Educating Nursing Students for Cultural Competence in Emergencies A Randomized Controlled Trial


 Background: Racial and ethnic minorities suffer significantly more than others in the wake of disasters. Despite the growing recognition of the importance of culturally competent health services, systematic cultural competence training in the medical education system is still scarce, especially in the field of emergency. The current study aimed to examine the effectiveness of an online culturally informed intervention for increasing cultural competence in emergencies among nursing students. Methods: A randomized controlled trial was used to test the intervention effectiveness in increasing nursing students' cultural competence in four domains: attitudes, knowledge, skills, and encounters. The study included 72 undergraduate nursing students recruited from two academic institutes. Participants were randomized (1:1 ratio) to an intervention (n=34) and control group (n=38). The study adheres to the Consolidated Standards of Reporting Trials (CONSORT). Results: Multivariate analysis of variance with repeated measures, followed by post hoc analyses with Bonferroni correction for multiple comparisons, revealed that the intervention was effective in increasing the participants' culturally competent knowledge. The effect of the intervention on the skills domain approached significance. No group differences were identified in the attitudes and the encounters domains. Conclusions: The current study supported the effectiveness of an online culturally informed intervention in increasing cultural competence in emergencies, especially in the cognitive domain (knowledge). Our results encourage the development of future intervention programs that are based on a deep understanding of local values, needs, and preferences.


Introduction
Natural and human-made disasters are priority public health concerns that are associated with adverse physical and mental impact on individuals and communities. While all population members are affected by disasters, research suggests that racial and ethnic minorities are more vulnerable than others to the physical, psychological, and economic effects of disasters [1]. An inclusive approach to disaster and emergency preparedness, response, and recovery activities requires that culturally and linguistically diverse populations are not overlooked [2]. Yet, systematic training in cultural competence is still missing from the medical education curriculum [3], especially in the eld of emergency.
The current study examined the effectiveness of a culturally informed online education program in increasing cultural competence during emergencies among nursing students. The program incorporates global knowledge of emergencies with local understating of cultural norms, values, and practices. It may assist in increasing nurses' cultural competence in different settings.

Background
Cultural competence in healthcare requires a systematic understanding of the cultural and social effects on individuals' health-related beliefs and behaviors and on the multiple levels of the healthcare system [4]. The most popular conceptualization of cultural competency, proposed by Sue et al. [5], includes three aspects: (1) awareness of one's own culturally related biases, attitudes, and values, (2) knowledge about the cultural values and historical background of diverse populations, and (3) speci c skills that can be applied to increase effectiveness when working with a diverse clientele. Cultural competence training has been proposed as a strategy that facilitates the provision of culturally appropriate care by enhancing cultural knowledge, attitudinal responses, or skills [6]. Studies demonstrated that cultural competence training programs could be effective in improving patient-provider communication, facilitate patient-centered care, and increase care access [7,8]. However, these programs' effectiveness remains elusive due to a lack of methodological rigor research in this eld [4].
There are three main reasons why culturally competent healthcare may be especially crucial during emergencies. The rst reason is the high vulnerability of racial and ethnic minority groups to the physical, mental, and economic effects of disasters [9]. The increased vulnerability of ethnic minority throughout the continuum of disaster phase has been attributed to multiple cultural, social, and nancial factors, including the level of language pro ciency, limited acculturation level, migration background, lower socioeconomic status, disparities in healthcare, reduced access to information, community isolation, and distrust in healthcare systems [10,11]. Also, the high interconnectedness of family and community members in collectivist cultures entails that the effects of disasters may impact a wide circle of individuals beyond the direct victims [12]. The lifestyles and behaviors of collectivist countries, such as conformity and tradition, which are a source of physical and social resilience [13], may also pose a threat in times of pandemic outbreaks [14,15].
The second reason why cultural competency is so important during emergencies is related to the key role that cultural values and traditions play in community resilience. Disaster has been de ned as an event in which the social structure is disrupted and prevents the ful llment of the society's essential functions [16,17]. Disasters may also create or exacerbate tensions between racial and ethnic groups, increasing discrimination and racism and putting communities of severe social and economic adversities [18]. Notably, some human-made disasters, such as war, terror, or violence, are often directed towards communities with limited resources that have already experienced a severe disruption to their social fabric due to displacement, loss, trauma, and distrust [19]. Therefore, the strengthening of community reliance and cultural identity is a crucial intervention goal [20]. Finally, cultural competency is essential because crisis interventions require an immediate development of trust between people or organizations [21]. Providing a respectful, empathic, and tolerant professional attitude might be particularly challenging in emergencies because healthcare providers are expected to work under extreme levels of stress, often in non-familiar geographical and socio-cultural contexts.
Although the importance of culturally competent health services has been recognized, the in uence of culturally competent intervention within disasters and emergency management has not been systematically studied [22]. There is also a lack of speci c cultural competency knowledge in the emergency management scholarship of learning and teaching literature [6]. Such lack of emergency-speci c cultural education, coupled with the increasing diversity of the patient population, requires that medical education systems train cultural competence among health professionals [23].
Based on the gaps described in the literature, the current study aimed to examine the effectiveness of an online culturally informed intervention in increasing cultural competence in emergencies among nursing students.

The development of a culturally informed intervention
The theoretical framework of the intervention program integrates models of culturally-sensitive mental health interventions [24,25]  issues. According to the model, developing culturally competent interventions mandates a preliminary qualitative phase to establish a systematic understanding of the community's needs and preferences and determine tentative intervention aims. Guided by this view, the described intervention was based on qualitative data collected through semi-structured interviews with ten key-informants in the elds of emergency and cultural competence healthcare. Informants were academic scholars (n = 4), military medical professionals (n = 2), community physicians (n = 3), and the head of one of the largest community emergency response teams. Most of them (70%) were a liated with one of the ethnic minority groups in Israel (Ethiopian, Muslim-Arabs, Bedouin Arabs, Druze, former-Soviet Union immigrants, and Ultra-orthodox Jews). The analysis was guided by a structured process [27], using the three core concepts of cultural competency [5]: attitudes, knowledge, and skills as a speci c theoretical framework. Additionally, the program drew from the education literature, which states that cultural competency is learned through interactive dialogue and re ection exercises [28] and is based on the expertise of staff and faculty [29]. Therefore, the program included short, recorded lectures of academic experts and self-monitoring exercises. Recorded segments of interview data were incorporated as well.
The course syllabus follows the model of cultural competence [30,31] and re ects the core concepts of cultural competence as set by set by the International Association of Emergency Managers' Code [26]. The model consists of three aspects of development. The rst aspect is concerned with attitudes or awareness towards culture, race, and ethnicity. This aspect includes self-re ection of our personal beliefs, values, and cultural history and how they in uence our own and our patients' lives. The second aspect is concerned with the cultural knowledge of diverse populations. This aspect involves a high motivation to learn about diverse cultures and their health-related beliefs, values, and practices.
The third aspect, "skills," refers to the ability to use cultural knowledge in real-life situations [32].

Methods
The study is a randomized controlled trial (RCT) designed to assess the effectiveness of a cultural competence intervention for nursing students.

Participants
The initial sample included 186 nursing students recruited from two academic institutes in Israel. Students were offered participation by the course lecturer, who was not part of the research team. A research assistant was present throughout the online course to assist students and address questions. Inclusion criteria were: (1) Nursing students who studied in their second academic year at least. (2) Participating in pre-and post-intervention assessments while providing personal code that allowed a reliable matching. The criteria for exclusion were (1) Completing less than 80% of the questionnaire.
(2) Inability to match pre-and post-intervention assessments.
All students signed an informed consent, approved by the IRB, that explains the study's aims and procedures and emphasizes their voluntary participation and the right to withdraw at any point without consequences. After signing informed consent, the 186 participants were randomized (1:1 ratio) to an intervention and control group. The intervention group were assigned to the cultural competence program. The control group was assigned to a non-intervention condition, an equivalent program addressing general guidelines for clinician-patient communication. Randomization was performed using computer-generated block randomization by an independent researcher. The principal investigators and data analysts were blinded to the group allocations of the participants. Of the 186 randomized participants, 91 participants in the intervention group and 95 in the control group completed the pre-intervention assessment (T0). A total of 115 participants completed the two-week post-intervention assessment (T1), 51 in the intervention group (56%), and 64 (67%) in the control group. After pairing pre-and post-intervention assessments, 72 participants were left and included in the nal analysis; 34 in the intervention group and 38 in the control group (see Fig. 1 for a ow chart of the study's methodology). The demographic and background characteristics of the two study groups are presented in Table 1. The two study groups did not differ on age, gender, migration status, and academic year.

Procedure
The course was incorporated into existing academic courses and was delivered as a distant learning program. The intervention consisted of two sessions of 60 minutes, each integrated across the curriculum [35,36]. The program included seven learning units: (1) De nitions of emergencies, (2) the unique challenges facing health services during emergencies, (3) introduction to cultural competency, (4) culturally competent attitudes, (5) culturally competent knowledge, (6) culturally competent skills, and (7) summary.
The control program-Incorporating the control program into the existing academic curricula required that the program provides relevant, educational content. As such, the rst two control program units were identical to those of the intervention program (i.e., de nitions of emergencies and the unique challenges facing health services during emergencies). The rest of the units focused on the social networks and aspects of community resilience during emergencies. The control program did not include any references to culture or cultural-competent care.

Measurements
Background variables-For each student, age, gender, academic program, academic year, and immigrant status were recorded.
Cultural Competency-To evaluate the pre-and post-intervention cultural competency of students, we used a modi ed version of the Clinical Cultural Competency Questionnaire (CCCQ) [37]. The original questionnaire was developed to assess physicians' provision of culturally competent healthcare to diverse patient populations. The questionnaire includes 63 items addressing four domains of cultural competence: attitudes (self -assessment of one's cultural values, beliefs, and behaviors, e.g., "Awareness of own racial, ethnic, or cultural stereotypes"), knowledge (search for knowledge about different cultural groups, e.g., "Knowledge on health disparities"), skills (the ability to accurately and thoroughly assess cultural need, e.g., "Providing culturally competent clinical preventive services"), and encounters (active engagement indirect interaction with different cultural groups, e.g., "Caring for patients from culturally diverse backgrounds "

Data Analyses
Based on previous ndings regarding multicultural education [39, for meta-analysis], the expected effect size of the educational program was d = 0.49. Taking this estimation into account, the study required sample size of 35 pairs to achieve a power of 80% and a level of signi cance of 5%. To examine group differences in changes of CCCQ, we performed a two-way repeated-measures analysis of variance (ANOVA). CCCQ domains (attitudes, knowledge, skills, and encounters) and time (pre vs. post-intervention) were the within-subject factors, and group (intervention vs. control) was the between-subject factor. All multivariate analyses were followed by posthoc analyses with Bonferroni corrections for multiple comparisons. The Statistical Package for the Social Sciences (SPSS) version 26 [40] was used for data analyses.

Baseline between-group comparisons
T-tests for independent samples and Chi-square tests were used to compare the two groups on baseline demographic characteristics. As seen in Table 1, no group differences were found in age, gender, academic year, and migration background. Group differences in baseline levels of cultural competence were examined using Univariate analysis of variance (ANOVA). No group differences were identi ed (F (4,66) = 2.16, p = 0.08).

Multivariate analysis of variance with repeated measures
To examine group differences in the four CCCQ domains, we performed two-way repeated-measures ANOVA ( Table 2).

Discussion
Previous research has recognized the clinical and ethical imperative of considering socio-cultural contexts in developing healthcare interventions for various populations [41,42]. The need for culturally sensitive interventions is especially crucial during and after an emergency due to the increased vulnerability of ethnic minorities and other underserved populations to disasters' physical, psychological, and economic effects [43]. Research examining cultural competence training programs suffered from methodological constraints, such as weak study designs (e.g., lack of RCTs), low or no reporting of consent rates, and non-validated measurement instruments, limiting rigorous evaluations on the effectiveness of interventions [3,4].
The current study used a randomized controlled design to examine the effectiveness of an online intervention in increasing nursing students' cultural competence in emergencies.
Overall, our results supported the use of an online program incorporated in the curriculum for increasing students' cultural competence. Speci cally, participants in the intervention group were more likely to report increased knowledge of socio-cultural characteristics, health disparities, and health risks experienced by particular racial and ethnic groups, as well as of alternative healing traditions and methods [44]. The effect of the intervention in increasing participants' ability to translate this knowledge into their daily practice (skills) approached signi cance. However, participants did not present increased con dence (encounters) in their ability to empower patients from diverse backgrounds or increased awareness of their own cultural background, stereotypes, or biases. These ndings are consistent with previous studies [45][46][47] and systematic reviews [48,49] showing that cultural competence training is especially effective in facilitating cultural-competence knowledge. For instance, a systematic review of 16 studies by Jongen et al. [48] found that cultural competence training improved knowledge in 9 of 16 studies, skills in 7 of 16, attitudes/beliefs in 5 of 16 studies, and con dence in 5 studies.
Several explanations may be proposed but warrant further exploration. First, focused intervention programs incorporated in the curriculum context are more likely to enhance the cognitive aspect of cultural competence (especially at the basic knowledge and understanding levels) than other domains. From an education perspective, culturally-diverse knowledge is easier to learn and teach than practical skills or attitudes (affective learning domain) [50]. Second, changes in culturally competent knowledge are easier to measure than changes in other domains [51]. The gains in culturally competent knowledge may also be attributed to the course delivery mode [48]. While different cultural competence training was delivered by professional trainers [45], sometimes from diverse backgrounds [46], our intervention was provided in two online sessions. Such delivery mode, especially in academic settings, may focus on the acquisition of facts rather than encouraging affective engagement or selfre ection. It is possible that longer courses that include active participation (e.g., students' presentations, classroom discussions, simulations) would increase the practical and affective domains of cultural competence.
A further explanation for our ndings is related to the considerable overlap between the control and the intervention programs in content and structure. Given that the control program was incorporated within the curriculum, it was necessary to develop a course that consists of relevant educational content. The control program addressed the pivotal role of healthcare services during emergencies and emphasized the importance of social communication and networks.
While not explicitly addressing culturally related topics, this program may encourage a patient-centered approach and promote sensitive and empathic attitudes among students. Indeed, our results showed that, compared to the preintervention assessment, both the intervention and the control groups showed an increase in their CCCQ scores. Such similarity between the intervention and control programs may explain why the culturally related knowledge was the most prominent gain from the intervention. Because most cultural competency training studies did not include a comparison group or used a non-intervention control group [3, for review], there is a need for a systematic investigation of what could be considered a "comparison condition." For example, Genao et al. [52], who examined a cultural competence curriculum for third-year medical students, presented a control program that included lectures on clinical preventive medicine, alternative medicine, and domestic violence, taught by faculty with expertise in those areas. This program, however, did not necessarily encourage a patient-centered approach, and therefore might be more distinguished from the intervention group than in our study.
The limited differences between the intervention and control group might also be attributed to the demographic nature of our sample, which consisted of a high proportion of immigrants (30%). Previous studies suggested that compared to white therapists, cultural and linguistically diverse professionals were more likely to be involved with ethnic minority communities, to use a cultural framework in their clinical practice, and to perceive their agencies as culturally sensitive [53]. Ethnic minority healthcare professionals often share patient's experiences of racism and prejudice [54], motivating them to provide more culturally competent care. It is possible that healthcare students of immigrant backgrounds were already aware of the importance of culturally-competent care and familiar with the concepts of cultural competence [55]. Therefore, the only effect of the intervention program was evident in the practical skills domain, where training was necessary.
Our ndings provide further support for the usefulness of online learning in health education. Recent studies that examined the effects of online learning on nursing assessment skills and knowledge supported its effectiveness [56, for a systematic review], especially in facilitating practical skills [57]. Online learning was found to be effective in increasing medical capacity in rural settings and low-and middle-income countries, as it provides greater educational opportunities for students while simultaneously enhancing faculty effectiveness and e ciency [58]. Our study had several notable strengths. First, the study used a theory-based intervention that incorporates universal as well as local understating of crisis responses and resilience. Second, the current study is built on the model of methodological excellence in educational studies [59] that advocates for the use of blind RCTs with valid instruments and appropriate statistical analyses of subgroups. This research is also one of the few studies that examined the e cacy of cultural competence training programs outside the United States.
The reported ndings should be considered under several limitations. First, this study relied on self-report measures of cultural competence and did not include an objective evaluation method, such as health outcomes [60, for a systematic review] or patient satisfaction [61, for a systematic review]. Self-report measures are also vulnerable to various biases, including social-desirability or response-shift bias, that may confound the intervention effect with bias recalibration [62]. Second, because the post-intervention assessment did not include a follow-up phase, it is di cult to determine whether the intervention's advantage would be stable over time. Third, because this study was based on healthcare students, our ability to generalize our results to other healthcare populations and setting is currently limited. Finally, due to the high attrition rate, the sample size was limited.

Conclusions
Immigration and the growth of multicultural societies have highlighted the need for culturally competent care worldwide, especially in times of emergencies. Our results encourage the development of future intervention programs that are based on a deep understanding of local needs and preferences and incorporate ethnographic cultural knowledge.
Equally important is the usage of large-scale randomized controlled trials that would evaluate real-life, cultural competence and not only self-report measures. There is also a need to examine the applicability of cultural competence training programs to different emergencies and to adapt their content and structure to the speci c needs of the disaster and the patient population.

Declarations
Ethical approval and consent to participate.
The study was approved by the Ethics Committee of the Education Department, Ben-Gurion University. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study.

Consent for publication.
Not applicable Availability of data and materials.
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors have no relevant nancial or non-nancial interests to disclose. Funding: Partial nancial support was received from Ben-Gurion University research grant for interdisciplinary research. Funders were not involved in the study design, analysis or interpretation.
Authors' contributions.  Group differences in the culturally competent attitudes Group differences in the culturally competent encounters

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