I S S U E S A N D IN N O V A T I O N S IN N U R S I N G E D U C A T I O N

Evaluation of a cultural competence educational programme

Angela Cooper Brathwaite MN PhD RN
Program Manager, Durham Region Health Department, Public Health Nursing & Nutrition, Whitby, Ontario,
Canada

Basanti Majumdar MSc MEd PhD RN

Professor of Nursing, Department of Family Medicine, McMaster University, Faculty of Health Sciences, Ontario,
Canada

Accepted for publication 17 June 2005

Correspondence: B R A T H W A I T E A . C . & M A J U M D A R B . ( 2 0 0 6 ) Journal of Advanced Nursing

Angela Cooper Brathwaite, 53(4), 470–479
Durham Region Health Department, Evaluation of a cultural competence educational programme
Public Health Nursing & Nutrition,
Aim. This paper reports a study, which evaluated the effectiveness of a cultural
1615 Dundas St East,
competence educational programme to increase Public Health Nurses’ cultural
Suite 210,
Whitby L1N 2L1,
knowledge.
Ontario, Background. Cultural competence has great significance for practising nurses and
Canada. has become a priority and commitment of the Nursing profession. Public Health
E-mail: angela.cooperbrathwaite@ Nurses interact regularly with clients from a variety of culturally diverse back-
region.durham.on.ca grounds. Thus, there is a need for an integrated programme with theoretical and
experiential knowledge related to cultural competence for PHNs to enhance their
knowledge and skills to better meet the needs of the population.
Design. This study used a combination of quantitative and qualitative methods for
data collection. A one-group Repeated Measures design was used to evaluate the
effectiveness of the educational programme.
Method. The sample consisted of 76 Public Health Nurses who attended a cultural
competence educational programme, which was offered over five consecutive weeks,
of 2 hours duration and reinforced by a booster session at 1 month postimple-
mentation of the programme. Cultural knowledge was measured on the Cultural
Knowledge Scale, which was a valid, reliable, 25-item Likert scale. Data were
collected at four points in time and were analysed with repeated measures analysis
of variance. Qualitative data were content analysed.
Results. Findings revealed that the intervention was effective [Wilks’ Lambda was
F(3,69) ¼ 142Æ02, P < 0Æ01] in increasing the nurses’ cultural knowledge. Quali-
tative results complemented the quantitative findings. Participants reported that the
programme was effective in increasing their cultural knowledge.
Conclusion. Although Public Health Nurses, who attended the educational pro-
gramme increased their cultural knowledge, these findings are not generalizable to
nurses working in other settings. However, the programme has clinical utility and
could be adapted and given to nurses in other settings.

Keywords: booster session, cultural competence, cultural knowledge, educational

programme

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Issues and innovations in nursing education
Introduction
In recent years, Canada’s population has increased in cultural
diversity due to immigration to Canada (Toward a Healthy
Future 2nd Report on the Health of Canadians 1999, Canadian
Nurses Association 2000). The largest group of immigrants has
settled in Ontario, thus increasing Ontario’s cultural diversity
(Statistics Canada 2001). Toronto’s population consists of
numerous cultural groups with heritages from Chinese, South
Asian, African and Caribbean, Filipino, West Asian, Latin
American, European, Southeast Asian, Korean and Japanese,
which contribute to its cultural diversity. Cultural diversity
refers to the variation and differences among and between
cultural groups due to differences in life ways, language,
values, norms, and other cultural aspects (Leininger 1995).
These varied cultural groups contribute to diversity in
health beliefs and practices. For example, the cultural
beliefs and practices of Chinese women during childbirth
are different from the values and practices of the Canadian
health care system (Cheung 1997, Fung 1998). According
to Majumdar (1997), the Canadian healthcare system is
built on a Western model of health and healthcare delivery.
This model does not reflect the variability in cultural beliefs
and practices that pertain to illness and prevention of
diseases. PHNs are in a strategic position to provide
culturally competent care to the population as they
interact regularly with diverse cultural groups during their
practice.
Background
Because of increased cultural diversity in Ontario, it is
imperative that Public Health Nurses (PHNs) provide effect-
ive cultural care to clients from diverse cultures. The lack of
formal professional cultural sensitivity training/education can
predispose healthcare providers to discriminatory practices
even though racial bias and calculated cultural insensitivity
are not intended (Majumdar et al. 2004). Healthcare profes-
sionals need an integrated theoretical and experiential
cultural educational programme to equip them with know-
ledge and skills to meet the diverse needs of the population
(Waite et al. 1994). Although many studies (Rooda & Gay
1993, Zollo 1998, Canales & Bowers 2001, Fahrenwald
et al. 2001) have shown the need for multicultural education
among healthcare professionals, it is a challenge for health-
care educators to incorporate cultural courses into undergra-
duate and graduate programmes. Few nursing curricula offer
Transcultural nursing courses to students (Wuest 1992, Masi
et al. 1993, Lester 1998) while others have minimal cultural
content. Nursing programmes that provide Transcultural

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Evaluation of a cultural competence educational programme
nursing courses offer them as electives and these can be
cancelled based on enrolment (Educating Professionals for
Diversity 1994). There is a need for an integrated course with
theoretical and experiential knowledge related to cultural
competence for RNs. In an attempt to resolve this problem,
the investigator has designed a cultural competence educa-
tional programme to fill the gap in registered nurses’ (RNs)
knowledge and skills, which are necessary to provide
culturally competent care to clients.
Several studies have evaluated the effectiveness of cultural
interventions aimed at enhancing cultural knowledge
(D’Andrea et al. 1991, Culhane-Pera et al. 1997, Majumdar
et al. 1999, 2004, Smith 1998) but most of them have
focused on students not practising nurses. For example,
D’Andrea et al. (1991) conducted a series of outcome
evaluation studies on five groups of graduate students (three
interventions and two control groups), who attended a
cross-cultural counselling course. Learning activities of the
course included: defining and discussing fundamental terms
and concepts like culture, ethnicity, racism, cultural encap-
sulation (promoting knowledge), etc., developing counsel-
ling skills through role-play, working with clients from
different cultures and examining the impact of stereotyping
a person from a cultural–racial–ethnic group. They found
that participants in the intervention groups had statistically
significant improvement in their cultural knowledge than
participants in the control groups postimplementation of the
course.
Culhane-Pera et al. implemented and evaluated a 3-year
curriculum for medical residents in order to increase their
cultural knowledge, cross-cultural communication skills, and
cultural competence. Goals of the programme were to:
(1) increase participants’ insight into how culture influences
them in their personal and professional lives; (2) increase par-
ticipants’ appreciation of how culture influences their perspec-
tives on health, disease and healing process and (3) enhance
participants’ multicultural skills to improve patient care.
Results showed that participants had a significant increase in
knowledge and skills between the initial and final evaluations.
Majumdar et al. (1999) evaluated the effectiveness of a
five 3-hour cultural sensitivity educational programme for
foreign-trained medical graduates licensed to practice in
Ontario. Content of the programme consisted of cultural
terms; information on psychosocial barriers to healthy
lifestyle, language, and culture; communication theory;
literature on cross-cultural assessment and multicultural
medicine; mock cultural assessment with simulated clients;
Native Canadian spirituality; medical treatments and the
philosophical differences between Western and traditional
medicine. Results of this study showed statistically significant
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differences between the experimental and control groups on
cultural knowledge and attitude (flexibility/openness, emo-
tional resilience, etc.).
Smith evaluated the effectiveness of an 8-hour educational
intervention to increase Registered Nurses’ cultural know-
ledge and competence. The intervention was comprised of
culturally competent care; strengths related to culturally
competent care; discussion of participants’ past experience
with culturally competent or incompetent care; overview of a
cultural competent model; demonstration of a cultural
assessment tool and discussion of three different cultural
groups (African American, Hispanic American, and Asian
American). Results showed a statistically significant differ-
ence between the intervention and control groups’ know-
ledge. The intervention group’s knowledge score was
sustained at 3 weeks postintervention.
In a randomized controlled trial, Majumdar et al. (2004)
evaluated the effectiveness of a 15-hour cultural sensitivity
training programme for healthcare providers who cared for
patients form two community agencies and a hospital.
Activities of the programme were: discussion on issues
related to racism, cultural bias, prejudices, segregation,
discrimination, team building and cultural sensitivity; self-
awareness exercises and role-play related to cross-cultural
encounters; communication exercises and review of Can-
ada’s policy on multiculturalism (Majumdar et al. 1995).
Results of the study indicated that the programme had
increased participants’ cultural knowledge and attitudes
among providers in the experimental group as well as
resulted in positive outcomes (utilizing social resources
and better financial and physical functioning) for their
patients.
The aforementioned studies found that participants in the
intervention groups had statistically significantly increased
their cultural knowledge following the intervention as com-
pared to participants in the control groups. These results
indicated that educational interventions with cultural content
had improved healthcare providers’ cultural knowledge.
However, none of these studies have examined the effect of
educational programmes on nurses working in Public Health
settings. Therefore, PHNs were selected as participants in the
present study.
The study
Aim
The aim of this study was to evaluate the effectiveness of a
cultural competence educational programme in increasing
PHNs’ cultural knowledge.
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Design
This study used a combination of quantitative and qualitative
methods for data collection. The design involved one-group
with Repeated Measures; that is, one group of participants
received the intervention and pertinent data were collected
twice prior to the intervention (initially T1 and 2 months
later T2) then at 1 week (T3), and at 3 months (T4),
postimplementation of the intervention. The time interval
between T1 and T2 represented the control condition,
whereas the time interval between T2 and T3 reflected the
experimental condition and between T3 and T4 captured the
sustainability of the intervention effects. A repeated measures
design was selected to avoid contamination of the interven-
tion and compensatory rivalry among staff working at the
same health department if they were randomly assigned to
control and experimental groups. Contamination and rivalry
are major threats to internal validity, as they reduce the
between-group difference (Cook & Campbell 1979, Fogg &
Gross 2000). Participants completed two open-ended ques-
tions at 3 months postimplementation of the programme in
order to provide an in-depth understanding of the impact of
the programme on participants. The open-ended questions
addressed the effectiveness of the programme and the impact
of the booster session.
Methods
Sample
The target population consisted of 100 RNs who worked in
Public Health Nursing at a Public Health Department in
Southern Ontario, Canada. All RNs were invited to partici-
pate in the study and were included in the study if they
consented to participate and were licensed to practice in
Ontario. RNs on long-term leave of absence or maternity
leave were excluded. From an eligible population of 92
nurses, 76 RNs (75 females and one male) participated in the
study and this sample size was adequate to detect a moderate
effect size with a beta of 0Æ80 and alpha of 0Æ05.
Variables and measures
Demographic data were collected at baseline and cultural
knowledge was measured with standardized questions at four
points in time. The instrument is discussed in relation to the
concept being measured.
Cultural knowledge was operationalized with being meas-
ured on the Cultural Knowledge Scale (CKS). The CKS was a
5-point Likert-type scale with 24 items. The CKS had four
Issues and innovations in nursing education
subscales measuring health seeking behaviours, perception/
understanding of health and illness, response to health and
illness and treatment of illness conditions. Its response options
ranged from strongly agree (5) to strongly disagree (1). Scores
on the scale were completed as means of the item scores and
ranged from 1 to 5. This instrument has face and content
validity because items were generated from the intervention
and the knowledge subscales of two valid reliable instruments
(Campinha-Bacote 1998, Bernal & Froman 2000). In this
study, the Cronbach’s coefficient a was 0Æ71 and 0Æ81 at
baseline and pre-test, respectively, and 0Æ92 and 0Æ96 at
immediate post-test and 3-month follow up, respectively.
The adapted version was pilot tested with 10 experts for
readability, response options, and understanding of content.
Results of this pilot showed that the scale was easy to read,
understand, and interpret. There was a 98% agreement
among raters on the content and format of the scale.
Description of the intervention
Campinha-Bacote’s (1994, 1999, 2002) model of cultural
competence guided the design of the educational interven-
tion. In this model, cultural competence was defined as ‘a
process in which the healthcare provider continuously strives
to achieve the ability to effectively work within the cultural
context of a client/individual, or family or community’
(Campinha-Bacote 1999, p. 203). Components of this
cultural competence model were: cultural awareness, cultural
knowledge, cultural skill, cultural encounter and cultural
desire. An individual must integrate all five components of
the model to achieve cultural competence.
The intervention reflected the five components of
Campinha-Bacote’s (2002) model of cultural competence.
Key concepts and processes related to providing culturally
competent care were the primary focus of the intervention,
grounded in the experiential–phenomenological perspective,
which advocated that the clinician does not assume superior
knowledge to the client but conserved a sense of humility and
openness (Dyche & Zayas 1995). In this approach, partici-
pants perceived the clients as teachers of their culture and
learned the processes for developing cultural competence
rather than three specific cultures. This global approach
permitted nurses to provide health care that was current,
accurate, and client focused.
Each component consisted of a discussion of the basic
processes related to providing culturally competent care.
The basic processes entail that the RN: (a) acknowledge
that all individuals have a culture and that there are wide
variations within a culture; (b) conduct a cultural assess-
ment on all clients to elicit shared beliefs, values, and

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Evaluation of a cultural competence educational programme
practice that affect health and health care; (c) develop a
plan of care that is mutually agreeable to the client and
RN; (d) identify clients as teachers of their culture;
(e) recognize that clients from diverse cultures have
internalized elements from other cultures (including the
dominant culture) in order to adapt to their new environ-
ment; and (f) be prepared to accommodate health beliefs
and practices of the client that are not harmful to clients’
well being even though these beliefs and practices are
different from the healthcare practitioner’s personal and
professional culture and practice.
The programme was comprised of five components and
was given over a period of five consecutive weeks, where each
component was covered in 1 week in a 2-hour session. In
conjunction with these five sessions, a booster session was
offered 1 month following the intervention to discuss nursing
experiences and ability to apply concepts of cultural com-
petence in practice. The booster session reinforced what
nurses learned in the group sessions. Components of the
programme were: an introduction of Transcultural terms and
overview of the model, cultural awareness, cultural know-
ledge, cultural skill, and cultural encounter. Table 1 has a
summary of the components, objectives and learning activ-
ities of the programme.
Data collection
The principal investigator (PI) hired two research assistants
(RAs) to recruit participants, collect data and enter the data
into a computerized database. A RA approached potential
participants individually to participate in the study, if they
met the selection criteria. At each point of data collection,
participants received a package containing the respective
scales and a stamped self-addressed envelope. All question-
naires were coded prior to distribution to participants and
data were collected.
The PI offered the intervention to all RNs at the Health
Department as a staff development workshop. She delivered
the intervention twice a day to a group of 8–18 RNs over five
consecutive weeks, at their workplace in a classroom setting,
in order to accommodate all participants. Class attendance
was maintained on an attendance log distributed by the
investigator at the beginning of each session. At the comple-
tion of the intervention, the investigator provided each
participant with a Certificate of Participation to maintain
interest and minimize attrition. The RA informed partici-
pants that they were eligible for $100Æ00 random prize (gift
certificate) in return for their participation in the study. The
draw took place 2 months following the fourth and final
questionnaire completion. These strategies were used to
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Table 1 Study intervention
Components Objectives
Component 1 Increase nurses’ understanding of cultural terms
and the importance of culturally competent care
Component 2 Increase nurses’ awareness of their own culture
Increase nurses’ awareness of different cultures
Component 3 Enhance participants’ knowledge of biological
variations in cultures and nutritional preferences
Improve clients’ care by incorporating their cultural
beliefs and practices during the provision of care
Component 4 Improve cultural assessment skills
Component 5 Improve cross-cultural communication skills
minimize attrition in this repeated measures design. All
attendees were invited to participate in the booster session.
Ethical considerations
The study received ethical approval by the Research Ethics
Board at the participating institution. The research assistant
gave potential participants a brief description of the study, its
risks and benefits, what was expected of them and their rights
as human subjects. For respondents indicating a willingness
to participate in the study, signed informed consent was
obtained from them at the time of recruitment.
Data analysis
Descriptive statistics were computed on the demographic
data and all pertinent variables to describe the sample and to
examine the distribution of the scores before inferential
statistical analyses were done. Data were analysed with
repeated measures analysis of variance (RM-ANOVA ) to
examine within-group differences in the cultural knowledge
mean scores across fours point in time (T1 ¼ baseline,
T2 ¼ pre-test, T3 ¼ immediate post-test and T4 ¼ 3-month
follow up). A significant time effect was followed with a
planned post hoc analysis. Post hoc, paired t-test was used to
compare the group’s mean scores between T1 and T2, T2 and
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Learning activities
Lecture-discussion on cultural terms, model of cultural
competence, small group discussion, and case studies
Role-play a simulated game (BaFa BaFa), developed
by Shirts (1977)
Lecture-discussion on cross-cultural communication,
principles of adaptation to a new culture and
characteristics of cultural desire.
Conduct cultural self-assessment.
Self-reflection exercise on taboo behaviours in the
Canadian culture and three practices from your own
culture that may be considered negative
Lecture-discussion on biological variation in cultures,
different types of health seeking behaviours and
practices, and nutrition
Small group discussions; sharing food from other
cultures; case studies; and an experiential game
(Cultural Bingo, developed by Campinha-Bacote 1998)
Mock cultural assessments with peers; and
lecture-discussion on the concept of caring
Reflective exercise on cross-cultural encounters.
Role-play of the Ambassador game, developed by
Biocchi & Radcliffe (1983).
Lecture-discussion on communication theory
T3, T3 and T4, to determine the point in time when
significant changes in the mean scores on cultural knowledge
occurred.
Results
Characteristics of participants
Participants were middle age (mean age of 41Æ4) with an
average of 8 (SD ¼ 9) years of public health experience and
17 (SD ¼ 14) years of nursing experience. Four of them had a
Masters degree, 17 had a College diploma and 54 had a
Bachelors degree in Nursing. The majority spoke only English
at home while five spoke two different languages including
English.
The results of the RM-ANOVA test for the total scale of
cultural knowledge revealed a significant time effect, which
indicated that the group’s mean scores differed over time
(Wilks’ Lambda F(3, 69) ¼ 142Æ02, P ¼ 0Æ000). Thus,
planned post-hoc comparisons using paired t-test were
conducted, with Bonferroni’s adjustment, where the P level
was set at 0Æ02.
The mean score between T1 (mean ¼ 3Æ78) and the mean
score at T2 (mean ¼ 3Æ77) were not statistically different.
However, the mean score at T2 (mean ¼ 3Æ77) was statisti-
cally different from the mean score at T3 (mean ¼ 4Æ57) but
Issues and innovations in nursing education
Cultural knowledge mean scores
6 assessment tools, which enriched participants’ learning. The
4
4·57 4·59
Mean
3·76 3·77
2
0
T1 T2 T3 T4
Time
Figure 1 Pattern of change in cultural knowledge over four points in
time. The effect size for cultural knowledge was 0Æ30 between time 2
and time 3.
the mean scores at T3 and T4 (mean ¼ 4Æ58) were not
significant, indicating that cultural knowledge increased
following the programme and was sustained at time 4. The
mean scores imply that the programme was effective in
increasing the participants’ cultural knowledge which was
sustained at 3-month follow-up. Figure 1 demonstrated the
pattern of change over time.
Qualitative results of the intervention
Qualitative data from the open-ended questions were content
analysed to further explore participants’ perspectives of the
educational programme. The investigator coded the data and
independently analysed them. These results were compared
with the research assistant’s results for consistency and
validation. Results of the analysis are in subsequent para-
graphs.
Overall, participants were very satisfied with the educa-
tional programme. They described it as excellent and useful.
They also said that the sessions were well organized with
adequate length of time for discussion. However, they would
have liked to spend more time on the cultural knowledge
component.
Participants were asked what factors affected the pro-
gramme effectiveness? They reported that the programme
content, interactive learning experiences, and resources
improved their cultural knowledge. The following quotes
exemplified programme content. ‘The great examples and
stories made the program very effective’. ‘The case studies,
artefacts, and role play increased the program effectiveness’,
and ‘The cultural lunch was an excellent way of sharing
knowledge’. Interactive learning experiences was comprised
of games, group discussions, sharing personal stories and
health care workers’ experiences with different cultures. The
following statements captured this theme. ‘I found the group
discussions and stories of healthcare workers’ experiences
with various cultures great for learning’; ‘The case studies
were realistic and applicable to practice’. Resources referred

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Evaluation of a cultural competence educational programme
to the teacher’s knowledge, programme manual, articles and
following quotes captured this theme. ‘ The group discus-
sions, manual, and articles all helped with the course’, and
‘The instructor had an excellent knowledge base, encouraged
interaction, valued the experience of the group, as well as
provided excellent written resources’.
Participants were asked to describe the impact of the
booster session on their practice. They reported that the
session was effective in reinforcing their knowledge and
improving their skills. They said that the booster session had
an impact on their practice in two different ways: consolid-
ation of the learning and opportunity to apply theory in
practice. Consolidation of learning was illustrated by the
following quote. ‘It reinforced previous learning, reviewed
and solidified the knowledge gained in previous sessions’.
Opportunity to apply theory in practice was captured by the
following quote. ‘The booster session reinforced my beha-
viour’ and ‘It provided a chance to use cultural assessment
tools and apply the theories learned’.
Discussion
Limitations of the study
Limitations of the study were primarily related to the
research design. Most of the limitations (attrition, experi-
menter’s expectation and testing effects) were minimized
through strategies incorporated as part of the research
process. For example, having a research assistant to recruit
participants and collect data eliminated the possibility of the
investigators influencing potential participants in the study
and minimized experimenter’s expectations of results. The
time intervals of 2 months between the baseline and pre-test
and 3 months between immediate post-test and follow-up
were selected to minimize testing effects, due to repeated
administration of the same measure and provided time for the
outcome to change. Participants received a Certificate of
Participation to maintain interest in the study and were
eligible for a $100Æ00 random prize for their participation,
which helped to minimized attrition.
Another possible bias of this study was the sampling
procedure. The sample was a convenient one taken from one
organization. Although, a convenient sample may appear to
be biased as compared to a random sample, the sample of 76
PHNs represented 82Æ6% of the eligible population of nurses
(92). In other words, the participants’ personal and profes-
sional characteristics were similar to those of the target
population. However, these PHNs’ characteristics may differ
from those of other RNs, which may limit the generalizability
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of the study findings to all RNs working in various Public
Health Departments.
Effectiveness of the programme
The present findings indicated that cultural knowledge could
be increased through educational sessions given over five
consecutive weeks and reinforced by a booster session at 1-
month postdelivery of the programme. The participants’ level
of knowledge did not change prior to the programme
delivery, but increased immediately at the completion of the
sessions. This sharp increase in the nurses’ knowledge
immediately after the programme indicated that the pro-
gramme was effective in achieving the outcome. This high
level of knowledge was maintained at 3-month follow up.
These findings are consistent with those of other empirical
studies.
Smith (1998) reported similar findings in an evaluative
intervention study with 94 RNs (48 in the experimental
group and 46 in the control group) who worked primarily in
medical–surgical settings. She found a statistically significant
(P < 0Æ001) difference between the experimental group and
the control group on cultural knowledge. The experimental
group’s knowledge scores improved at immediate post-test
and this improvement was sustained at 3 weeks postinterven-
tion. D’Andrea et al. (1991) also found that graduate
psychology students in the intervention group had statisti-
cally significant (P < 0Æ001) improvement in their multi-
cultural knowledge as compared with the control group.
The present findings also corroborated with those of
Culhane-Pera et al. (1997). In an evaluative intervention
study of medical residents, Culhane-Prea et al. found that
participants had a significant (P ¼ 0Æ000) increase in their
cultural knowledge and skills between the initial and final
evaluations of a 3-year curriculum. The faculty’s evaluation
of respondents’ final cultural knowledge correlated with
participants’ final self-evaluations, indicating that partici-
pants had increased their cultural knowledge.
In addition to the aforementioned intervention studies,
Bernal and Froman (2000) and Ottavi et al. (1994) surveyed
206 PHNs and 128 doctoral and master degree psychology
students, respectively, to determine the effects of cultural
diversity courses and/or practica’s influence on multicultural
knowledge and competencies. Bernal et al. reported that
participants’ cultural knowledge increased following attend-
ance at cultural diversity courses, which in turn increased
respondents’ sense of confidence in caring for culturally
diverse clients. Similarly, Ottavi et al. found a significant
correlation between the number of practica attended and
cultural knowledge. All these studies illustrated the impact of
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educational interventions in increasing cultural knowledge in
healthcare providers, thus providing support for the findings
of the present study.
The qualitative results confirmed the quantitative findings.
Participants reported that the increase in cultural knowledge
and skills were attributed to the programme. For example,
they said that the programme content, interactive learning
experiences, and resources facilitated the programme effect-
iveness. Other investigators (Matsuoka & Sorensen 1991,
Panos & Panos 2000, Williams 2002) have found that
cultural resources (manuals, teachers and peers’ knowledge)
contributed to the effectiveness of cultural competence
educational programmes and the development of cultural
competence, because they added a different dimension to the
learning experience. In Williams’ study, peers shared their
experiential knowledge with one another during and after the
educational sessions and more specifically, consulted with
one another in clinical practice.
The present findings are consistent with Ford et al. (1998)
who found that peers were a valuable resource for supporting
learning and transfer of learning to the work environment.
Thus, educators and researchers should deliberately select the
type of resources used and the best methods to disseminate
the content. Participants of the present study were able to
interact with their colleagues and the teacher during and after
the educational sessions. Sharing of information with their
colleagues, receiving input from them as well as giving
feedback to one another facilitated integration of the infor-
mation.
Lastly, participants evaluated the programme as effective.
This result may be due to the value they placed on different
components of the programme. A plausible explanation was,
the cultural encounter component of the programme was
comprised of a simulated game as well as an exercise in
reflection and these have been cited in the theoretical
literature (Tsang & George 1998, Shearer & Davidhizar
2003) as contributing to cultural knowledge and competence.
For example, Tsang and George emphasized the value of self-
reflection as a skill leading to cultural competence. On the
other hand, Shearer and Davidhizar postulated that role-play
contributed to the development of cultural competence
because participants may experience diverse roles or test
behaviours and decisions in an experimental environment
without the risk of negative effects on the nurse–client
relationship. Similarly, the cultural skill component was
comprised of a simulated exercise where participants con-
ducted mock cultural assessments on peers and received
feedback from them on these assessments. Both role-play and
feedback from peers have been cited in the literature as
contributing to learning and cultural competence (Williams
Issues and innovations in nursing education
What is already known about this topic
• Most cultural educational interventions have been
offered to students (medical, nursing, social work, and
psychology) and not practitioners.
• Cultural knowledge could be achieved through cultural
competence courses, workshops and immersion into a
different culture.
What this paper adds
• New information to the literature on cultural know-
ledge and cultural competence.
• An innovative approach to develop cultural knowledge
and skills in Public Health Nurses.
• Suggestions to modify the design of future cultural
educational programmes.
2002, Shearer & Davidhizar 2003). It must be emphasized
that attending all programme sessions may not impact
knowledge unless the information given was viewed as useful
to participants. This has implications for design and
evaluation of educational programmes. Future studies should
measure the perceived helpfulness of educational pro-
grammes to determine whether different components of the
programme are perceived as differentially helpful to partici-
pants.
The qualitative findings also indicated that participants
benefited from the booster session. Participants reported that
it consolidated their learning and provided the opportunity
for them to apply theory into practice. Thus, the qualitative
results clarified the nature of the impact of the booster session
on the outcome. Some investigators (Dijkstra et al. 1999)
found that the booster session was associated with some
improvement in knowledge while others (Brown & Deck
1999, Hollen et al. 1999) did not examined the booster
session unique effect separately from other components of the
programme. These results indicate the benefit of having a
booster session since participants saw it as valuable. How-
ever, booster sessions need to be further evaluated in future
studies.
Implications for practice and research
This study has implications for practice and research. The
implication for practice is that the programme is effective in
enhancing PHNs’ cultural knowledge. Taken further, the
result indicates that the programme has equipped nurses to
provide culturally competent services to clients. Culturally
competent service is important in every area of practice

2006 The Authors. Journal compilation
2006 Blackwell Publishing Ltd
Evaluation of a cultural competence educational programme
because culture shapes clients’ beliefs, behaviours, practices
and expectations. Subsequently, nursing care/services must
match the clients’ needs and expectations, so that they would
have positive and satisfying health outcomes. Additionally,
the programme has clinical utility; that is, the findings have
relevance and applicability to practice. Thus, the programme
could be adapted and given to RNs in other settings.
Future studies should include replication of the study and
conducting of the study with nurse–client dyads. The study
should be replicated using a larger sample of nurses working
in Public Health Nursing, to determine whether the pro-
gramme works with nurses who may be dissimilar to
participants in terms of personal and professional character-
istics. Similarly, future research should address the nurses’
actual application of knowledge in practice to determine the
benefits of culturally competent care to clients. Such a study
would involve nurse–client dyads where nurses receive the
intervention and clients receive nursing services. Findings
from clients’ and practitioners’ groups would be compared to
determine the programme effectiveness from two different
perspectives.
Conclusion
Results of this longitudinal study provided empirical evidence
supporting the study’s objective, that is, the educational
programme was effective in increasing the cultural know-
ledge of 76 PHNs. This study required extended participation
by respondents and several strategies were used to reduce
attrition. Participants received a certificate of participation on
the last day of the programme, which could have been used as
a Continuing Education credit for Quality Assurance at the
nursing regulatory body. They also had the opportunity to
enter their names for a $100Æ00 prize at completion of the
study. Although the Ethical Review Board did not consider
the incentives to be coercive, incentives for participants in
research are controversial topics. Thus, the investigators
recommend that future researchers should apply ethical
principles of respect for participants, beneficence, and justice
when considering incentives for research participants. Other
limitations of longitudinal studies are maturation and history,
which are threats to internal validity. This study was
completed in 8 months and no major events occurred during
data collection. Therefore, the effects of history were not
considered in the interpretation of results, however, matur-
ation of participants could have influenced the results. Thus,
future investigators should examine the effects of history and
maturation in longitudinal studies.
Another limitation of this study was the convenient
sample. Although participants comprised 82Æ6% of the
477
A.C. Brathwaite and B. Majumdar
population of nurses at the Health Department, these
participants were not representative of nurses in other Public
Health Departments. Participants’ characteristics may differ
from those of other RNs, which may limit the generalizability
of the study findings to all RNs working in various Public
Health settings. Therefore, the study should be replicated
with different populations of PHNs to determine if results are
consistent with the present findings.
Author contributions
ACB was responsible for the study conception and design,
data collection and analysis, provision of statistical expertise,
obtaining funding and providing administrative support.
ACB and BM drafted the manuscript. BM critically revised
the paper.
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