In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Nu sing Lec u e s’ Pe cep ion and Expe ience o Teaching
Cul u al Compe ence: A Eu opean Quali a i e S udy
Isabel An ón-Solanas 1,* , Isabel Hué canos-Espa za 2,*, Nadia Hamam-Alcobe 3, Valé ie Vanceuleb oeck 4,
Shana Dehaes 4, Ind ani Kalkan 5, Nu an Kömü cü 5, Ma ga ida Coelho 6, Te esa Coelho 6,
An onio Casa-No a 7, Raul Co dei o 7, En ique Ramón-A bués2, Se gio Mo eno-González 2
and Elena Tambo-Lizalde 8


Ci a ion: An ón-Solanas, I.; Hué canos-
Espa za, I.; Hamam-Alcobe , N.;
Vanceuleb oeck, V.; Dehaes, S.;
Kalkan, I.; Kömü cü, N.; Coelho, M.;
Coelho, T.; Casa-No a, A.; e al.
Nu sing Lec u e s’ Pe cep ion and
Expe ience o Teaching Cul u al
Compe ence: A Eu opean Quali a i e
S udy. In . J. En i on. Res. Public
Heal h 2021,18, 1357. h ps://doi.o g/
10.3390/ije ph18031357
Academic Edi o s: Lon Je ey
Van Winkle, Shane L. Roge s and
Nicole M. Michels
Recei ed: 14 Decembe 2020
Accep ed: 27 Janua y 2021
Published: 2 Feb ua y 2021
Publishe ’s No e: MDPI s ays neu al
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Licensee MDPI, Basel, Swi ze land.
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A ibu ion (CC BY) license (h ps://
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1Depa men o Physia y and Nu sing, Facul y o Heal h Sciences, Uni e sidad de Za agoza,
Calle Domingo Mi al s/n, 50009 Za agoza, Spain
2Facul y o Heal h Sciences, Uni e sidad San Jo ge, Au o ía Mudéja , km. 299, Villanue a de Gállego,
50830 Za agoza, Spain; [email p o ec ed] (E.R.-A.); [email p o ec ed] (S.M.-G.)
3Se icio A agonés de Salud, Miguel Se e Women’s and Child en’s Hospi al, Paseo Isabel la Ca ólica, 1-3,
50009 Za agoza, Spain; [email p o ec ed]
4Depa men o Nu sing, AP Uni e si y o Applied Sciences and A s, Lange Nieuws aa 101,
2000 An we pen, Belgium; [email p o ec ed] (V.V.); [email p o ec ed] (S.D.)
5Facul y o Heal h Sciences, Hali Aydin Campus 38, Is anbul Aydin Uni e si y, Se aköy-Küçükçekmece,
Is anbul 34295, Tu key; [email p o ec ed] (I.K.); nu ankomu [email p o ec ed] (N.K.)
6Ins i u o Poli écnico de Po aleg e, School o Educa ion and Social Science, P aça do Município 11,
7300-110 Po aleg e, Po ugal; ma [email p o ec ed] (M.C.); e [email p o ec ed] (T.C.)
7Ins i u o Poli écnico de Po aleg e, School o Heal h Sciences, P aça do Município 11,
7300-110 Po aleg e, Po ugal; casano a@ippo aleg e.p (A.C.-N.); aulco dei [email p o ec ed] (R.C.)
8Ins i u o de In es igación Sani a ia, Hospi al Uni e si a io Miguel Se e , 50009 Za agoza, Spain;
[email p o ec ed]
*Co espondence: ian on@uniza .es (I.A.-S.); ihue [email p o ec ed] (I.H.-E.)
Abs ac :
Cul u al compe ence is an essen ial componen in p o iding e ec i e and cul u ally
esponsi e heal hca e se ices, educing heal h inequali ies, challenging acism in heal h ca e and
imp o ing pa ien sa e y, sa is ac ion and heal h ou comes. I is hus easonable ha unde g adua e
nu sing s uden s can de elop cul u al compe ency h ough educa ion and aining. The aim o
his pape was o in es iga e nu sing lec u e s’ pe cep ion and expe ience o eaching cul u al
compe ence in ou unde g adua e nu sing p og ams. A phenomenological app oach was selec ed
o illici nu sing lec u e s’ pe cep ion o cul u e and expe ience o eaching cul u al compe ence.
Semi-s uc u ed pe sonal in e iews we e held wi h a sample o 24 lec u e s om ou Eu opean
uni e si ies. The anonymized ansc ip s we e analyzed quali a i ely ollowing B aun and Cla k’s
phases o hema ic analysis. Six hemes and i een sub hemes eme ged om hema ic analysis o
he ansc ip s. Cul u al compe ence was no explici ly in eg a ed in he nu sing cu icula. Ins ead,
he lec u e s used mainly examples and case s udies o illus a e he heo y. The in eg a ion o
cul u al con en in he modules was unplanned and no based on a speci ic model. Nu sing p og ams
should be examined o es ablish how cul u al con en is in eg a ed in he cu icula; clea guidelines
and s anda ds o a sys ema ic in eg a ion o cul u al con en in he nu sing cu iculum should
be de eloped.
Keywo ds: cul u al compe ency; nu sing educa ion; quali a i e esea ch; anscul u al nu sing
1. In oduc ion
Acco ding o he Eu opean Commission [
1
], “social inclusion is a he co e o he
Eu opean
Social Model and Eu opean alues ensh ined in he Lisbon T ea y”. Ne e he-
less, in he pas ew yea s, social exclusion and inequali y ha e eme ged as a majo conce n
in Eu opean socie y. Eu opean highe educa ion ins i u ions (HEI) ha e a esponsibili y o
In . J. En i on. Res. Public Heal h 2021,18, 1357. h ps://doi.o g/10.3390/ije ph18031357 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 1357 2 o 20
add ess hese issues h ough he p omo ion o social, ci il and anscul u al compe ences,
democ a ic alues and undamen al igh s, social inclusion, non-disc imina ing ac i e ci i-
zenship and c i ical hinking [
2
]. T anscul u al Nu sing: A Eu opean P io i y, a P o essional
Responsibili y (TC-Nu se), is a p ojec unded by he E asmus+ p og am unde Key Ac ion
203 S a egic Pa ne ships o Highe Educa ion. I ep esen s a collabo a ion be ween ou
Eu opean HEI: Uni e sidad San Jo ge, Spain; Ins i u o Poli écnico de Po aleg e, Po ugal;
A esis Plan ijn (AP) Uni e si y o Applied Sciences and A s, Belgium; Is anbul Aydin
Uni e si y, Tu key. In his pape , we p esen he esul s om ou in es iga ion o Eu opean
lec u e s’ pe cep ion o cul u e and expe ience o eaching cul u al compe ence in ou
unde g adua e nu sing educa ion p og ams o e ed by he a o emen ioned uni e si ies.
Acco ding o Gallegos, Tindall y Gallegos [
3
], he concep o cul u al compe ence
i s appea ed in he nu sing li e a u e in he 90s. Since hen, he cons uc o cul u al
compe ence has ecei ed a signi ican deg ee o a en ion [
3
,
4
] om nu sing and heal hca e
schola s, due in pa o he inc eased di e si y o he popula ion in de eloped coun-
ies [
4
]. The e e -g owing olume o li e a u e p oduced on he concep o cul u al
compe ence highligh s i s impo ance as a ool o “e ec i e communica ion, in e en ion,
and ou comes in oday’s mul icul u al en i onmen pe asi e in he heal hca e p o es-
sions” [
3
]. Howe e , he meaning o cul u al compe ence is ambiguous in he li e a u e [
3
,
5
].
Acco ding
o Cai [
5
], he e is deba e on he concep ual unde s anding o he concep , pa ly
due o he ange o di e en e ms used in e changeably in he li e a u e, namely cul u al
compe ence, cul u al sa e y, c oss-cul u al compe ence, anscul u al nu sing, cul u al
humili y [
6
] o ansna ional compe ence [
7
]. Pe haps one o he mos widely accep ed
de ini ions o cul u al compe ence in he nu sing ield is Campinha-Baco e’s [
8
], who sug-
ges ed ha cul u al compe ence in ol ed unde s anding and app ecia ing simila i ies and
di e ences in heal h belie s and beha iou s, ecognising and espec ing di e ences wi hin
and be ween cul u al g oups and being able o adap one’s p ac ice in o de o gua an ee
high quali y, cul u ally mind ul, sa e and e ec i e ca e o all [2,8].
A changing socie y wi h ee mo emen o ci izens wi hin he EU, dis an pa s o
ou globe becoming mo e accessible, and an inc easingly mul icul u al popula ion a e
ac o s in luencing heal hca e, highligh ing he need o cul u al compe ence and cul u al
awa eness among heal hca e p o essionals [
9
–
12
]. Eu opean heal h se ices designed o
mee he needs o s a ic monocul u al popula ions a e hus equi ed o e iew hei abili y
o mee he needs o di e se pa ien s, amilies and communi ies [
13
]. The e o e, p o iding
cul u e-speci ic ca e o he my iad cul u ally di e se popula ions has become a Eu opean
p io i y and a p o essional esponsibili y [
10
,
14
,
15
]. Fu he mo e, he Global S anda ds
o he Ini ial Educa ion o P o essional Nu ses and Midwi es [
16
] ad ises nu sing and
midwi e y schools o ain g adua es who a e able o demons a e cul u al compe ence.
Nu sing ca e should add ess he social, cul u al and biological de e minan s o heal h
in o de o ensu e equi able heal h ou comes o all. Quali y c oss-cul u al ca e ha
explici ly a ge s s uc u al ba ie s o heal h such as disc imina ion is necessa y o achie e
heal h equi y. The e o e, c oss-cul u al and an idisc imina ion ca e, in addi ion o ca e
a ge ing he social de e minan s o heal h, a e expec ed s anda ds o he nu sing p o ession,
and hus should be expec ed componen s o unde g adua e cu icula [17–23].
Eu opean HEI a e becoming inc easingly awa e o he need o espond o di e se
pa ien popula ions. Nu ses a e expec ed o be able o p o ide app op ia e ca e o di-
e se g oups, and o ensu e ha hese pa ien s’ human igh s a e espec ed ega dless
o (bu no limi ed o) hei acial, e hnic, socioeconomic, eligious backg ound and gen-
de
[12,14,15,24]
. Howe e , cul u al compe ence is a ela i ely new a ea o conce n o
nu se educa o s in Eu ope and he e is limi ed knowledge and unde s anding o hese
skills [
13
,
25
–
28
]. A b ie scoping e iew o nu sing cu icula in Spain, Belgium,
Po ugal
and Tu key e ealed a agmen ed, non-consis en app oach o he concep [
19
,
29
]. Fo ex-
ample, in Spain, only 4 ou o 94 unde g adua e nu sing p og ams o e ed du ing he
academic yea 2019-2020 included he e m anscul u al, 7 included he e m mul icul-
u al and 1 included he e m in e cul u al in hei p og am desc ip ions [
30
]. This is
In . J. En i on. Res. Public Heal h 2021,18, 1357 3 o 20
in ag eemen wi h Bohman and Bo glin’s [
31
] asse ion ha Eu opean nu sing cu icula
lack de ailed anscul u al nu sing con en . In ac , he e is conce n among nu sing schol-
a s ega ding nu sing s uden s’ abili y o mee he demands p esen ed by mul icul u al
socie ies and demons a e cul u al compe ence [
32
,
33
]. Ca ing o a cul u ally di e se
pa ien popula ion poses plen y o challenges [
34
]. Eu opean nu se educa o s ha e a dual
esponsibili y: (1) o help s uden s de elop cul u al compe ence by implemen ing c ea i e,
e idence-based educa ional ac i i ies ha p omo e posi i e, cul u al compe ence lea ning
ou comes and, subsequen ly, (2) o con ibu e o enhance he quali y o ca e p o ided o
di e se pa ien popula ions [10,35].
Theo e ical Pe spec i e
T anscul u al nu sing in ol es he s udy o cul u al di e ences and simila i ies in
heal h and illness eme ging om each cul u al g oup’s unde pinning socie al and o gani-
za ional s uc u es [
13
]. Such unde s anding o cul u al alues, belie s and p ac ices is he
ounda ion o cul u ally cong uen ca e; ca e ha mee s e e y pa ien ’s needs, is mean-
ing ul o hem and suppo s hei li es yle [
36
]. In he wo ds o Madeleine Leininge [
37
],
cul u al compe ence in nu sing is “de ined as a o mal a ea o s udy and p ac ice o-
cused on compa a i e holis ic cul u e ca e, heal h and illness pa e ns o people wi h
espec o di e ences and simila i ies in hei cul u al alues, belie s, and li eways wi h
he goal o p o ide cul u ally cong uen , compe en and compassiona e ca e.” Cul u al
compe ence is hus a b oad and complex cons uc which enables heal hca e p o ession-
als o acqui e “ he a i udes, knowledge and skills necessa y o p o iding quali y ca e
o di e se popula ions” [
38
] while aking in o accoun hei cul u al backg ound [
32
],
including
pa ien s’ heal h and illness belie s, eligious in luences, hei p ima y language,
alues and o he cul u al ac o s ha in luence hei heal h. I is an essen ial componen
in p o iding e ec i e and cul u ally esponsi e heal hca e se ices, educing heal h in-
equali ies, challenging acism in heal h ca e and imp o ing pa ien sa e y, sa is ac ion
and heal h ou comes [
17
,
26
,
28
,
39
]. Acco ding o se e al au ho s [
24
,
40
,
41
], i is easonable
ha unde g adua e nu sing s uden s can de elop cul u al compe ency h ough educa ion
and aining.
The e is a g owing body o e idence abou nu sing s uden s’ pe cep ions o hei own
cul u al compe ence, as well as hei opinion and impac o di e se aining cou ses on hei
abili y o deli e cul u ally compe en nu sing ca e. In e ms o he heal hca e eaching
s a ’s pe cep ion and expe ience o in eg a ing cul u al con en in he cu icula, p e ious
s udies [
42
–
45
] ha e concluded ha heal hca e acul y may bene i om speci ic aining
in o de o imp o e hei knowledge o cul u al issues and a ec i ely add ess hese issues.
Howe e , less is known abou he nu sing lec u e s’ pe cep ion and expe ience o eaching
cul u al compe ence as pa o unde g adua e nu sing cu icula. The e o e, he aim o
his s udy was o in es iga e nu sing lec u e s’ pe cep ion o cul u e and expe ience o
eaching cul u al compe ence in ou unde g adua e nu sing p og ams o e ed a ou
Eu opean uni e si ies.
2. Ma e ials and Me hods
2.1. Design
A phenomenological app oach was selec ed o illici he nu sing lec u e s’ pe cep ion
o cul u e and expe ience o eaching cul u al compe ence in ou Eu opean nu sing deg ee
p og ams. This is app op ia e as phenomenological esea ch is a quali a i e esea ch
me hod which seeks o unde s and complex phenomena h ough he pa icipan s’ li ed
expe ience, meaning and pe spec i es [46,47].
The COREQ epo ing guidelines we e used in bo h he aming and epo ing o
his s udy [47].
In . J. En i on. Res. Public Heal h 2021,18, 1357 4 o 20
2.2. Se ing
This a icle p esen s he esul s om he in es iga ion ca ied ou as pa o he i s
yea o he EU unded p ojec “T anscul u al Nu sing: A Eu opean P io i y, a P o essional
Responsibili y. o Highe Educa ion”. The s udy ook place a ou Eu opean uni e si ies,
namely Uni e sidad San Jo ge (Spain), Ins i u o Poli écnico de Po aleg e (Po ugal), AP
Uni e si y o Applied Sciences and A s (Belgium) and Aydin Is anbul Uni e si y (Tu key).
W i en pe mission om he pa icipa ing HEI o ec ui pa icipan s was sough and
ob ained p io o he in es iga ion.
2.3. Pa icipan s
The s udy a ge popula ion consis ed o nu sing educa o s om ou Eu opean
unde g adua e nu sing p og ams. We ec ui ed a o al sample o 24 nu sing lec u e s,
se en om Spain, se en om Po ugal and se en om Tu key and h ee om Belgium.
A con enience sample ep esen ing nu sing lec u e s om a a ie y o a eas o expe ise
was ec ui ed acco ding o he ollowing inclusion c i e ia:
(1) Nu sing lec u e s employed a one o he pa icipa ing HEI eaching in an unde g ad-
ua e nu sing s udy p og am.
(2)
Lec u e s who ag eed o he condi ions o he s udy and ga e in o med consen
o pa icipa e.
2.4. Me hods
Semi-s uc u ed, one- o-one in e iews ook place a he pa icipan s’ uni e si y and
in he pa icipan s’ own language; in e iews we e conduc ed by an academic om each
o he s udy si es. The in e iews ook place be ween Ma ch and Augus 2019 and las ed
be ween 15 and 45 minu es. One- o-one in e iews we e chosen because hey can elici
ich, cul u ally g ounded insigh s in o people’s expe iences [
48
]. All o he da a we e
audio eco ded and ansc ibed e ba im. The esul s we e la e ansla ed in o English
by he academic unde aking he in e iew, all o whom we e luen in English. All o he
esea che s we e expe ienced quali a i e esea che s wi h p o essional heal h backg ounds
o ei he a nu se o a nu i ionis . All o he esea che s used he same (p e iously ag eed)
in e iew guide. The in e iew ques ions add essed opics such as how one’s own cul u e.
may in luence one’s eaching p ac ice; how, when and whe e cul u al issues we e add essed
du ing lec u es; whe he pa icipan s had had o mal o expe ien ial aining in cul u al
compe ency; and how di icul ies eme ging om a mul icul u al s uden g oup we e deal
wi h (Table 1).
Table 1. Topic guide o he semi-s uc u ed in e iews.
Opening ques ion
I am in e es ed in hea ing abou you expe ience o eaching cul u al con en o nu sing s uden s. Do you add ess cul u al issues
du ing lec u es? How and when do you ac ually do i ?
Follow up ques ions
•
Do you usually each in a mul icul u al class oom? Can you desc ibe he a ious cul u al g oups ep esen ed in he class oom?
•Can you ell me mo e abou you eaching me hods/ eaching and lea ning ac i i ies in ela ion o cul u al
compe ence/con en ? Wha wo ks and wha doesn’ , and why do you hink ha happens?
•Wha impac do you hink hese ac i i ies ha e had on he s uden s?
•Wha aspec s ela ing o ca ing o pa ien s om di e se cul u al backg ounds do you hink should be augh o
nu sing s uden s?
•Ha e you e e conside ed how you own cul u e in luences you eaching p ac ice?
•A e you con iden in you le el o cul u al compe ence o each s uden s abou ca ing o di e se pa ien popula ions?
•
Ha e you had any o mal aining and/o expe ien ial lea ning in cul u al compe ence? Wha do you hink a e you aining
needs in his a ea?
•Unde wha ci cums ances is i di icul o discuss cul u al issues wi h you s uden s in he class oom?
•How do you deal wi h con lic eme ging om eaching and lea ning in a mul icul u al en i onmen ?
In . J. En i on. Res. Public Heal h 2021,18, 1357 5 o 20
The pa icipan s we e also in i ed o comple e a sociodemog aphic ques ionnai e wi h
he aim o desc ibing ou sample, including a iables equen ly associa ed wi h a high
le el o cul u al compe ency.
2.5. Da a Analysis
Desc ip i e s a is ics was used o analyze he sociodemog aphic da a using equency
and pe cen age o quali a i e a iables and mean and s anda d de ia ion o quan i a-
i e ones.
Two esea che s, I.A.-S. and E.T.-L., analyzed he ansc ip s sepa a ely and de i ed
hemes and sub hemes om he da a. A e a p ocess o compa ing and discussing he
da a, consensus be ween he esea che s was eached. Six hemes and i een sub hemes
eme ged om hema ic analysis o he ansc ip s. A summa y o he hemes and sub-
hemes iden i ied, illus a ed by ep esen a i e examples o quo es, is p esen ed in Table 2.
The codes assigned o each o he pa icipan s do no iden i y hei uni e si y o o igin in
o de o p o ec hei pe sonal iden i ies.
The anonymized ansc ip s we e analyzed quali a i ely ollowing B aun and Cla k’s [
49
]
phases o hema ic analysis, namely (1) amilia izing wi h da a, (2) gene a ing ini ial codes,
(3) sea ching o hemes, (4) e iewing hemes, (5) de ining and naming hemes and (6)
p oducing he epo . Quali y was gua an eed by using he ollowing echniques:
•
Space iangula ion was achie ed by in e iewing lec u e s om di e en Eu opean
HEIs o check consis ency o indings o e mul iple si es.
•
In o de o enhance he igo o he s udy, wo esea che s (I.A.-S. and E.T.-L.) analyzed
he ansc ip s independen ly.
•
An audi ail was kep o he esea che s’ decision-making p ocess and c i ical
sel - e lec ion.
•
Field no es, including pe sonal e lec ions on how in e iews we e conduc ed, how pa -
icipan s esponded o he in e iew p ocess and any key poin s a ising om he
in e iews, we e aken.
•
F equen con ac be ween au ho s was main ained in o de o p omo e u he discus-
sion on eme ging hemes and po en ial biases.
2.6. E hical Conside a ions
App o al om San Jo ge Uni e si y Resea ch E hics Commi ee (s udy e e ence
numbe 16-2019) was sough and ob ained. In addi ion, each uni e si y ga e explici
pe mission o collec da a. E e y e o was made o sa egua d he pa icipan s’ anonymi y
and con iden iali y. The lec u e s pa icipa ed olun a ily in he s udy p ocedu es ollowing
explana ion o he s udy which included in o ma ion ega ding hei igh o op ou a
any ime du ing he p ocess and decline o pa icipa e in he s udy wi hou any e ec on
hei p o essional ca ee . All he pa icipan s we e asked o gi e in o med consen p io o
being in e iewed.

In . J. En i on. Res. Public Heal h 2021,18, 1357 6 o 20
Table 2. Summa y o hemes and sub hemes and example quo es om he pe sonal in e iews.
Theme Sub-Themes Selec ed Quo es
Concep o cul u e
Meaning o cul u e
I unde s and cul u e as a space, igh ? Like a momen in which he e a e a ious ways o unde s and he same concep , in his case heal h. (
. . .
)
Like ha ing di e en poin s o iew depending on whe e and how we ha e been aised (L5).
I is whe e you come om, no? People ha come om a di e en coun y, also ha e a di e en cul u e; he e a e di e ences e en wi hin he same
coun y, no? We ha e s uden s who come om di e en egions, o who a e om he same coun y bu hey e hnici y is di e en , like being a
gypsy; hei cul u e is di e en , eligion is ano he aspec (L6).
Cul u al di e si y in
he class oom
Wha do you mean? Like ha ing s uden s om di e en places? (L1).
The e a e people om di e en age g oups, he e a e people . . . , his is an in ui ion, okay? F om di e en educa ional le els, people who ha e
o he diplomas o deg ees. I don’ emembe ha ing s uden s om a di e en ace, o cul u e. I do belie e we once had a emale s uden who was
gypsy Roma (L2).
Impac o own
cul u e on eaching
p ac ice
T aining, pe sonal
and clinical
expe ience
Yeah, I don’ ha e any, um, I ha en’ had any lessons abou ha . Jus om my own expe ience. Bo h in he ca e sec o and in he educa ional se ing... (L9).
No, none. Wi h ha name and all ha . . . , I am oo old! Pe haps li e, yes (L1).
I had no o mal aining, and his ac highligh s he need o s uc u ed p og ams o mul icul u al aining in nu sing (L19).
Pe cep ion o
own cul u e
I’ e ne e hough abou ha be o e., I was aised a Ca holic, bu I don’ belie e any hing mysel , so gosh, I don’ know i ha eally a ec s my
lessons. I don’ hink so because o he ac ha I don’ belie e in any hing speci ic. And i o example you see cul u e as a ision on clo hing,
on a oos, on.... I hink ha ’s p e y b oad ou he e, oo, I hink (laughs) (L8).
Yes, I guess one is in luenced by his o he own cul u e and belie ’s consciously o sub-consciously. I y o u ilize he posi i e aspec s o my
cul u e and amily adi ion in my p o essional li e o e.g., ha ing empa hy owa ds o he s, showing ole ance o o he belie s and cul u es,
impa iali y in eaching as well as clinical p ac ice and likewise (L15).
Cul u e as a sou ce o
misunde s anding
Yes, hey had o example a e y di e en s yle o li e, hose ypical hings. They a e less ale han he local s uden s in class and ha is ce ainly
no he case wi h all o hem. Bu ha is e y ypical o he g oup whe e he e a e a lo o s uden s o o eign o igin, ha my lessons he e a e a bi
mo e di icul ... (L10).
Since my class oom has mos ly Muslim s uden s, i I had o speak on a opic ha is agains he no ms o he eligion and cul u e, I would ind ha
somewha di icul . Discussing sexuali y and sex ela ed opics a e di icul o me (L11).
Teaching and
lea ning cul u al
compe ency
Con en
I alk a lo abou wha I call nego ia ion, ha is, o abandon he idea ha his is mine and i is all ha ma e s, and he es doesn’ coun , no? Tha
is no possible, and i is a lie. I hink li e is pu e in e p e a ion; ( . . . ) you ha e o nego ia e and ag ee wi h whoe e is in on o you. You a e
nobody o disca d hei opinions o p e e ences (L2).
Yes, I do. In he con ex o a mul icul u al app oach o paedia ic pa ien s. I emphasize he p epa a ion ha nu ses should ha e, be a en i e when
ecei ing and p o iding nu sing ca e, pa icula ly wi h ega d o speci ic aspec s such as eligion, e hnici y, belie s, and nu i ion (L19).
Teaching me hods
I hink hese gende issues could lead o . . . , don’ you hink? I mean, hey could be con o e sial. Fo example, once, in clinical simula ion,
we ga e one o he pa ien s a mo e blaséa i ude, a mo e . . . , you know, and one o he s uden s ac ually de ied him. Well, I hink ha hese
s uden s in he end . . . , hey ha e much o lea n (L5).
So, I discuss hese opics in class p esen ing case s udies. I also p esen hese opics o open discussion in my class (L15).
I inse ha con en as I go. O en, i isn’ planned; i jus happens. Ci cums ances, examples ha kind o sneak in. I don’ plan o hese hings,
bu hey happen, and qui e equen ly oo! (L1).
In . J. En i on. Res. Public Heal h 2021,18, 1357 7 o 20
Table 2. Con .
Theme Sub-Themes Selec ed Quo es
In eg a ing cul u al
compe ence in he
nu sing cu icula
Values
You know, we y in class, we all say i . . . , espec . No only owa ds o he cul u es, bu also owa ds di e en poli ical o eligious opinions,
o wha e e (L4).
I hink empa hy as a ool o in e ac ing wi h people based on uni e sal alues such as espec , digni y, jus ice and equali y (L22).
They should no judge indi iduals coming om o he cul u es, by hei own hinking and belie s. Good communica ion and empa hy is e y
impo an o pa ien sa is ac ion—i also plays a ole in hei ecupe a ion. These aspec s o nu sing ca e should be augh o s uden s (L13).
Knowledge
To gi e a simple example; o a pa ien diagnosed wi h Cance , how should he news be sha ed o he pa ien o his amily— his would di e in
e e y cul u e. So, he nu sing s uden s mus be awa e o he pa ien ’s backg ound and cul u e and beha e acco dingly (L13).
Wha I was elling you abou be o e, he mo e heo e ical aspec s, knowing he needs o people om di e en cul u es maybe, he mo e basic
aspec s, pe haps? (L6).
Skills
They should be good lis ene s, minu e obse e s and excellen communica o s. They should lea n o accep di e ences in opinion and y o ease
ou some o hei conce ns o pa ien s h ough p ope communica ion and help wi h hospi al s a (L16).
I hink ha , when you ela e o o he cul u es, ages, blah, blah, blah i ’s complica ed; you ha e o wo k wi h language issues and many o he
hings ha , in u h, I do no add ess; only as case s udies, o ac o s o conside (L2).
Ba ie s o eaching
and lea ning
cul u al compe ence
Educa ional
(lec u e s)
As a eache ..., (pause) I don’ ha e enough ime o each hem e e y hing; I don’ ha e ime o hink abou wha else I should add, you know (L4).
I mean, I hink I ha e acqui ed he (cul u al) compe ences h ough my clinical expe ience in he hospi al, bu I may no be able o pass hem on o
my s uden s (L6).
Educa ional
(s uden s)
Somehow, we a e no able o ge o some o he s uden s... I wonde i i is some hing ha is deeply oo ed wi hin hem; I don’ know i we would
capable, no ma e how much e o we pu in, o changing ce ain hings ha hey ha e acqui ed om hei amily pe haps, and ha hey accep
as an absolu e and immo able u h. I don’ know (L4).
People end o hold on o hei p econcep ions. (
. . .
) Then..., i ’s like some hing isce al. Bu isce alism is encou aged nowadays. Visce alism is
p omo ed so ha people a e less a ional..., less e lexi e. So, oilá, he mess is se ed. I say o hem: “i you a e isce al, hey’ll do any hing wi h
you. You ha e o be e lexi e. You ha e o ha e inne li e”. Then, okay, I can be i esome. Some people accep i e y well, and some people don’
unde s and o don’ ca e (L1).
Social
I always happens. When you y o explain ha ..., ha we ha e o adap o he pa ien and he s uden s hink ha i should be he opposi e, ha
hey a e he e and should he e o e do hings as hey a e done he e. This is way o hinking should be banished i you ask me, bu I am no su e
ha I con ince hem because, o do ha , you need o know he eali y in such a way ha I don’ know i i can be explained heo e ically (L2).
We ha e had some uncom o able deba es abou ..., in public heal h we alk abou heal hca e sys ems, and he ne e -ending deba e abou which
heal hca e se ice model is mo e app op ia e and who should be co e ed by ou public heal hca e se ice. And he e is always deba e, like:
“immig an s canno ha e he same heal hca e co e age as us”. Bu , ela i ely, ha is also a e lec ion o he socie y we li e in and, well, pe haps
hey say hings ha a e poli ically inco ec in he class oom, bu hey a e ou he e oo, you know (L3).
In . J. En i on. Res. Public Heal h 2021,18, 1357 8 o 20
Table 2. Con .
Theme Sub-Themes Selec ed Quo es
Facili a o s o
eaching and
lea ning cul u al
compe ence
Lec u e s
B inging someone who ep esen s a cul u e, ha ’s wha wo ks. I would be amazing o b ing a nu se who was Gypsy Roma, o example (L4).
While discussing he case s udies, he s uden s know ha he e is no “one igh app oach”. E e ybody eels ee o sha e hei ideas o p ac ices
in hei communi y ega ding ha issue. The e is no bias o p ejudice o any idea. This de ini ely c ea es a posi i e impac on s uden s lea ning
p ocess (L15).
Whene e necessa y, I mobilize ano he language such as English, I y o iden i y he s uden s’ lea ning needs, aking in o accoun hei
expe iences and ying o a icula e e e y hing wi h he subjec ’s p og am. In his way I y o comply wi h i , mee ing he di e si y p esen ed by
he s uden s hemsel es (L22).
S uden s
We we e aking abou b ain dea h and ic us and I emembe ha he e was a Muslim s uden in he class oom; he o he s uden s kind o wan ed
o ask him, bu hey did no wan o say some hing ha could o end him, and hey wan ed o ask him how bes o app oach someone who was a
Muslim and who was in ha same si ua ion (L5).
I hink ha was especially su p ising. Uh yes, I hink hey can lea n om each o he , om each o he ’s cul u e and some imes s uden s don’ e en
hink abou i , because we see a lo o di e en cul u es in ou socie y and we a e so used o ha ha ha some imes we don’ hink abou hem
enough, because we a e di e en , you know wha I mean? (L8).
Sys em
Gee, I hink he ac ha hey a e al eady in a p og am whe e ha al eady has a mo e di e se audience, ha ha al eady helps. You c ea e a ce ain
con ex wi hin a uni e si y o applied sciences in which he mul icul u al aspec s a e al eady in e wo en, so I hink ha hey will be able o ake
ha in o accoun mo e, e en unconsciously, han pe haps 20 yea s ago. Wha else can we do ou sel es? Um... yes, he ixed amewo k o
adi ional nu sing, o wha should I call ha , which we some imes gi e, is kind o limi ing (L10).
In . J. En i on. Res. Public Heal h 2021,18, 1357 9 o 20
3. Resul s
The sociodemog aphic and cul u al cha ac e is ics o ou sample a e p esen ed in
Table 3. The a e age age o ou pa icipan s was 40 yea s. Mos o in e iewees we e emale
(70.8%), ma ied (83.3%) and had a whi e e hnic backg ound (95.8%). All o ou pa icipan s
desc ibed hemsel es as middle o high social class, and all o hem we e bo n in he coun y
whe e hey we e wo king a he ime o being in e iewed. Wo h men ioning is he ac
ha almos 80% o ou pa icipan s spoke a leas ano he language and almos 90% had
p io expe ience o ca ing o pa ien s om di e en cul u al backg ounds. Finally, only a
mino i y had had p io aining in cul u al compe ency and/o had li ed o s udied ab oad
o o e h ee mon hs (29.2% and 20.8%, espec i ely).
Table 3. Sociodemog aphic and cul u al cha ac e is ics o he sample (n= 24).
Pa icipan s’ Cha ac e is ics N (%) o Mean (SD)
(To al n= 24)
Age (yea s) 40.25 (9.143)
Clinical wo k expe ience (yea s) 10.33 (8.186)
Gende
Female 17 (70.8)
Male 7 (29.2)
Ma i al s a us
Di o ced 1 (4.2)
Ma ied 20 (83.3)
Single 3 (12.5)
Race/e hnici y
Asian 1 (4.2)
Caucasian/Whi e 23 (95.8)
Residen ial en i onmen
Ru al 3 (12.5)
U ban 21 (87.5)
Socio-economic le el
High social class 3 (12.5)
Middle social class 21 (87.5)
Fa he ’s le el o educa ion
Bachelo ’s deg ee 6 (25)
Voca ional aining 8 (33.3)
Seconda y educa ion 8 (33.3)
P ima y educa ion 2 (8.3)
Mo he ’s le el o educa ion
Bachelo ’s deg ee 3 (12.5)
Voca ional aining 1 (4.2)
Seconda y educa ion 12 (50)
P ima y educa ion 8 (33.3)
Coun y o bi h and wo k
Belgium 3 (12.5)
Po ugal 7 (29.2)
Spain 7 (29.2)
Tu key 7 (29.2)
Mo he ongue
Du ch 3 (12.5)
Po uguese 7 (29.2)
Spanish 7 (29.2)
Tu kish 6 (25)
O he 1 (4.2)
In . J. En i on. Res. Public Heal h 2021,18, 1357 16 o 20
Bo h he lec u e and he s uden s’ cul u al backg ound a e in luen ial in he p ocess
o eaching and lea ning; his is pa icula ly ue in he case o mul icul u al class ooms [
2
].
Fo example, in a s udy ca ied ou in Je usalem, Bena i [
53
] desc ibed how Jewish Is aeli
and Muslim Pales inian nu sing s uden s needed o lea n o unde s and and espec each
o he in o de o be able o p o ide empa he ic nu sing ca e o hei pa ien s. In his
a mosphe e, nu sing lec u e s played a key ole in dealing wi h ension, acknowledging
di e ence and, mo e impo an ly, ocusing on simila i y a he han di e ence. This is
a somewha ex eme example o a cul u ally di e se class oom. Howe e , cul u ally
di e se s uden s do ha e di e se cul u al lea ning needs. Acco ding o Mackay e al [
54
],
nu sing educa o s should be awa e o , and esponsi e o, hese needs, acili a ing he
s uden s’ accul u a ion in o bo h he academic and social milieu. In o he wo ds, cul u ally
compe en nu sing acul y should be able o each wi hin, and adap o, he cul u al con ex
o hei s uden s [55].
Ou pa icipan s discussed how cul u al di e ences be ween hemsel es and hei
s uden s, and be ween he s uden s hemsel es, we e some imes a cause o di icul y
and con lic in he class oom. Fo example, one o he lec u e s desc ibed he o eign
s uden s’ a i ude in he class oom as “wo se” han ha o he local s uden s. This may
be explained by cul u al di e ences be ween he o eign and he local s uden s including
hei e hnici y, na ionali y and language. Howe e , i may also be due o di e ences
be ween he s uden s’ educa ional cul u e, which is unde s ood as he amewo k in which
educa ional ac i i ies ake place [
56
]. Fo example, some coun ies ha e a longe adi ion
o s uden -cen e ed lea ning; his is he case o coun ies such as he UK and Belgium,
whe eas some o he coun ies ely hea ily on a mo e eache -cen e ed app oach. I is
he e o e no su p ising ha s uden s om di e se cul u al backg ounds, who ha e been
la gely exposed o a di e en educa ional cul u e, beha e in wha can be in e p e ed by
he eache as an inapp op ia e o disin e es ed manne . Thus, we a gue ha nu sing
lec u e s should be awa e o he lea ning needs o di e se s uden s and selec eaching
echniques ha sui hei speci ic cha ac e is ics. In ac , he need o academic and cul u al
suppo o di e se s uden s is widely acknowledged [
54
]. Acco ding o A unasalam and
Bu on [
57
] and Mackay e al [
54
], di e se s uden s ace h ee main challenges: di icul ies
wi h language i he local language is no hei mo he ongue, di e ences in educa ion
s yle, and social in eg a ion and connec edness. Nu sing educa o s ha e an essen ial
ole o play in helping o c ea e a posi i e lea ning en i onmen o cul u ally di e se
lea ne s [
58
]. Speci ically, Adeni am and Smi h-Glasgow [
58
] p oposed i e s a egies
o c ea ing and p omo ing a posi i e lea ning en i onmen , ha is de eloping nu sing
educa o s’ awa eness and sensi i i y, equi ing educa ion on inclusion and di e si y o all
nu sing educa o s, inco po a ing speci ic elemen s o cul u al esponsi eness, os e ing
in e g oup ela ions, and implemen ing inclusi e e alua ion. Failu e o adequa ely suppo
he needs o di e se s uden s, including in e na ional and exchange s uden s, esul s in
nega i e s uden ou comes.
None o he ou nu sing deg ee p og ams explici ly in eg a ed cul u al compe ence
in he cu iculum. Howe e , he majo i y o ou pa icipan s, wi h he excep ion o ou
o he Po uguese lec u e s, in eg a ed cul u al con en in o hei lec u es. This usually
happened on an unplanned basis and as illus a i e examples o he heo y and case
s udies, equen ly eme ging om he lec u e s’ own clinical p ac ice. Ou pa icipan s
u ilized a ange o eaching me hods o discuss cul u al con en including case s udies,
deba es, clinical simula ion, u o ials and s and-up lec u es. These eaching s a egies
ha e also been desc ibed in he li e a u e. Fo example, ou o class oom cul u al imme -
sion expe iences [
39
,
40
,
59
,
60
], case s udies [
61
], liaison and pa icipa ion o se ice use s
om a di e se cul u al backg ound [
14
], sociocul u al ac i i ies [
27
], class deba e and
discussion [
18
] and pho o oice [
62
]. Simila ly, none o he lec u e s we e awa e o , no im-
plemen ed, a speci ic model o eaching s a egy o assis ing s uden lea ning abou ca ing
o pa ien s om di e en cul u es. This is despi e he ac ha models o implemen ing
cul u al con en in he nu sing cu iculum ha e been de eloped in bo h he USA [
17
,
38
,
63
],

In . J. En i on. Res. Public Heal h 2021,18, 1357 17 o 20
as well as in Eu ope [
64
,
65
]. This appa en lack o planning, acco ding o Bond e al [
12
],
may explain nu sing s uden s’ ela i ely low le el o cul u al knowledge.
The lec u e s iden i ied a numbe o aspec s p omo ing he acquisi ion o cul u al
knowledge, skills and a i udes. In pa icula , one o he Po uguese lec u e s used English
as a medium o ins uc ion when he s uden s’ le el o Po uguese was insu icien ; he abil-
i y o c ea e a sa e and inclusi e lea ning en i onmen was also equen ly men ioned
as a p omo e o s uden lea ning. Finally, mos o he lec u e s desc ibed he mul icul-
u al en i onmen as conduci e o s uden lea ning. P e ious s udies [
50
] ha e iden i ied
ac o s ha p omo e cul u al compe ence. These include inc ease nu sing eache s’ le el
o cul u al compe ency, alida ing he s uden s’ cul u al iden i ies in he class oom and
maximizing lea ning oppo uni ies o hei s uden s by inding al e na i e ways o each
he same ma e ial.
Ou pa icipan s desc ibed simila ba ie s o eaching and lea ning cul u al compe-
ence in highe educa ion. Speci ically, he lec u e s iden i ied ba ie s o he in eg a ion o
cul u al con en in hei a ious modules, ba ie s o he unde s anding o accep ance o
cul u al con en on he s uden s’ pa and s uc u al ba ie s de i ing om each coun y’s
heal h sys em and social con ex . I was in e es ing o obse e ha all o ou pa icipan s
pe cei ed cul u al compe ence as an addi ion o, and no an essen ial componen o , hei e-
spec i e modules. O he ac o s hinde ing he in eg a ion o cul u al con en in he nu sing
cu icula included lack o eaching ime and igid syllabuses designed by hi d pa ies
(e.g., acc edi ing bodies such as p o essional councils and go e nmen agencies). In e es -
ingly, mos o he Spanish lec u e s also pe cei ed he socie y as ha ing a nega i e e ec
on he s uden s’ capaci y o acqui e cul u al compe ence knowledge, skills and a i udes.
In hei iew, he Spanish s uden s’ a i ude owa ds cul u al di e si y mimicked ce ain
p ejudices and disc imina ing iews o he gene al Spanish popula ion, posing p oblems
when ce ain opics we e add essed in class. Fo example, gende issues, case s udies
in ol ing Gypsy Roma pa ien s and access o heal hca e. Un a o able ou comes in he
in eg a ion o anscul u al nu sing in he cu icula ha e been linked o a numbe o ac o s
including: di icul y i ing i in o an al eady ull cu iculum, lack o expe ience in his
a ea [28,34,59] he s a ’s lack o p epa a ion and con idence o each cul u al compe ency
concep s [
14
], emphasis on inc easing knowledge a he han on de eloping cul u e-speci ic
skills [
12
], lack o suppo o o mally ain acul y membe s, insu icien e o on he pa
o he acc edi ing bodies o include in eg a ion and applica ion o anscul u al nu sing
in he cu icula [
66
], and a lack o consis en measu emen app oaches, using alid and
eliable ools, which has made i di icul o in e p e di e ences ac oss s udies [
63
]. This e-
eals a need o clea guidelines and s anda ds o a sys ema ic implemen a ion o cul u al
awa eness in o he cu iculum [
21
,
34
,
66
], as well as a ho ough examina ion o how un-
de g adua e nu sing p og ams inco po a e issues o cul u e and cul u al compe ency in
hei cu icula [
24
,
63
]. Based on ou esul s, we ecommend ha u u e esea ch in his
a ea ocuses o cla i ying he ba ie s o he in eg a ion o cul u al con en in he nu sing
cu icula and assesses he e ec i eness o in e en ions o o e come hem. These may
include eache aining p og ams, in e en ions o inc ease he adap abili y o he nu sing
cu iculum o he needs and demands o socie y and speci ic s a egies o p omo e cul u al
compe ence, such as he in ol emen o se ice use s belonging o cul u al mino i ies in
class oom ac i i ies.
Limi a ions
Al hough i is no usually he na u e and pu pose o a quali a i e in es iga ion o
in ol e a ep esen a i e sample o he a ge popula ion, we wish o d aw a en ion o
he ac ha only h ee lec u e s om Belgium we e ec ui ed o pa icipa e in his s udy.
The h ee Belgian lec u e s did p o ide in e es ing and insigh ul in o ma ion; howe e ,
i is possible ha a la ge sample o Belgian pa icipan s may ha e p o ided an addi ional
o an al e na i e pe spec i e.
In . J. En i on. Res. Public Heal h 2021,18, 1357 18 o 20
5. Conclusions
Cul u al di e ences be ween eache s and s uden s, and be ween he s uden s hem-
sel es, we e some imes a cause o di icul y and con lic in he class oom. Howe e ,
lea ning in a mul icul u al en i onmen was also pe cei ed by he lec u e s as p omo ing
he acquisi ion o cul u al knowledge, skills and a i udes. Ba ie s o he implemen a ion
o cul u al con en in he unde g adua e nu sing cu icula included ime and syllabus
cons ain s; speci ic opics, such as gende and eligious issues, which we e deemed as di -
icul o deal wi h in he class oom; and deeply oo ed p ejudices and opinions, equen ly
in luenced by socie y. Cul u al compe ence was no explici ly in eg a ed in he nu sing
cu icula. Ins ead, he lec u e s mainly used examples and case s udies o illus a e he
heo y. The in eg a ion o cul u al con en in he a ious modules was unplanned and no
based on a speci ic s a egy o model. Nu sing p og ams should be examined o es ablish
how cul u al con en is in eg a ed in he cu icula; clea guidelines and s anda ds o a
sys ema ic in eg a ion o cul u al con en in he nu sing cu iculum should be de eloped.
Fu he esea ch on e ec i e eaching s a egies and pa ien ou comes is needed in o de o
add ess and cla i y hese issues.
Au ho Con ibu ions:
Concep ualiza ion, I.A.-S. and E.T.-L.; me hodology, I.A.-S.; o mal analysis,
I.A.-S. and E.T.-L.; in es iga ion, I.A.-S., I.H.-E., N.H.-A., E.T.-L., V.V., S.D., I.K., N.K., A.C.-N. and
R.C.; da a cu a ion, I.A.-S. and E.T.-L.; w i ing—o iginal d a p epa a ion, I.A.-S.; w i ing— e iew
and edi ing, I.H.-E., N.H.-A., E.T.-L., V.V., S.D., I.K., N.K., A.C.-N., R.C., M.C., T.C., E.R.-A. and
S.M.-G.; p ojec adminis a ion, I.A.-S.; unding acquisi ion, I.A.-S. All au ho s ha e ead and ag eed
o he published e sion o he manusc ip .
Funding:
This esea ch was unded by he E asmus+ p og am unde Key Ac ion 203 S a egic
Pa ne ships o Highe Educa ion, g an numbe 2018-1-ES01-KA203-050800.
Ins i u ional Re iew Boa d S a emen :
The s udy was conduc ed acco ding o he guidelines o he
Decla a ion o Helsinki, and app o ed by he E hics Commi ee o Fundación Uni e sidad San Jo ge
(p o ocol code 16-2019 on 2 May 2019).
In o med Consen S a emen :
In o med consen was ob ained om all subjec s in ol ed in he s udy.
Da a A ailabili y S a emen :
The da a p esen ed in his s udy a e a ailable on eques om he
co esponding au ho . The da a a e no publicly a ailable due o e hical es ic ions.
Acknowledgmen s:
The au ho s would like o hank all pa icipa ing nu sing lec u e s who ook he
ime o comple e in e iews and made his s udy possible.
Con lic s o In e es :
The au ho s decla e no con lic o in e es . The unde s had no ole in he design
o he s udy; in he collec ion, analyses, o in e p e a ion o da a; in he w i ing o he manusc ip ,
o in he decision o publish he esul s. The Eu opean Commission’s suppo o he p oduc ion o
his publica ion does no cons i u e an endo semen o he con en s, which e lec he iews only o
he au ho s, and he Commission canno be held esponsible o any use which may be made o he
in o ma ion con ained he ein.
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