Date of Degree


Document Type


Degree Name





Marianne R. Jeffreys

Committee Members

Arlene Farren

Eleanor Campbell

Keville Frederickson

David Bimbi

Subject Categories

Educational Assessment, Evaluation, and Research | Educational Methods | Nursing


Standardized Patient Simulation, Cultural Competence Development, Transcultural Self-Efficacy


Nursing students find it challenging to provide culture-specific care for patients representing diversity in ethnicity, race, language, socioeconomic status, religion, gender, sexual orientation, immigration history, and lifestyle and frequently lack confidence in their knowledge, skills, and abilities. Simulation has become a useful strategy for teaching nursing students assessment skills, technical skills, teamwork, delegation, self-efficacy, and professional communication. An alarming gap exists within the literature concerning innovative teaching and learning strategies that are carefully designed, implemented, and evaluated and follow a conceptual model, guidelines, and standards to enhance cultural competence development of diverse student groups, who must work with patients from various backgrounds.

This longitudinal, one-group, pretest and post-test educational intervention study involved two research questions to understand changes instudents’ (n = 53) transcultural self-efficacy (TSE) following the Diverse Standardized Patient Simulation (DSPS) cultural competence education strategy. Jeffreys’ (2016a) Cultural Competence and Confidence (CCC) theoretical model guided the development of the DSPS strategy. The National League for Nursing (NLN) Jeffries Simulation Theory (JST) (2015), the International Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: SimulationSM (2013; 2016), and guidelines for coaching standardized patients from Wallace (2007) were followed closely in simulation scenario design, evaluation, implementation, and training processes. As a multidimensional strategy, the DSPS strategy carefully weaves together cognitive, practical, and affective transcultural nursing skills; encompasses assessment, planning, implementation, and evaluation; and involves the TSE appraisal process in addition to other considerations from the educational and self-efficacy literature and the CCC model. Two DSPS scenarios designed by the researcher and validated by five doctorally prepared transcultural nursing experts were implemented with 53 ADN students enrolled in a second-semester, nine-credit, 15-week medical-surgical nursing course. DSPS scenario #1 targeted culturally competent care for a Turkish Muslim patient in the preoperative setting; DSPS scenario #2 targeted culturally competent care for chronic disease management (diabetes) for a patient self-identifying with the lesbian, gay, bisexual, and/or transgender population. The Jeffreys’ Transcultural Self-Efficacy Tool (TSET) (Jeffreys, 2016b, Toolkit Item 1) was administered as a pretest and post-test to assess students’ changes in cognitive, practical, and affective dimensions of TSE. To obtain data specific to each scenario, two researcher-developed measuresthat corresponded with each TSET subscale (Cognitive, Practical, and Affective) and the total TSET were administered: The Simulation Survey and Simulation Participation Survey.

For research question 1, the students’ self-efficacy strength (SEST) scores and self-efficacy level (SEL) groups (low, medium, high) changed significantly from pretest to post-test (p < .05) in the Cognitive and Practical subscales and total TSET. Although changes occurred in the expected direction (increase), the Affective subscale missed statistical significance on both SEST (p = .054) and SEL (p = .058) analyses. Bivariate analyses on the Simulation Survey and the Simulation Participation Survey indicated that the mean scores for cognitive, practical, affective dimensions and overall confidence questions were similar regardless of answering immediately after the scenario or post-test TSET for both DSPS #1 and DSPS #2. A statistically significant positive correlation was observed between the specific scenario (DSPS #1 or DSPS #2) and the post-test TSET responses. For research question 2, results supported that all students, regardless of background, benefit (and require) formalized cultural competence education.

This study supports the adaptation and utilization of the DSPS cultural competence education strategy for various populations and settings to develop cultural competence and TSE. The utilization of the CCC model and its corresponding TSET, along with recommended guidelines and standards, can assist to direct future research and focus educational strategies to support students’ confidence in providing cultural competent care. Consequently, this study fills a gap in the literature by providing a carefully orchestrated cultural competence educational intervention specifically utilizing the SP pedagogy that: was guided by a theoretical framework; followed international guidelines and standards for the design, implementation, evaluation, and SP training; and had content validity review. Implications and recommendations for theory, education, research, policy, and administration are presented.


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