Nursing students’ experiences with improving cultural competence through education and practices in rural Indonesia: a qualitative study†
Categoria dell'articolo: Original article
Pubblicato online: 14 mar 2025
Pagine: 37 - 45
Ricevuto: 09 set 2024
Accettato: 21 set 2024
DOI: https://doi.org/10.2478/fon-2025-0005
Parole chiave
© 2025 Petrus Kanisius Siga Tage et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Culture is an important part of nursing care because it can influence perceptions of health, behavior, and responses to care.1 Despite this, global reports of cultural insensitivity continue, and a growing body of evidence highlights the importance of developing cultural competence in nursing education and practice.2 Cultural competence has been recognized as an important part of developing nursing education competencies.3
Cultural competence in nursing is defined as a formal area of study and practice that focuses on comparative holistic cultural care, patterns of health and disease of people concerning differences and similarities in their cultural values, beliefs, and ways of life to provide culturally congruent, and competent care as well as loving.4 Cultural competence is thus a broad and complex construct that enables health professionals such as nurses to acquire the attitudes, knowledge, and skills necessary to provide quality care to diverse populations.
In rural Indonesia, behavior related to public health becomes more complex due to being a multicultural, ethnically diverse region with various health service providers. Therefore, the problem of learning cultural competence in tertiary institutions needs to be evaluated. There is a need for high-quality studies investigating educational interventions to develop the cultural competence of nurses so that nurses can provide culturally appropriate nursing care.5 In rural areas of Indonesia, there is still a community culture that is very influential on their patterns of health and illness. Various cultures influence health, such as chewing betel leaves >5 times a day in the Timor region, so most people experience oral health problems such as incomplete teeth, dental caries, and teeth discoloration to brown and black.6 In the Flores region, it was found that pregnant women should not consume eggs because the mother will excrete feces at the same time as the child is born.7 In the Sumba region, childbirth and modern medical practices are considered offensive to sacred ancestral wishes, and many believe that doing so can harm pregnancies or cause future infertility.8 In Soe, there is a practice of
Cultural diversity, as described, requires nursing students to have cultural competence as a guide to future professional practice to provide care to their clients in rural areas easily. By having good cultural competence, students can shape their culture in professional relationships with the community, which will help influence and shape the process of care provided.10 Studies regarding cultural education and student practice in rural areas with diverse cultures still need to be completed. Therefore, this study aimed to identify students’ experiences of cultural competency education and practices that influence their cultural competence in rural areas of Indonesia.
The approach used in this study is descriptive phenomenology. This study approach is relevant as an attempt to describe the phenomenon by exploring cultural education and practices that affect students’ cultural competence from the perspective of students who have experienced it in rural areas of Indonesia. All interviews were conducted between December 2022 and August 2023. All researchers have experience in qualitative studies. One researcher was male, and 5 researchers were female. The consolidated criteria for reporting qualitative research (COREQ) advocated by Tong et al.11 followed in this study.
Recruitment of participants in this study used a purposive sampling approach to 32 participants spread across 6 East Nusa Tenggara, Indonesia regions. Researchers and participants did not know each other before or during the interview. The distance between each region and the city center varies because it is a large archipelago. In each of these areas, there is a health campus with a faculty of nursing and a hospital where students practice. Participant inclusion criteria were nursing students who had carried out clinical practice, had carried out education for >2 years, were undergraduate and diploma-level students, and had received courses on culture.
Interviews were conducted face-to-face for 50–60 min using guided questions and were conducted in-depth and semi-structured. The interview process was conducted by 2 authors with master’s degrees in nursing. All researchers have experience in qualitative studies. One researcher was male, and 5 researchers were female. The researchers and participants only knew each other after and during the interview process at the student’s campus and clinic. The interview process was carried out only once, and confirmation of the interview findings was returned to the participant for examination. Each interview process and expression were recorded on a field note sheet. During the interview process, the researcher adjusted the phrases and order of questions based on the circumstances in each interview session. The interview guide includes questions that address the following: (a) feelings and experiences related to learning cultural competence in universities and clinics, (b) opinions about the support needed, (c) strategies used to deal with barriers, and (d) expectations in the future. Detailed guide questions can be seen in Table 1. The interview communication process used Indonesian. No participants dropped out of this study. Data saturation was fulfilled in the 28th participant.
Question guide list.
| Question |
|---|
Can you explain the situation related to the learning process to improve cultural competence while on campus, including teaching capacity, teaching curriculum forms, and related subjects? Can you explain the situation related to the learning process to improve cultural competence in the clinic, including mentor capacity, forms of practice, and related courses? How do you apply theory in your practice to improve your cultural competence? What problem-solving strategies do you use if you experience obstacles during the learning process on campus and in the clinic? What are your expectations regarding increasing cultural competence during learning? Is there anything else you would like to say? |
The method of data analysis in this study used thematic analysis following the guidelines of Braun and Clarke,12 which was carried out by 6 authors with the following steps: (1) all researchers tried to understand the data by repeatedly reading the results of the interviews; (2) code as much as possible from the topic and apply the code to contextual segments, not just phrases; (3) create themes by sorting code into more detailed categories; (4) review candidate themes by revising encoded data into proper theme component code; (5) refine theme names and ensure that they occupy fields the same semantics, namely, that they are conceptually parallel; and (6) produce reports based on related themes.
In ensuring the validity of this research, we followed the guidelines of Denzin and Lincoln,13 which include: (1) credibility is filled with 2 researchers (PKST and FTF) who are long-up with participants through the indepth interview process for 2-3 weeks at each study site process, and the interview technique was tested with 2 examples of participants, and the researcher ensured that the participants interviewed met the established criteria and objectives; (2) dependability by triangulating the source of theory and participant by 3 researchers (PKST, FTF, and MYG) to ensure the correctness of data and results written. We also implemented a reflexive and weekly meeting between 6 researchers. (3) Confirmation was carried out by detailing 6 researchers’ data collection processes of 32 participants. To avoid bias, each piece of data is confirmed based on the participants’ information and not the researchers’ interpretation. (4) Transferability is met with a study approach and sampling technique with maximum variation by the research objectives. It is commonly used in qualitative studies and ensures data saturation research.
Ethical approval was granted by the Citra Bangsa University Research Ethics Committee (No. 021/EC/KEPK/FK/2022). All participants provided signed informed consent after explaining the purpose and rationale of this study. Since the research was conducted in a limited context, the anonymity of the participants was protected, and no detailed information about them was presented.
Participants were predominantly female (56%), with most of them aged 20–24 years. Over half (63%) of them have a Bachelor of Nursing Education with a length of education between 4 years and 6 years (75%). Most participants identified as “Catholic” or “Protestant”. The culture of origin of the participants is generally from Flores and Timor. Up to 47% of participants had a practical experience 3 times a year, with the longest practicum being 4–6 months (53%). It can be seen in detail in Table 2.
Characteristics of participants.
| Characteristics | Frequency | Percentage (%) |
|---|---|---|
| Female | 18 | 56 |
| Male | 14 | 44 |
| 15–19 | 10 | 31 |
| 20–24 | 15 | 47 |
| 25–29 | 5 | 16 |
| 30–35 | 2 | 6 |
| Diploma 3 in nursing | 10 | 31 |
| Diploma 4 of nursing | 2 | 6 |
| Bachelor of nursing | 20 | 63 |
| 2–3 years | 8 | 25 |
| 4–6 years | 24 | 75 |
| Catholic | 10 | 31 |
| Muslim | 8 | 25 |
| Protestant | 9 | 28 |
| Hindu | 5 | 16 |
| Rote | 3 | 9 |
| Flores | 5 | 16 |
| Sumba | 3 | 9 |
| Timor | 4 | 13 |
| Alor | 3 | 9 |
| Jawa | 3 | 9 |
| Sulawesi | 3 | 9 |
| Papua | 3 | 9 |
| Timor Leste | 3 | 9 |
| Sabu | 2 | 6 |
| 3 | 15 | 47 |
| 2 | 10 | 31 |
| 1 | 7 | 22 |
| 1–3 months | 3 | 9 |
| 4–6 months | 17 | 53 |
| 7–10 months | 12 | 38 |
This study produced several important themes related to nursing students’ cultural competency learning experiences in education and practice in rural areas of Indonesia, and Table 3 describes the details.
Main themes, subthemes, and examples of quotes from the experiences of nursing students while learning cultural competency on campuses and clinics in rural areas of Indonesia.
| Themes and subthemes | Illustrative quotes |
|---|---|
| Cultural competence includes awareness, sensitivity, knowledge, and skills related to culture | “I consider that cultural competence is broad and can be related to how we are aware, sensitive, understand and we can show it to patients when providing nursing care” (P22) |
| Cultural competence is something that nurses need to have | “When I am in clinical practice and meet different patients, I feel that cultural competence is necessary for a nurse” (P9) |
| How to learn to respect different cultures | “The main thing about cultural competence is related to efforts to respect patients with different cultures” (P17) |
| Cultural competence is an important thing | “Cultural competence is always important” (P16) |
| Some lessons support the improvement of cultural competence | “While on campus, there were 3–4 courses which I felt were very supportive to increase our understanding of cultural competence” (P2) |
| Teaching on campus is going well | “At our university, learning related to cultural competence goes very well and supports the learning process” (P21) |
| There are various ethnic groups in the class | “Our class has many friends with various ethnicities, so it helps us to learn well about different cultures” (P27) |
| There are differences in perceptions among students regarding cultural competence learning | “In discussions during lectures and practice, we often have different views about cultural competence” (P1) |
| Meet different cultures | “Clinical practice allows us to meet patients from different cultures” (P18) |
| There is a conflicting culture in the practice field | “Some cultures conflict with the care we provide, so we must communicate well (P20).” |
| Provide care that is culturally appropriate for the patient | “Professionally, we try to provide care according to the patient’s culture” (P18) |
| Receiving violent threats | “The patient and his family almost beat me because they misunderstood” (P11) |
| Need to increase understanding of the patient’s cultural background | “After meeting patients at the practice site, I feel the need to improve cultural competence so that I am better prepared for graduation” (P28) |
| Learn to negotiate with patients from different cultures | “Ultimately, we need to learn to negotiate with patients of different cultures to reduce conflict” (P23) |
| Addition of learning related to culture in the practice field | “In the practice area, there needs to be additional learning assistance about cultural competence; I feel it is very limited and only focuses on action” (P4) |
| The curriculum needs to provide sufficient opportunities to learn about the culture | “After I was in clinical practice, I felt there was still a lack of cultural lessons, and our educational curriculum was very limited to support it” (P18) |
| Very diverse culture | “Various cultures make us often confused about implementing culturally sensitive care for patients” (P7) |
| Low competency capacity of mentors | “Our biggest challenge in clinical practice rests on the low competence of our clinical mentors so that the teaching received is not optimal” (P12) |
| Language difficulties | “Patients who come from different cultures have different languages, and it is difficult for us to understand when communicating” (P6) |
This theme explains various perspectives related to cultural competence that are understood by the participants, which consist of several subthemes: (1) cultural competence includes awareness, sensitivity, knowledge, and skills related to culture; (2) cultural competence is something that nurses need to have; and (3) how to learn to respect different cultures. Several participants explained that cultural competence consists of several attributes. They call it
Classroom learning as a theme that appears in this study has several subthemes such as: (1) some lessons support the improvement of cultural competence, (2) teaching on campus is going well, (3) there are various ethnic groups in the class, and (4) there are differences in perceptions among students regarding cultural competence learning. Students see
Practical experience relates to cultural competency learning situations in students’ clinical practice. Within this theme, there are several subthemes, such as (1) meeting different cultures, (2) there is a conflicting culture in the practice field, (3) providing care that is culturally appropriate for the patient, and (3) receiving threats of violence. Participants described
When going through the learning process within campuses and clinics, nursing students have several expectations with the following divisions: (1) need to increase understanding about the patient’s cultural background, (2) learn to negotiate with patients from different cultures, and (3) addition of learning related to culture in the practice field. Most participants said the need to improve cultural competence:
Some of the obstacles expressed by the participants related to the cultural competence learning process are illustrated in the following subthemes: (1) the curriculum does not provide sufficient opportunities to learn about the culture, (2) very diverse culture, (3) low competency capacity of mentors, and (4) language difficulties. Participants expressed the lack of learning that supports increasing cultural competence
Cultural competence includes several important elements. In this study, participants expressed elements of cultural competence, including awareness, sensitivity, knowledge, and skills related to culture. Cultural competence can help nurses provide patient-centered care and reduce bias, stereotypes, preconceptions, and clinical uncertainty among ethnically diverse patients.14 The cultural competency elements identified in this study can be used in nursing education, research, and managerial, and organizational planning. Competency development promotes greater awareness and recognition of the different cultural attributes of patients and increases respect in healthcare delivery.15 Participants also see that cultural competence is an important thing that nurses need to have. The perceptions expressed by participants can help educational institutions develop realistic education and training techniques, leading to quality professional nursing practice for an increasingly diverse population.16
Several participants said that lessons during class had supported the improvement of cultural competence, and learning on campus had been going well. Cultural competence education is significantly reported to have a positive effect on increasing the competence of nursing staff.17 Cultural competency education is offered through traditional contact teaching or web-based modules to increase student understanding. The learning model is enhanced through lectures, group discussions, case studies, reflective exercises, and simulations.18 The teaching process can be well projected because there are various ethnic groups in the class. The input from a variety of cultural backgrounds will help institutions develop appropriate systems. Failure to project a culturally competent teaching team hurts the quality of care. Studies show that defects in cross-cultural communication and understanding stem from the tendency of nurses to project their culture-specific values and behaviors onto patients, contributing significantly to patient nonadherence and degrading the quality of care.19 To address this problem, nurses must develop a culturally competent and humble approach to care.20
Another finding that emerged was the difference in perceptions among students regarding cultural diversity. Studies show that cultural diversity often leads to misunderstandings, clashes, conflicts, ethnocentrism, discrimination, and stereotypes due to the frequent intersection of many variables, such as differences in traditions, attitudes, ethical and moral perspectives, conceptions of health and disease, and language barriers.21 The problem’s root is related to how people conceptualize the differences and unique cultural and historical circumstances that have shaped the heritage of different groups. Educational institutions need to see this so that improvements can be made through proper teaching.
Encounters with different cultures in clinical practice are commonplace. Different cultures can become barriers to communication during the care process.22 Some communication practices rely on nonverbal methods due to the lack of a common language, often resulting in the meaning of communication needing to be more understood. Furthermore, more nurse-patient communication helps the nurse-patient relationship, affecting patient safety and satisfaction. In this study, there is a culture contrary to the principles of starvation, which can increase the tension between students and patients during the care process. Studies show that when dealing with conflicts between patients and nurses, it is necessary to develop an attitude of empathy as part of cultural competence to understand the patient’s feelings, concerns, and perspectives.18
Participants’ expectations regarding increased cultural competence must be translated appropriately according to needs, especially to overcome cultural differences between patients and student nurses. One of the lessons of cultural competency is negotiating with patients from different cultures. Negotiation can be seen as a positive effort to unravel barriers caused by differences and produce acceptable solutions for all parties. Studies show that negotiation is the key to culturally competent care and needs to be continually developed in a wide range of practice and learning settings.23 Learning to negotiate must begin with an increased understanding of the patient’s cultural background, as expressed by the participants. Negotiation training programs should focus on students’ awareness of their attitudes during negotiations, incorporating the assertiveness shown through empathy and emotional involvement in patient interactions.24
Participants reported that the curriculum setting needed to provide more opportunities to learn about culture, so cultural learning programs must be designed to improve the cultural competence of nursing students. This teaching program will be effective if learning needs, appropriate assignments, and acceptable teaching methods are considered by students.25 Based on the study, 5 categories of cultural learning must be built, including knowledge of different aspects of cultural competence, fostering culturally competent communication skills, learning culturally competent nursing skills, increasing self-awareness of cultural competence, and strengthening self-efficacy in various cultural situations.26
Another obstacle expressed by the participants was related to mentors’ low competency capacity in guiding students who deal with patients of different cultures. Mentors’ cultural competence is important for guiding students and treating culturally diverse patients.27 The mentor’s behavior can directly influence the student’s professional growth. High-quality mentoring can ensure that they remain in the health sector in the future.
Language difficulties were found to be one of the barriers that students felt related to learning cultural competence in practice areas. Previous studies have shown that language barriers in nursing care can cause communication difficulties, increase emotional disturbance, and trigger conflicts and misunderstandings.28
This study indicates that the learning processes aimed at enhancing cultural competence among nursing students in clinical practice and academic settings vary significantly in rural Indonesia. Students reported encountering barriers such as language constraints, insufficient clinical mentor capacity, and inadequacies in the curriculum that hindered their cultural competence learning experience. Nursing education institutions need to address these barriers by improving the curriculum and providing competent clinical mentors. Additionally, continuous evaluation of the student’s learning processes related to cultural competence is necessary to determine effective strategies for enhancing their cultural skills, given that they will be future nurses interacting with culturally diverse patients in rural settings.
To improve cultural competence education in both clinical and academic environments for nursing students in rural areas, several innovations, recommendations, and research ideas can be applied. Key innovations include developing community-based training programs where local community members act as mentors to provide direct insights into local cultural practices and health care. Mobile applications offering interactive educational materials can also aid students in learning about cultural aspects flexibly. Additionally, virtual reality (VR) simulations depicting clinical scenarios in rural settings can provide relevant practical experience.
Recommendations for improvement involve integrating cultural education deeply into the curriculum to ensure that nursing students acquire comprehensive knowledge about local cultures. Collaboration with local health practitioners is also crucial to provide direct guidance and insights into the specific cultural challenges faced in rural areas. Community-based evaluations should be conducted to assess the relevance of educational materials and the effectiveness of the programs.
Future research could focus on the impact of cultural education on clinical practice in rural areas, evaluating the effectiveness of community-based training programs and assessing the involvement of technology in cultural learning. Case studies exploring the challenges and solutions in implementing cultural practices in rural settings could offer additional insights to enhance nursing students’ cultural competence.
This qualitative research has limitations that must be acknowledged. First, this study focuses on a small sample of nurses. To generalize the findings and help correct cultural competency issues, future research should use qualitative and quantitative methods on a much larger and more representative sample in different rural areas. In addition, reviews should be two-way across educational institutions and practices to get appropriate feedback and corrections.