The Cultural Competency Scale for Clinical Pediatric Nurse

(CCS-CPN) in Indonesia: Scale Development and Psychometric

Evaluation

Dewi Elizadiani Suza, Setiawan, Farida Linda Sari Siregar and Diah Arruum

Faculty of Nursing, Universitas Sumatera Utara, Indonesia

Keywords: Culture Competency, Pediatric Nurse, Children.

Abstract: Nurses play an important role to apply practice in cultural competence in hospitals. To perform this role nurses

need to provide information on the conceptual aspects of cultural competence by using instruments and

assessing cultural competence in a clinical setting. Objectives of the study was to develop the cultural

competency for clinical pediatric nurse (CCS-CPN) and psychometric evaluate the validity and reliability of

CCS-CPN. Qualitative and quantitative methods were used to develop an instrument to measure nurse

perceptions of cultural competency for clinical pediatric nurse. The data was examined using exploratory

factor analysis (EFA) to identify the internal dimensions of the CCS-CPN. Using an EFA, 30-items with a

six-factor structure were retained to form the CCS-CPN. The 30-item CCS-CPN yielded an overall

Cronbach’s alpha coefficients .85. and for subscales were .81, .73, .81, .75, .78 and .87, respectively. The 30-

item CCS-CPN version of Indonesia consists of six factors: culture awareness of pediatric nurses (5 items),

culture knowledge of pediatric nurses (6 items), culture skill of pediatric nurses (5 items), culture encounter

of pediatric nurses (4 items), and culture sensitivity of pediatric nurses (7 items) were acceptable and

significant. Unfortunately, factor 4 obtained an item that does not represent the dimensions of the culture

encounter of pediatric nurses. Therefore, further research is needed by using different method of Delphi

method.

1 BACKGROUND

Indonesian culture has been shaped by several factors

namely indigenous customs and influenced by

foreign cultures. Indonesia is centered along ancient

trade routes between East, South Asia, and the Middle

East, resulting in cultural practices strongly

influenced by ethnic, religious, religious, and

economic status as trading cities. The impact of a

complex cultural blend shows different cultural

results from the original. (Wikipedia, 2018). Culture

therefore not only affects health practice but also how

health care providers and patients feel the disease

(Murphy, 2011). In practicing its profession, health

professionals in Indonesia must have the ability to

find diversity in the nurse-patient relationship. The

ability to establish effective relationships with

patients, other health professionals and others with

different backgrounds is cultural competence.

Cultural competence is one of several aspects of

professional health professionalism. In a clinical

setting cultural competence should focus on attitudes

and behavioral changes to diversity. Nurses play an

important role to apply practice in cultural

competence in hospitals. To perform this role nurses

need to provide information on the conceptual aspects

of cultural competence by using instruments and

assessing cultural competence in a clinical setting.

The lack of recognition of the crucial of cultural

competence in nursing care ignores the important role

nurses play in promoting patient well-being and

maintaining a holistic approach to health (Lin,

Mastel-Smith, Alfred, & Lin, 2015). Failure to

provide culturally competent nursing care results in

inaccurate application of nursing care to patients and

non-adherence to care plans by individuals and their

families (Van Ryn & Fu, 2003). Serent (2007) states

that most nurses consider them culturally

incompetent and thus have no ability to apply cultural

competence which may place patients at risk of

delayed treatment, improper diagnosis, non-

adherence to treatment, and even death.

664

Suza, D., Setiawan, ., Siregar, F. and Arruum, D.

The Cultural Competency Scale for Clinical Pediatric Nurse (CCS-CPN) in Indonesia: Scale Development and Psychometric Evaluation.

DOI: 10.5220/0008330606640671

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 664-671

ISBN: 978-989-758-336-0

There is little literature available to identify and

describe instruments that measure cultural

competence in nursing (Loftin, Hartin, Branson, &

Reyes, 2013). Cultural competence includes gender,

sexual orientation, socioeconomic status, faith,

profession, taste, disability, age, and race, and

ethnicity. According to Campinha-Bacote (2002),

cultural competence is a long-term process whereby

nurses must continue to learn in improving the ability

to work effectively in the context of patient culture.

This process includes cultural desires, cultural

awareness, cultural knowledge, cultural skills, and

cultural gatherings. For someone who does not

belong to a particular group, cultural diversity is

increasingly diverse because of the diversity of ethnic

backgrounds, languages, beliefs, and religions that

have implications in the field of nursing. Although

suitable health settings are increasingly

representative of several different cultures, nurses

feel their cultural competence is not optimal. Health

settings become increasingly representative of

several different cultures; nurses have limitations in

the practice of cultural competence. Incorporating

cultural competence in the curriculum of nursing

education, organizational policy, and research will

help prepare nurses to work within the practice of

cultural competence (Magdalena, 2009).

Loftin, Hartin, Branson, and Reyes (2013)

identified that tools for assessing cultural competence

in nursing and nursing students are self-managed and

based on individual perceptions. Such a tool is usually

used to assess the effectiveness of educational

programs designed in enhancing cultural competence.

The tool reviewed measures self-perceptions of

nurses or self-reported level of cultural competence

but does not measure objectively for culturally

competent nursing care from a patient's perspective

that may be a problem (Loftin, Hartin, Branson, &

Reyes, 2013). Therefore, an assessment framework

for cultural competence should be performed by

nurses with assessments that emphasize inclusion

care with a holistic caring approach that includes the

physical, psychological, social, and cultural needs of

the patient. Shen (2015) reports that there are several

models of cultural competence and cultural

competence assessment tools developed, but most of

them were not empirically tested and very few have

developed model-based on tools. The limitations of

the models and tools developed affect the cultural

competence of health service gaps.

Uncertainty of research evidence based on

cultural nursing and knowledge of cultural

differences makes nurses or other health care

providers difficult to provide quality services and cost

effective treatments. Although there are similarities

between people or patients of some people in the

world, there are also differences that arise from

cultural, religious, family background and individual

or group experiences affecting care. This difference

not only affects the patient's values, beliefs and

behaviors, but also supports the idea of health care

and affects patient expectations.

According to the American Nursing Association

(2011), nurses must understand how different ynag

are within culturally diverse groups. Therefore nurses

must understand how to understand their culture, how

they determine the health and severity of the disease,

how they believe in the cause of the illness they are

suffering, and how they care for family members with

the illness. Lack of awareness and unsuccessful

nurses in providing culturally competent nursing care

can increase the stress or pressure experienced by

patients or families and can lead to nursing care that

is not optimal. Research conducted by Hardy et al.

(2011) related to the culture of competence obtained

by the lack of familiarity between families and nurses,

difficulties in communicating, religious diversity,

difficulty in obtaining information, distrust of health

services, and the discomfort of discrimination. The

difficulty often experienced by nurses to avoid errors

in applying cultural competence is stereotypes to

patients. This often makes the label stand out for a

particular culture or ethnic group based on

characteristics such as patient or family appearance,

patient or family response, ethnicity, country of

origin, or custom of a particular religious group.

Berlin, Nilsson and Tornkvist (2010) conducted a

study of 51 child nurses working in hospitals, divided

into 2 groups: 1) 24 child nurses conducted cultural

competence training for the intervention group and 2)

27 child nurses in the control group not training. The

results obtained have significant improvements in the

areas of cultural knowledge, cultural skills, and

cultural gatherings among child care nurses who are

trained in cultural competence. There are 92% of

child nurses from the intervention group there is an

increase in their desire to learn more about culturally

competent health services. Davis, Larson, Control,

and Cabrera (2011) conducted a study of 13 Mexican-

American Families whose children were admitted in

hospital for diseases that restricted family activity in

hospitals. Families get different behaviors in places

where their child is being treated. Non-Hispanic

white patients feel the difference in health services for

their children with special needs compared to other

ethnic groups. Delayed care is reported more

frequently by Hispanic white patients, followed by

The Cultural Competency Scale for Clinical Pediatric Nurse (CCS-CPN) in Indonesia: Scale Development and Psychometric Evaluation

665

other Hispanic / Hispanic blacks (Kerfeld, Hoffman,

Ciol, & Kartin, 2010).

Pergert, Enskar, and Bjork (2008) conducted a

study of 12 patient interviews administer with nurses

in the Swedish children's ward. They found that the

nurses need to be prepared for emotional over-

expression in cross-cultural care and to know

strategies to protect professional calm so they can use

it consciously and positively. Research conducted by

Tavallali et al. (2016) reported that communication

between patients and minority nurses is the most

important and key indicator of successful nursing care

quality. All parents involved in the study expressed

the importance of ethnic minority nurses with skills

and skills in Swedish which lacked less satisfaction

with parents of nursing care provided by minority

nurses. Similarly, in a study conducted by Davies,

Larson, Contro and Cabrera (2011) on Mexican-

American families gained a lack of nursing care

services and there was discrimination received from

their child health providers as a result of language

barriers.

Barriers to cultural sensitivity in the nursing

profession may include stereotypes, discrimination,

racism, and prejudice. There are situations where we

can describe the lack of sensitivity without realizing

it or intending to offend others. Simple steps such as

dealing with patients by naming their last names or

asking how they want to be handled show respect. In

addition, there is limited research in the literature to

inform care providers in children, especially doctors

and nurses about their progress in providing culture

competent care for their patients and parents and what

problems develop as they care for different patient

populations. Although, a large number of literatures

exist which state why it is important to provide

culture competent care for patient populations. A

guide factor in the need to prepare cultural-based care

competencies is a quickly changing demographic

culture worldwide.

Furthermore, in Indonesia there is little or no

knowledge of the patient's cultural background,

especially for pediatric, socio-economic, ethnic,

linguistic, and religious patients; Cultural

competence among nurses has received little attention

in Indonesia; and the lack of formal education and

training for nurses may contribute to the lack of

culturally competent care. Therefore, psychometric

development and evaluation of Cultural Competency

Scale for Clinical Pediatric Nurse (CCS-CPN) in

Indonesia is urgently needed. This scale can serve as

a guide for child nurses to provide cultural

competence and identify strengths or weaknesses in

the delivery of nursing care.

2 METHODS

Qualitative and quantitative design was used to

develop an instrument to develop Indonesian cultural

competency for clinical pediatric nurse and evaluate

its psychometric property. In this study, the setting

was in general hospitals, Indonesia. Based on

DeVellis (2012), scale development procedures

involved the following eight steps.

2.1 Step 1: Review Literature

Based on the literature review regarding cultural

competency, cultural competency in nursing, in-

depth interviewed (n=15) and the focus group

discussion (n=30), six dimensions and 75 items of the

Cultural Competency Scale for Clinical Pediatric

Nurse (CCS-CPN) in Indonesia were identified. It

consisted of 1) culture awareness of pediatric nurse

(18 items), 2) culture knowledge of pediatric nurse

(17 items), 3) culture skill of pediatric nurse (16

items), 4) culture encounter of pediatric nurse (7

items), 5) culture desire of pediatric nurse (8 items),

and 6) culture sensitivity of pediatric nurse (9 items).

2.2 Step 2: Generation of an Item Pool

The six dimensions of the CCS-CPN were performed

based on data collected from literature review, focus

group, and interview then generated into a large pool

of items.

2.3 Step 3 Determination of Item Format

All items will be written in a structure of the five-

point Likert scale format. Five-point Likert scale was

used to increase response rate and response quality

along with reducing respondents’ frustration level.

2.4 Step 4: Determination of Validity

Content validity of the CCS-CPN was conducted by

pediatric nurses form five hospitals. The Content

Validity Index (CVI) was .86. Twelve items were

modified because of lack of clarity. Thus, the CCS-

CPN consisted of six dimensions with 75 items.

2.5 Step 5: Pre Test

Content validity of the CCS-CPN was conducted by

The Cronbach’s alpha coefficients for overall scale

and its six dimensions were .86, .81, .81, .78, .78, and

.63, respectively. After deleting one item that had low

item-to-total correlation, Cronbach’s alpha

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

666

coefficient of culture sensitivity of pediatric nurse

dimension increased to 0.70.

2.6 Step 6: Field-test

The researcher administered the CCS-CPN,

Demographic Data Form, and Marlowe-Crowne

Social Desirability Scale to 450 pediatric nurses at

twenty pediatric wards in Indonesia.

After an approval from the Ethics Committee at

Faculty of Nursing, University of Sumatera Utara,

Indonesia and the directors of nursing from twenty

general hospitals in Indonesia, the survey packages

were distributed to respondent through the head nurse

of the pediatric ward in each general hospital from

June to October, 2017. Each survey package included

a cover letter, CCS-CPN, Demographic Data Form,

and Marlowe-Crowne Social Desirability Scale, and

informed consent form. Respodent were asked to

complete the questionnaires and return it to the

researcher.

2.7 Step 7: Evaluation of Items

At this step, evaluate the performance of the

individual items by processing rotation according to

EFA principle.

2.8 Step 8: Determination of Reliability

At this step consisted of 1) internal consistency, 2)

test-retest, and 3) contrasted group approach.

3 RESULTS

After testing the assumptions for EFA, 450

participants were retained for further analysis

To test for the construct validity of the CCS-CPN, the

distributions and Pearson correlation coefficients

between the variables were first examined. The

descriptive statistics indicated the absence of highly

skewed distribution and kurtosis. The results of the

correlational analysis showed that no pairs of

variables were highly correlated based on Munro’s

criteria (Munro, 2005). The scatter plot show strong

linear relationship with positive correlation. In factor

analysis, the most commonly recommended approach

for outlier detection is the Mahalanobis Distance and

box plots. Using a criterion of p-values equals to .001

with 75 df, critical X2 equaled 118.59, 40 outliers

were deleted. Therefore, 450 participants were

retained.

Table 1: Results of demographic data of pediatric nurses

(N=450).

Items

Frequency

Percent

Gender

Male

Female

387

Age (years)

< 30 years old

30-40 years old

>40 years old

319

Religion

Muslim

Christian

Catholic

246

198

Marital Status

Single

Married

166

284

Education

Bachelor degree

450

100

Work experience in pediatric

nursing

< 6 years old

equal 6 years old

> 6 years old

179

187

At first, an EFA was performed with the 75 item

CCS-CPN. Regretable, the model was unworthy.

Thus, an item-total correlationwas estabilhed. The

results revealed that 17 items had low item-total

correlations, ranging from .06 to .30 showed that the

items might be less consistent and less reliable to

reflect the construct when compared with diffrent

items in the 75 item CCS-CPN. Consequently,

seventeen items were eliminated from 75 item CCS-

CPN. Accordingly, 58 items were used to further

carry out the EFA and finally resulting in the 30

items.

In this study as shown at table 3, EFA was

performed various times with the CCS-CPN. The

final model be composed of 30 items. Before

interpretation of the results, the model fit of the 30

items CCS-CPN were identified. A Kaiser-Meyer-

Olkin index of the model was satisfactory (.87).

Bartlett’s test of sphericity was significant. The

Eigenvalues represent in to 16 factors and scree test

showed 5-6 factors. The percentages of total variance

explained and variance explained for each factor were

acceptable only for the model of 30 item CCS-CPN

(total 43.21%, each factor varied from 20.71-5.23%).

The Eigenvalues of the 30 item CCS-CPN ranged

from 2.00 to 12.43.

Factors, items, and factor loadings were interpret

for 30 items CCS-CPN because it had a model fit. The

30 item CCS-CPN be composed of six factors. The

factor loadings of: Factor 1) culture awareness of

pediatric nurses (5 items, varied from .46 to .84, p =

.000), 2) culture knowledge of pediatric nurses (6

The Cultural Competency Scale for Clinical Pediatric Nurse (CCS-CPN) in Indonesia: Scale Development and Psychometric Evaluation

667

items, varied from .45 to .76, p = .000), 3) culture skill

of pediatric nurses (5 items, varied from .54 to .84, p

= .000), 4) culture encounter of pediatric nurses (3

items, varied from .40 to .63, p = .000), 5) culture

desire of pediatric nurses (4 items, varied from .62 to

.84, p = .000) and 6) culture sensitivity of pediatric

nurses (7 items, varied from .52 to .79, p = .000 ) were

acceptable and significant.

Table 2: The Criteria of EFA for selecting the optimal

number.

Methods/The

criteria to be

retained

CCS-CPN

N=450

30 items

Normal Value

Factor method

PAF

PAF may be used

if data are not

normally

distributed

Factor method

Varimax

Varimax rotations

produce factors

that are

uncorrelated

KMO

.87

≥ .60

Bartlett's test of

sphericity

.000

Sig.000

Eigenvalues

≥ 1

Scree test

5-6

Data points above

the break

Percent of total

variance

explained

43.21

40% or more

Table 3: The Mean (M), Standard Deviation (SD), and t of

the CCS-CPN Indonesian Version.

Groups

30 item CCS-CPN

Mean

(SD)

(1-tailed)

4.11

(0.25)

8.55*

.000

2.94

(0.29)

*p<.05

The results in the table 3 revealed that the mean

scores of the 30 items CCS-CPN Indonesian version

of pediatric nurses (n = 271) having work experience

six years or more were significantly higher than those

of nurses (n = 179) having work experience in

pediatric ward less than six years (M = 4.11, SD =

0.25; M = 2.94, SD = 0.29; t = 8.55, p = .000).

The Cronbach’s alpha coefficients of total 30

items CCS-CPN were excellent (.85). Cronbach’s

alpha coefficients of each dimension of the 30 items

CCS-CPN were .83, .73, .70, .70, .81, and .83,

respectively. The test-retest results revealed that the

mean score of the overall 75 item CCS-CPN and its

dimensions measured at Time 1 were positively

significant and high correlated with those of

measured at Time 2. The means are similar and r is

strong and positive (r = .70).

Social desirability test was used to examine the

tendency among pediatric nurses to answer in a

socially desirable way when taking some personality

tests was investigated. In this study, the Indonesian

version of Marlowe-Crowne Social Desirability

Scale-C (MCSDS-C) was used to establish the degree

of social desirability to the respondents answer true

or false to a set of socially desirable but impossible

statements. The on the whole mean scores of the 30

items of the CCS-CPN did not significant and

positively correlated with that of the social

desirability (r =.06, p = .05).

4 DISCUSSION

4.1 The Development and Components of

the CCS-CPN

Many of the criteria considered in developing of the

CCS-CPN were based on nurses need to recognize

their own cultural values in seeking cultural

competence; the nurses perceived the fear of mistakes

and crossing boundaries related to the cultural and

religious practices of minority patients as particularly

stressful (Sindayigaya, 2016).

Increasing cultural and linguistic competence for

child nursing is extremely important for several

reasons, including: because of age restrictions;

eliminating the old gaps in the health status of people

of different backgrounds; improve the quality of

nursing care; fulfill the legislative, regulatory and

accreditation mandates; gain competitive advantage

in the market; and reduce the likelihood of

liability/malpractice claims.

In this case for Indonesian pediatric nurses

defined the term of cultural competence was

something new concept, and they did not grasp the

concept. The majority respondents had not received

education or training in caring for patients with the

different ethnic. They were developed cultural

competency based on self- experience and feeling.

This is different from developed countries, they have

a curriculum on cultural competence for nursing

students and clinical nurses. Language barriers are

reported as the most difficult problem in treating

pediatric patients. The substantial perceived barrier is

the language barrier, which consists not only of

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

668

communication dynamics, but is revealed when

parents are not fluent in English. These findings are

supported by Beckstrand, Rawle, Callister, and

Mandlecothe as congruent with other studies of

nurses that identify the influence of language and

cultural differences on the interaction of nurses with

patients and parents (Beckstrand, Rawle, Callister, &

Mandleco, 2010).

Thus, development of components of cultural

competency in clinical pediatric nurse was based on

an extensive review of the literature regarding

cultural competency as previously mentioned, focus

group discussion, in-depth interview, and expert

review. In this study used eight steps of DeVellis’s

Theory of Scale Development. Scale Development is

a process of developing a reliable and valid measure

of CCS-CPN in order to assess an attribute of interest.

The CCS-CPN was developed based on the

Campinha-Bacote theory cultural competence

(Campinha-Bacote, 2002).

Even though the 30 items CCS-CPN model was

acceptable,but could not decribe the culture

encounter of pediatric nurses dimension because it

only 3 item loading in factor 6. This is because most

of the pediatric nurses have difficult experinece to

encounter the patients come from different

background, culture, and language. Based on the

conceptual framework bagotte theory , in this study

found the different dimension of cutural competency.

The researcher expected that the culture competence

of clinical pediatric nurse composed six dimension,

how ever only five dimension that reperentative to

cultural competency in clinical pediatric nurse in

Indonesian version.

It should be the number of items for each dimension

equal so that when loading on the six factors will be

distributed equally for each dimension (Mitt & Bolt,

2003). Therefore if the number of items is the same

per dimension, each dimension will have the same

proportion. Pediatric nurses report that it is difficult

to express the insecurity and uncertainty they feel

when approaching patients or families from different

cultural backgrounds from themselves.

They report that they do not always know how to

approach or cope when faced with patients who come

from different cultural backgrounds but also language

differences. Thus, research in the context of cultural

competence for child care is required. Barrier to

perform cultural encounter included 1)

communication difficulties (language differences,

confidentiality, and cultural identity in

communication related to gender or relating to

attitudes in the families), and 2) the institutional

aspects that affect the delivery of excellent care to the

family are respected section of the external

badistinctionsrriers, determined by (shortfall of space

in care areas to house all family members, restriction

of resources to offer food and accommodation to all

family members and restricted time of the nurses to

take care of the family) (Murcia & Lopez, 2016). In

addition, this study was conducted in Indonesia; thus,

nurses probably perform only nursing assessment in

this dimension.

The contrasted group was performed and found

that the mean scores of the two versions of the CCS-

CPN were significantly different between two nurse

groups. This indicated that the construct measured by

the CCS-CPN was used in evaluating construct

validity. Waltz et al (2017) stated that contrasted

group approach was used to compare the two groups

of different experience levels using the t-test as well

as to assess the ability of the CCS-CPN to detect

differences experience between the different group.

The researcher found that some evidence for

construct validity that is the instrument measures the

CCS-CPN Indonesian version. In this study, the

cultural competence for clinical pediatric nurse in

Indonesian version found that 30 items with six

dimension consisted of 1) culture awareness of

pediatric nurse, 2) culture knowledge of pediatric

nurse, 3) culture skill of pediatric nurse, 4) culture

encounter of pediatric nurse, 5) culture desire of

pediatric nurse, and 6) culture sensitivity of pediatric

nurse. However, in the culture encounter dimension

of CCS-CPN it was less representative because it

consisted of only 3 from 7 items which could not

measure the complete dimension of the cultural

encounter aspect. This different from Duck-Hee Chae

and Chung-Yul (2014) were developed and

psychometrically test the Korean version of the

Cultural Competence Scale for Nurses (K-CCSN).

They found that the 33-item K-CCSN comprised four

subscales: cultural awareness, cultural knowledge,

cultural sensitivity, and cultural skills.

5 CONCLUSIONS

The 30-item CCS-CPN version of Indonesia consists

of six factors: 1) culture awareness of pediatric nurses

(5 items), 2) culture knowledge of pediatric nurses (6

items), 3) culture skill of pediatric nurses (5 items), 4)

culture encounter of pediatric nurses (4 items), and 6)

culture sensitivity of pediatric nurses (7 items) were

acceptable and significant. Unfortunelly, factor 4

obtained an item that does not represent the

dimensions of the culture encounter of pediatric

nurses. Therefore, further research is needed by using

The Cultural Competency Scale for Clinical Pediatric Nurse (CCS-CPN) in Indonesia: Scale Development and Psychometric Evaluation

669

different method of Delphi method. It is hoped that

using Delphi method will be more applicative and

more representative to represent the six factors of

cultural competence for Indonesian culture. The

Delphi method is designed as a group communication

process which aims to achieve a convergence of

opinion on a specific real world issue of cultural

competency.

ACKNOWLEDGMENTS

This study was supported by Rector of Universitas of

Sumatera Utara and Research Department of

Universitas of Sumatera Utara.

REFERENCES

ANA, 2011. ASHA Board of Ethics.(2013). Cultural and

linguistic competence [Issues in ethics]. Available from

www.asha.org/Practice/ethics/.

Banner, P., 2000, From novice to expert: Excellence and

power in clinical nursing practice. Upper Saddle River,

NJ: Prentice Hall.

Beckstrand, R. L., Rawle, N. L., Callister, L., & Mandleco,

B. L., 2010 . Pediatric nurses’ perceptions of obstacles

and supportive behaviors in end-of-life care. American

Journal of Critical Care, 19(6), 543–552.

http://doi.org/10.4037/ajcc2009497.

Berlin, A., Nilsson, G. & Tornkvist, L., 2010, Cultural

competence among Swedish child health nurses after

specific training: A randomized trial. Nursing Health

Science, 12 (3), 381-391.

Campinha-Bacote, J, 2007, The process of cultural

competence in the delivery of healthcare services: The

journey continues (5th Ed.). Cincinnati, OH:

Transcultural C.A.R.E. Associates.

Comrey, A., & Lee, H., 1992, A first course in factor

analysis. Hillsdale, NJ: Erlbaum.

Davies, B., Larson, J., Contro, N., & Cabrera, A., 2011,

Perceptions of Discrimination among Mexican

American Families of Seriously Ill Children. Journal of

Palliative Medicine 14(1), 71-76.

De Vellis, R. F. 2012, Scale Development: Theory and

Applications (3nd ed). Thousand Oaks, CA: Sage

Publications.

DeVon, H. A., Block, M. E., Moyle-Wright, P., Ernst, D.

M., Hayden, S. J., Lazzara, D. J., Savoy, S. M.,&

Kostas-Polston, E., 2007, A psychometric toolbox for

testing validity and reliability. Journal of Nursing

Scholarship, 39(2), 155-164.

Duck-Hee Chae & Chung-Yul Lee., 2014, Development

and Psychometric Evaluation of the Korean Version of

the Cultural Competence Scale for Clinical Nurses. Asian

Nuursing Reearch, 8, 305-312.

Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R. E.,

2010, Multivariate data analysis (7th ed.). Upper

Saddle River, NJ: Prentice Hall.

Hardy, D., Chan, W., Liu, C. C et al., 2011, Racial

disparities in the use of hospice services according to

geographic residence and socioeconomic status in an

elderly cohort with nons mall cell lung cancer, Cancer

117, 1506-1515.

Kerfeld C.I., Hoffman J.M., Ciol M.A. & Kartin D., 2011,

Delayed or forgone care and dissatisfaction with care

for children with special health care needs: the role of

perceived cultural competency of health care providers,

Maternal Child Health Journal 15 (4) 487-496.

Lin, C. N., Mastel-Smith, B., Alfred, D., & Lin, Y. H.,

2015, Cultural Competence and Related Factors

Among Taiwanese Nurses, Journal Nursing Research

14.

Loftin, C., Hartin, V., Branson, M., & Reyes, H., 2013,

Measures of cultural competence in nurses: an

integrative review. The Scientific World Journal 30, 1-

10.

Magdalena, V. 2009. Cultural competence and holistic

practice: implications for nursing education, practice,

and research. Holistic Nursing Practice 23(3):153-157.

Mroch, A. A., & Bolt. D. M., 2003, A monte carlo

comparison of parametric and non parametric

dimensionality detection procedures. Paper presented

at the annual meeting of the National Council on

Measurement in Education Chicago, IL. Paper

presented. Retrieved from

http://irt.com.ne.kr/data/ncme03md.pdf

Munro, B. H. 2005. Statistical methods for health care

research (5th ed.). Philadelphia, PA: Lippincott

Williams & Wilkins.

Murcia, S, E, A., & Lopez, L., 2016, The experience of

nurses in care for culturally diverse families: A

qualitative meta-synthesis. Revista Latino-Americana

de Enfermagem 24, 1-11.

Murphy, K. 2011. Editorial: The importance of cultural

competence. Nursing made Incredibly Easy 9 (2) 5.

Nunnally, J. C., & Bernstein, I. H., 1994, Psychometric

theory. New York, NY: McGraw-Hill.

Pergert, P., Ekblad, S., Enskär, K., & Björk, O., 2008,

Protecting professional composure in transcultural

pediatric nursing. Qualitative health research 18(5)

647-657.

Scherer, R. F., Wiebe, F. A., Luther, D. C., & Adams, J. S.,

1988, Dimensionality of coping: Factor stability using

the ways of coping questionnaire. Psychological

Reports, 67,763-770.

Seright, T., 2007, Perspectives of registered nurse cultural

competence in a rural state- Part 1. Journal of Rural

Nursing & Health Care, 7 (1), 47-56.

Shen, Z. 2015. Cultural competence models and cultural

competence assessment instruments in nursing: a

literature review. Journal Transcultural Nursing, 26

(3), 308-321

Sindayigaya, F. 2016. How do nurses feel about their

cultural competence? A Literature

Review.https://www.theseus.fi/bitstream/handle/10024

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

670

/125280/Final%20thesis.pdf?sequence=1&isAllowed=

Tabachnick, B. G., & Fidell, L. S., 2013, Using multivariate

statistics (6th

ed.). Boston: Pearson Education

Tavallali, AG., Kabir, ZN., & Jirwe, M., 2014, Ethnic

Swedish Parents' experiences of minority ethnic nurses'

cultural competence in Swedish pediatric care.

Scandinavian Journal of Caring Sciences 28 (2), 255-

263.

Van Ryn, M., & Fu, S., 2003. Paved with good intentions:

Do public health and human service providers

contribute to racial/ethnic disparities in health?

Americana Journal of Public Health, 93(2), 248-255.

Waltz, C. F, Strickland, O. L., & Lenz, E. R., 2017, Issue in

nursing measurement. In. C. F. Waltz, O. L. Strickland,

& E. R. Lenz (5

ed.), Measurement in nursing

research. New York, NY: Springer Publishing

Company.

Wikipedia .2018. Culture of Indonesia.

https://en.wikipedia.org/wiki/Culture_of_Indonesia

Worthington, R. L., & Whittaker, T. A., 2006, Scale

development research: A content analysis and

recommendations for best practices. The Counseling

Psychologist, 34,806-838.

The Cultural Competency Scale for Clinical Pediatric Nurse (CCS-CPN) in Indonesia: Scale Development and Psychometric Evaluation

671