean score of the cultural sensitivity scale was reported to be moderate. Thus, the present research result is consistent with those of Erkin et al.[25] The cultural sensitivity in the present study was moderate, too.

In a study conducted by Yilmaz et al.[26] to investigate the cultural sensitivity in nurses working in rural and urban hospitals in Turkey, the cultural sensitivity of nurses was somewhat high. It was found that nurses who had in-service training courses had more cultural sensitivity than those who did not receive intercultural training courses. However, in the present study, moderate cultural sensitivity was reported; the discrepancy in the results could be due to our target community. In Yilmaz's study, most of the nurses who received in-service training courses had participated. Still, in the present study, in-service training courses for nurses were only held for the intervention group to increase the cultural sensitivity and were not routinely held in hospitals. Furthermore, that study was done in a part of Turkey where many immigrants lived, but this was not the case in the present study. In Yilmaz's study, Chen and Starosta's cultural sensitivity scale questionnaire was used. In contrast, in the present study, Jibaja's cultural sensitivity questionnaire was used, another reason for the discrepancy in the results.[26]

The research conducted by Choi et al. (2016) in South Korea aimed to develop and evaluate an educational program to promote the cultural competence of nurses in cancer prevention. The results of this study showed that the nurses' cultural competency mean score was significantly increased (P < 0.05), which indicates the effectiveness of the training program. In the present study, which focused on cultural aspects, the communication skills training improved the cultural competence of nurses. The present study results were consistent with those of the research carried out by Choi et al.[27]

Dabney et al. (2016) in the USA conducted a study to evaluate the effects of a cultural competency training program on the knowledge, awareness, and skills of child healthcare providers in providing appropriate cultural care for the sick children with cultural diversity; they found that training cultural competence in children's environments significantly increased knowledge, awareness, and somewhat the skills of caregivers of sick children with cultural diversity (P < 0.05) (34). The present study results were consistent with those of Dabney et al.,[28] showing the positive effect of cultural training on cultural competency.

The research conducted by Lee et al.[29] in the USA showed that nursing students had a high level of cultural competence. However, in the present study, the cultural competence of the pediatric ward nurses was at a moderate level which is inconsistent with Lee et al.'s findings. The reason for this discrepancy can be the difference in the study environment so that in other countries, people have a well background in awareness of cultural needs, and this issue has received more attention during the education process or that was performed in the university compared to the present study done in clinic and hospital. The samples of Lee et al. research were nursing students. In contrast, in the present study, nurses were the samples, and the involvement of nurses at their bedside and a busy schedule can be another reason to pay less attention to the cultural needs of patients. On the other hand, Lee's study was descriptive, correlational, and cross-sectional, while the present study was an interventional study. The use of different collection tools and questionnaires can also cause other inconsistencies in the results. The questionnaire used to assess Lee's cultural competence was different from that of the present study.

Based on the findings, training communication skills can affect cultural sensitivity and competence in the pediatric ward nurses. Therefore, the findings of this study can provide reliable information for managers to provide comprehensive care plans; attract researchers; provide a good foundation; guide for future research; plan and perform suitable care programs with clear sight, enough knowledge, and cognition; and value different cultures. The findings of this study can be used by all nurses, especially the pediatric ward nurses, to resolve problems arising from family/nurse cultural interaction in caring for sick children and reduce discrimination and cultural bias.

Limitations and recommendation

The most important limitation of this study was the small sample size, and it was done only in one educational and medical center. It is suggested that studies should be performed in several educational centers and hospitals with a larger number of nurses and in more diverse wards. Another limitation was the lack of long-term follow-up after the intervention since only one posttest was considered due to the sample's attrition.

The present study results showed the positive effect of the communication skills training on the sensitivity and cultural competence of the nurses in the pediatric wards. Cultural sensitivity and competence are the two important components among the medical staff and nurses. Awareness of the patients' cultural needs is an essential part of the nurses' communication skills that can improve the performance of nurses in improving the quality of care for hospitalized children with different cultural backgrounds; therefore, the proposed communication skills training is suggested as a factor to improve the sensitivity and cultural competence of pediatric nurses.

Conclusion

The results of this study showed that the communication skills education has a positive effect on cultural sensitivity as well as cultural competence of pediatric nurses and has promoted them. Therefore, the implementation of the theoretical and practical teaching methods of communication skills is suggested as a way to improve the cultural competence and cultural sensitivity of nurses.

Author contributions

Azin Zeidani and Mitra Soltanian were involved in concept, design, definition of intellectual content, literature search, clinical studies, experimental studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, and manuscript review.

Elham Mirshah and Mitra Edraki helped in clinical studies, experimental studies, data acquisition, and data analysis.

Mitra Soltanian is the guarantor responsible for the integrity of the work.

Financial support and sponsorship

This article is extracted from the master's thesis in nursing, which was presented by the first author of the article and done with the financial support of SUMS with the code of 20311-08-01-98.

Conflict of interest

There are no conflicts of interest.