Study design
This experimental research followed a pre-test, post-test design and was conducted at two comprehensive urban health centers affiliated with the Kerman University of Medical Sciences in southeastern Iran. The study included two groups: an intervention group and a control group.
According to the academic regulations in Iran, a bachelor’s degree in nursing typically consists of four years of study, which includes both theoretical and clinical coursework. During the final year of the program, nursing students participate in an internship program that aims to prepare them for professional nursing practice. During this internship, senior students work under the supervision of nurse instructors in various clinical settings. To ensure effective clinical education and address any educational challenges faced by the students, the school of nursing appoints faculty members from each educational department based on the students’ credits. In Iran, cultural competence, capacity, and humility have received minimal attention in the nursing education program and are not formally addressed in the official curriculum. Students continue to learn about cultural care through an informal program. Similarly, nurses acquire cultural competence and humility through their work experience in healthcare settings [26].
In this study, a mobile app-based cultural care training program was developed specifically for senior undergraduate nursing students. The development process followed the five stages of the ADDIE instructional model, which included analysis, design, development, implementation, and evaluation.
Step 1: analysis
The primary objective of the mobile app-based cultural care training program was to enhance the cultural capacity and humility of nursing students. During the analysis stage, specific objectives were identified, along with the necessary features of audiences, resources, and technology required for the program. Additionally, methods for presenting the content and ensuring the performance of the mobile application were determined. To guide the design and development of the program’s content, Purnell’s model for cultural competence and Foronda’s rainbow model of cultural humility were selected as the framework [17, 27].
Step 2: design
During the design stage, the learning modules, content, and educational strategies for the mobile application were determined. The educational content was developed following a review of the literature [6, 10, 14, 17, 21, 22, 26,27,28,29] and was presented in the form of 16 modules in the Persian language. These modules included one general module covering cultural care and an overview of the Purnell model, 12 modules focusing on the cultural domains of the Purnell model, and 3 modules based on Foronda’s rainbow model of cultural humility. Additionally, the app included 8 videos and 4 images. The images included visuals such as the culture iceberg, Purnell’s model for cultural competence, and the rainbow model of cultural humility. The references of the text used in the app were cited separately in the references section. The mobile app was designed to operate on Android 4.4 or higher.
To ensure the quality and accuracy of the module contents, validation was conducted by three faculty members from the Razi School of Nursing and Midwifery. The cultural care training curriculum was thoroughly reviewed and revised based on their feedback (Table 1).
Step 3: development
During the development stage, a mobile application called the cultural care training program was designed and created by SPERLOS, as outlined in Table 1. The app was developed to offer students comprehensive and easily understandable educational content across various categories, employing visual effects and practical training methods. The app development involved creating 37 screens, including pages for 16 learning modules, settings, references, and goals, incorporating text, 8 videos, and 4 images aligned with the module content. Additionally, a formative test based on the module content was integrated. The materials were arranged on the pages to enable students to dedicate an average of 10 to 15 min to each module. The intention behind this organization was to ensure that students could study the materials efficiently without feeling overwhelmed or bored.
A heuristic evaluation of the mobile app was conducted by three medical informatics specialists to assess its usability and user-friendliness. Following the evaluation, a pilot test was carried out to determine the comprehensibility of all the modules before implementing the training program. For the pilot test, four nursing students were selected as participants, and no revisions were requested.
Step 4: implementation
During this phase, the sample size was determined according to previous studies [10, 16] and the sample size formula. With α = 0.05, a test power of 80%, and a moderate effect size (Cohen d = 0.6), the required sample size was calculated to be 35 participants for each group. To improve the results and increase the statistical power of the test while accounting for dropout probability, the required sample size was adjusted to 40 participants in each group (resulting in a total of 80 participants for both groups). The study population included all senior nursing students from the School of Nursing and Midwifery (N = 80) at the time of data collection. Given that the sample size was equal to the study population, all students were included in the study by a census. Subsequently, the students were assigned into the intervention (n = 40) and control (n = 40) groups using a random number table. The inclusion criteria for the study students included passing the Objective Structured Clinical Examination (OSCE) for the nursing internship course, being willing to participate in the training program, owning a smartphone, and having the ability to use a mobile-based application. Exclusion criteria consisted of unwillingness to install the app on their mobile phones at the designated time, departure or transfer to another faculty, and failure to complete more than ten percent of the questions in questionnaires.
After the random assignment of students to the intervention and control groups, the project manager held separate meetings with the students from each group. During these meetings, the project manager explained the objectives and procedures of the study and obtained written consent from the students to participate in the study. Following the consent process, pre-test data were collected from both the intervention and control groups. This data collection involved the administration of a demographic and professional information questionnaire, the Cultural Capacity Scale, and the Foronda Cultural Humility Scale, which were provided in paper form. Before commencing their activities at the centers, the students from both the control and intervention groups were divided into smaller groups of four individuals each. Based on the predetermined schedule, a total of 8 students (4 from each group) attended the comprehensive health centers every month to undertake “community, family, and individual nursing internships”. The duration of each group’s internship period was one month. To ensure fairness, one center was designated as the intervention group and the other as the control group each month, with the centers being switched the following month. The entire process of the intervention, spanning from September 23, 2022, to July 22, 2023, covered a period of ten months.
To execute the training program, the first researcher visited the comprehensive health centers at the onset of each month in line with the students’ internship program. The researcher presented the students with an overview of the educational objectives and the mobile application for the cultural care training program. She provided instructions to the students in intervention group on how to register and install the cultural care training application on their mobile phones. Additionally, the researcher explained how to utilize the program at scheduled times and complete evaluations. The students’ contact numbers were also collected for follow-up purposes. To ensure their active participation, the first author sent reminder messages to the participants’ mobile phones every three days, prompting them to engage with the application’s content. In order to avoid the spread of treatment effects between the intervention and control groups, the members of the intervention group were advised not to share educational content with the control group until the study was completed.
At the end of the study, a total of 39 participants from the intervention group and 37 participants from the control group completed the questionnaires. One individual from the intervention group was excluded from the study due to failure to install the mobile application, while 3 individuals from the control group were excluded for not completing the post-test questionnaires (Fig. 1).
Flow diagram of the study, representing data collection points for the intervention group and the comparison group
Step 5: evaluation
The evaluation phase of the study consisted of both formative and summative evaluations. During the formative evaluation, the intervention group was required to complete a 15-item test within the software at the end of each month. Out of the 39 students in the intervention group, only 4 students did not achieve the minimum passing score. However, these students were given an additional 7 days to review and study the program. The first researcher closely monitored the outcomes of the formative evaluation and sent alarm messages to remind participants to complete steps 4 and 5 in the program. For the summative evaluation, aimed at assessing the effectiveness of the application, data from both the intervention and control groups were collected one month after the intervention. Three scales were utilized for this purpose: the characteristics questionnaire, the scale of cultural capacity and humility, and the pre-and post-test scores. By comparing these scores, the impact of the intervention could be determined.
Three tools were used to collect data in the study:
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1)
Demographic and professional information was used to gather information about gender, marital status, ethnicity, history of participating in cultural care training courses, and the level of care for people with cultural diversity in the clinical settings from the participants (Table 2).
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2)
The Cultural Capacity Scale Arabic (CCS-A) gathered data for the cultural capacity of the students. This scale was developed by Perng and Watson (2012) [30] and was adapted to the Arabic language by Cruz et al. (2016). CCS-A consists of 20 items divided into three conceptual subscales: cultural knowledge (items 3, 9, 11, 12, 13, 15), cultural sensitivity (items 17, 20), and cultural skills (items 1, 2, 4, 5, 6, 7, 8, 10, 14, 16, 18, 19) [31]. The items in the CCS-A are designed on a 5-point Likert scale, with response options ranging from 1 (never or not at all sure) to 5 (always or completely sure). The total score ranges from 20 to 100, with higher scores indicating greater cultural capacity [32].
The original CCS-A underwent content validity assessment by five experts. The Item Content Validity Index (I-CVI) was found to be 1, indicating unanimous agreement among the experts. The Scale Content Validity Index (S-CVI) was also 1, indicating high content validity. To assess the reliability of the tool, internal consistency and intraclass correlation coefficient (ICC) were calculated. The Cronbach’s alpha coefficient was calculated for the entire scale and yielded a value of 0.96. Additionally, the calculated ICC rate was 0.88, indicating good reliability [32].
In this study, permission was obtained to use the Persian version of the cultural capacity scale which underwent a process of cultural adaptation using the translation-back translation method. The reliability of the questionnaire was assessed using internal consistency on a sample of 30 participants. The Cronbach’s alpha coefficient was calculated for each subscale, resulting in values of 0.86 for cultural knowledge, 0.87 for cultural sensitivity, 0.91 for cultural skills, and 0.94 for the entire scale.
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3)
The Foronda’s Cultural Humility Scale, developed by Foronda et al. (2021), consists of 19 questions divided into three subscales:
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The Context for Differences in Perspective (questions 1–7): This subscale assesses participants’ awareness of various factors that can influence changes in perspective. These factors include the physical environment, historical background, political climate, power imbalance, and situational context.
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Self-attributes (questions 8–11): This subscale measures the degree of flexibility, openness, and awareness of cultural prejudices and humility within oneself.
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3
Outcomes of Cultural Humility (questions 12–19): This subscale explores the outcomes of practicing cultural humility such as mutual empowerment, respect, collaboration, partnership, exceptional care, and lifelong learning.
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The scoring method for the Foronda Cultural Humility Scale is based on a 5-point Likert scale, ranging from 1 (never/rarely) to 5 (always). The total score ranges from 19 to 95, with higher scores indicating higher levels of cultural humility. Interpreting the scores, a range of 19 to 35 suggests that individuals rarely exhibit cultural humility. Scores between 36 and 75 indicate that individuals sometimes demonstrate cultural humility. A score of 76 to 85 suggests that individuals usually exhibit cultural humility, while a score of 86 to 95 indicates that individuals are habitually culturally humble [17].
The content validity of the Foronda Cultural Humility Scale was assessed by 6 experts. The Item Content Validity Index (I-CVI) exceeded 0.83, indicating a high level of agreement among the experts. The Scale Content Validity Index (S-CVI) was calculated to be 0.96, and the calculated Cronbach’s alpha coefficient was 0.85, indicating good internal consistency [33].
In this study, permission was obtained to use the Persian version of the cultural capacity scale, which underwent a process of cultural adaptation using the translation-back translation method. The reliability of the questionnaire was assessed using internal consistency and Cronbach’s alpha coefficient on a sample of 30 participants for both the subscales and the entire scale. The Cronbach’s alpha coefficient was calculated for the subscales of context for difference in perspective (0.85), self-attributes (0.82), outcomes of cultural humility (0.86), and the entire scale (0.85).
Statistical analysis
The data from the summative evaluation were analyzed using SPSS22. Descriptive statistics such as frequency, percentage, mean, and standard deviation were utilized to summarize the data. Inferential statistics, including independent samples t-test, paired t-test, and chi-square test, were employed to examine relationships and differences within the data. To determine whether the data followed a normal distribution, the Kolmogorov–Smirnov test was conducted. The significance level for the statistical tests was set at ≤ 0.05.
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