https://doi.org/10.14528/snr.2022.56.1.3085 2022. Obzornik zdravstvene nege, 56(1), pp. 49–69. ABSTRACT Introduction: Measuring cultural competence is a crucial step in evaluating the strategies for the development and achievement of cultural competence in nurses and nursing students. The aim of this systematic literature review was to examine the content and characteristics of available questionnaires and to select the most appropriate questionnaires for assessing cultural competence in nurses and nursing students. Methods: A systematic review of the literature was conducted in the CINAHL, ERIC, EBSCO and ScienceDirect databases. The following English search terms were used: transcultural nursing, culturally competent care, cultural competence, nursing education, questionnaire. The review included original research articles on relevant topics available in full text and published after 2010. Results: Of the 247 articles found, 11 articles were included in the final analysis. Based on their content and psychometric features such as reliability and construct validity, four of the analysed questionnaires were found to be most appropriate for measuring cultural competence in nurses, three questionnaires for measuring cultural competence in nursing students and one questionnaire for measuring cultural competence in nurse educators. Discussion and conclusion: Our analysis shows that some of the questionnaires included in this review are better suited for measuring cultural competence in nurses, while others are more suitable for measuring cultural competence in nursing students. This systematic review of the literature provides a useful starting point for other researchers in the field of cultural competence assessment in selecting appropriate questionnaires for further research. IZVLEČEK Uvod: Merjenje kulturnih kompetenc je temeljni korak pri oceni strategij učenja kulturnih kompetenc ter doseganju kulturne kompetentnosti med medicinskimi sestrami in študenti zdravstvene nege. Namen sistematičnega pregleda literature je bil proučiti vsebino in lastnosti vprašalnikov ter izbrati najprimernejše vprašalnike za ocenjevanje kulturnih kompetenc pri medicinskih sestrah in študentih zdravstvene nege. Metode: Izveden je bil sistematični pregled literature v podatkovnih bazah CINAHL, ERIC, EBSCO in ScienceDirect. Uporabljeni so bili angleški izrazi: transcultural nursing, cultural competent care, cultural competency, education nursing, questionaire. V pregled so bili vključeni izvirni znanstveni članki z ustrezno preiskovano tematiko, dostopni v celotnem besedilu ter objavljeni po letu 2010. Rezultati: Izmed 247 člankov je bilo v končno analizo vključenih 11 člankov. Med analiziranimi vprašalniki smo na podlagi vsebine ter psihometričnih lastnosti, kot sta zanesljivost in konstrukcijska veljavnost, ugotovili, da so štirje vprašalniki najbolj primerni za merjenje kulturnih kompetenc pri medicinskih sestrah, trije vprašalniki za merjenje kulturnih kompetenc pri študentih zdravstvene nege in en vprašalnik pri medicinskih sestrah v izobraževanju. Diskusija in zaključek: Določeni vprašalniki, ki smo jih vključili v naš pregled, so na podlagi analize kakovosti merilnih lastnosti vprašalnikov primernejši za merjenje kulturnih kompetenc pri medicinskih sestrah, ostali vprašalniki pa za merjenje kulturnih kompetenc pri študentih zdravstvene nege. Sistematični pregled literature predstavlja dobro izhodišče za druge raziskovalce s področja merjenja kulturnih kompetenc pri izboru ustreznih vprašalnikov za nadaljnje raziskave. Key words: transcultural nursing; cultural competence; clinical practice; education; nursing; instruments Ključne besede: transkulturna zdravstvena nega; kulturne kompetence; izobraževanje; zdravstvena nega; vprašalnik ¹ Izola General Hospital, Division of Surgery, Department of Anaesthesiology and Resuscitation, Polje 40, 6310 Izola, Slovenia ² University of Primorska, Faculty of Health Sciences, Department of Nursing, Polje 42, 6310 Izola, Slovenia The article is based on the master thesis of Liridon Avdylaj Cultural competence assessment among nurses in clinical practice and nursing students: a systematic review of the literature (2020)./Članek je nastal na podlagi magistrskega dela Liridona Avdylaja Merjenje kulturnih kompetenc medicinskih sester in študentov zdravstvene nege; sistematični pregled literature (2020). * Corresponding author/ Korespondenčni avtor: liridon.avdylaj@gmail.com Review article/Pregledni znanstveni članek Identification of measurement instruments used to measure the cultural competence of nurses and nursing students: A systematic literature review Identifikacija merskih instrumentov za merjenje kulturnih kompetenc pri medicinskih sestrah in študentih zdravstvene nege: sistematični pregled literature Liridon Avdylaj¹, *, Sabina Ličen² Received/Prejeto: 21. 12. 2020 Accepted/Sprejeto: 6. 12. 2021 50 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Introduction As a result of migration and globalisation, many countries today are experiencing increasing cultural diversity (Czaika & Haas, 2014; Regev, 2014). Due to significant demographic changes in recent decades, Slovenia has transformed into a multicultural society (Ličen, Karnjuš, Bogataj, Rebec, & Prosen, 2019). On the one hand, the increasing diversification of businesses has created multiple opportunities for social and economic growth, but on the other hand, it has also presented a challenge for host countries (Abubakar et al., 2018; Handtke, Schilgen, & Mösko, 2019). This can also be observed in Slovenia, as data from the Statistical Office of the Republic of Slovenia of 1 January 2019 shows that foreigners made up 6.6% of the total population of Slovenia (Statistical Office of the Republic of Slovenia, 2019). In parallel with the growing influence of globalisation, there is also a noticeable influence of culture on the determinants of health, as culture influences the way individuals or groups perceive health, well-being, illness, youth and aging (Halbwachs, 2019). One's cultural background often shapes one's attitudes towards health and one's body, just as it influences the patient's role and expectations regarding health care (Ličen et al., 2019). Healthcare professionals are now more aware than ever of the challenges associated with providing health care to a culturally diverse population. Cultural competence thus provides a framework for recognising health differences between racial and ethnic groups (Crenshaw et al., 2011; Handtke et al., 2019), as well as for acknowledging cultural diversity in other populations, e.g., women, older people, and cultural diversity related to sexual orientation and gender identity, disability, and religious minority affiliations (Crenshaw et al., 2011; Ličen et al., 2019; Lipovec Čebron & Huber, 2020). These observations increased the awareness of the need to provide appropriate cultural training in the field of health care and nursing (Delgado et al., 2013). While there are several definitions of cultural competence, all emphasise the need for health systems and providers to recognise and accommodate cultural diversity and to take into account the specific cultural background of patients (Cai, 2016; Henderson, Horne, Hills, & Kendall, 2018). The first definition was proposed by Cross, Bazron, Dennis, & Isaacs (1989), who defined cultural competence as "a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross- cultural situations." The widely accepted definition of the National Center for Cultural Competence (n.d.) describes cultural competence as a set of knowledge and skills which enhance one's understanding, sensitivity, acceptance, respect and response to cultural differences and attitudes in one's interactions with others. Cultural competence improves the quality of health care and enables us to achieve better outcomes when working with people from other cultures. As the development of cultural competence is a long-term process, it is crucial that intercultural topics are included early in the nursing curriculum. This can help students develop or at least begin developing cultural competence at an early stage (Prosen, Karnjuš, & Ličen, 2017). Moreover, measuring cultural competence in nurses represents a critical step in the evaluation of cultural competence learning strategies so as to improve the quality of care provided to an increasingly diverse population (Cai, 2016; Ličen et al., 2017; Sharifi et al., 2019). It is important to note that researchers view cultural competence as an abstract and theoretical concept which is difficult to define and therefore also difficult to understand and investigate (Diallo & McGrath, 2013). Nurses engaged in scholarly research have therefore developed various instruments for measuring the knowledge, skills, and attitudes related to cultural competence (Shen, 2015; Alizadeh & Chavan, 2016; Lin, Lee, & Huang, 2017). To date, 54 different questionnaires measuring cultural competence in the training of health professionals and nursing students have been identified (Loftin, Harin, Brenson, & Reyes, 2013; Shen, 2015; Lin et., 2017). Aims and objectives As there are many questionnaires and other instruments used to measure or assess cultural competence in nursing, the purpose of this systematic literature review is to examine the content and characteristics of such questionnaires as potential instruments to determine the attainment of cultural competence in nurses and nursing students. The aim of the study was to conduct a systematic literature review to identify the most appropriate and valid instrument for measuring cultural competence, which could be used in the field of clinical practice and nursing education in Slovenia. To this end, we addressed the following research questions: – Which questionnaire for measuring cultural competence is most suitable for use in the field of clinical practice and nursing education in Slovenia ? – What are the common features/characteristics/ components of questionnaires measuring cultural competence in nurses and nursing students? Methods A systematic review of the scientific literature was conducted. 51Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Review methods In November 2019, we conducted a systematic literature review in the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Educational Resources Information Census (ERIC), EBSCO and ScienceDirect databases. In defining our search terms, we used a combination of titles, phrases and free text or keywords in the Medical Subject Headings (MeSH) search engine. We obtained the desired results by using the following English-language search terms: transcultural nursing; culturally competent care; cultural competence; education, nursing; questionnaire. To retrieve relevant results and filter out irrelevant entries, we used the Boolean AND and OR operators in different search combinations: transcultural nursing OR culturally competent care OR cultural competence AND education nursing AND questionnaire. Records identified through database searches: CINAHL + ERIC + EBSCO + ScienceDirect (n = 101 + 72 + 32 + 42 = 247) Records after removing duplicates (n = 102) Screening of articles based on title (n = 102) Full-text articles assessed for eligibility (n = 64) Full-text articles excluded, reasons for exclusion: population (n = 28), topic (n = 9), information on questionnaires (n = 16), a total of 53 Studies included in the analysis (n = 11) Id en tif ic at io n Sc re en in g El ig ib ili ty In cl ud ed Figure 1: PRISMA flow diagram of systematic literature review 52 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Inclusion criteria were met by original research articles on relevant topics published between 2010 and 2020. Exclusion criteria included letters to the editor, protocols, professional journal articles, articles published in languages other than English and articles published before 2010, studies with unsuitable population selection and inadequate features/ characteristics/components of questionnaires. Results of the review Without pre-defined criteria, our search resulted in 247 references. Most of these, i.e.101, were obtained from the CINAHL database. The database with the second highest number of search results was the ERIC database with 72 references, while the EBSCO database returned 32 references and the ScienceDirect database 42 references. After applying criteria pertaining to year of publication, duplicate removal, full-text availability and English language, the number of search results was reduced to 102. Based on an analysis of article titles and/or abstracts, we removed an additional 38 references, and 28 references due to unsuitable population selection, as it did not include nurses or nursing students. A further 16 articles were excluded as based on our analysis we were unable to identify their features/characteristics/components. An additional nine articles were excluded as the questionnaires focused on measuring other types of nursing competencies. As shown in Figure 1, our final systematic literature review included 11 articles. To illustrate the literature review process (Figure 1), we used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach (Moher, Liberati, Tettzlaf, & Altmanet, 2009). Quality assessment of review and description of data processing The eleven articles included in our systematic literature review met all the specified inclusion criteria. Articles which met the purpose and aim of our study were critically assessed using the Critical Appraisal Skills Programme (CASP) with the CASP checklist for systematic literature review (CASP, 2014). According to the results of this appraisal, more than half of the included studies were rated as good (Halter et al., 2015; Kouta et al., 2016; Cai et al., 2017; Safipour et al., 2017; Herrero-Hahn et al., 2019; Park et al., 2019) and some studies as excellent (Delgado et al., 2013; Cruz et al., 2017; Noji et al., 2017; Cruz, Aguinaldo et al., 2017; Baghadi & Ismaile, 2018). The studies included in the analysis involved a total of 11,937 participants, of whom 8,493 were registered nurses, 2,983 were nursing students, and 461 were nursing teachers and mentors. In measuring the quality of the questionnaires analysed, we used the rating system developed by Terwee et al. (2007). This system provides criteria for assessing the measurement properties of questionnaires such as validity (internal consistency, reproducibility and number of questionnaire items) and reliability (population, content, construct validity) using three rating categories: "positive" (+), "negative" (-) and "data not available" (?). A cross-comparison was used to re-evaluate the information on the measurement properties of the questionnaires included in the analysis. The authors of the present study discussed this information after reading and summarising the psychometric information on the questionnaires and reviewing their content. The results were then imported into Zotero, a research tool which allows the simultaneous organisation, storage, and management of sources and citation of references. Results Table 1 details the main features of the research and the characteristics of questionnaires used to assess and measure each dimension of cultural competence in nurses and nursing students. Table 2 shows the quality of the measurement properties of the analysed questionnaires after their appraisal using the rating system developed by Terwee et al. (2007). Table 3 shows the data on validity and reliability of the questionnaires measuring cultural competence according to the rating system developed by Terwee et al. (2007). One of the questionnaires measuring cultural competence is the so-called Cultural Self-Efficacy Scale − CSES). The CSES was developed by Bernal and Forman in 1987 (Bernal & Forman, 1993). It measures the confidence level of the licensed registered nurses in providing cultural care five ethnic groups (Middle Eastern/Arab American, Hispanic, African American, Native American, and Asian Pacific Islander) (Hagman, 2004). The scale consists of 30 statements produced on the basis of a review of the relevant literature and comprises the key concepts, knowledge and skills in transcultural nursing. The scale also includes 16 behaviour-related statements which respondents use to rate their self-perceived efficacy on a five-point Likert scale (Hagman, 2004, 2006). The Transcultural Self-Efficacy Tool (TSET) was developed and psychometrically evaluated by Jeffreys and Smodlaka (Jeffreys & Smodlaka, 1996; Jeffreys, 2000). The questionnaire consists of 83 statements divided into three sets measuring the cognitive, practical, and emotional dimensions of cultural competence (Jeffreys, 2000; Lim et al., 2004). The TSET uses a ten-point Likert scale. The questionnaire was developed as a diagnostic tool to measure and assess nursing students' perceptions of self-efficacy in providing care to patients from diverse cultural backgrounds (Jeffreys, 2000). 53Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Ta bl e 1: Q ue sti on na ire s m ea su rin g c ul tu ra l c om pe te nc e i n nu rs es a nd n ur sin g s tu de nt s Au th or (s ), Ye ar , C ou nt ry In st ru m en t Pu rp os e Sa m pl e D es cr ip tio n of th e i ns tr um en t C on ce pt ua l m od el D im en sio ns o f c ul tu ra l co m pe te nc e Ba gh ad i & Is m ai le , 20 18 U ni te d A ra b Em ira te s Cu ltu ra l D iv er sit y Q ue sti on na ire fo r N ur se E du ca to rs — C D Q N E To a ss es s t he le ve l o f c ul tu ra l co m pe te nc e am on g hi gh er ed uc at io n te ac he rs . 46 1 nu rs e ed uc at or s. 72 st at em en ts m ea su rin g 5 co ns tr uc ts o f c ul tu ra l c om pe te nc e: de sir e, aw ar en es s, kn ow le dg e, sk ill s a nd e nc ou nt er s. Th e sc al e us es a fi ve -p oi nt L ik er t s ca le a s t he m et ho d of a ss es sm en t. It is ba se d on C am pi nh a- Ba co te M od el o f C ul tu ra l C om pe te nc e. A ll di m en sio ns o f cu ltu ra l c om pe te nc e. C ai e t a l., 2 01 7 C hi na Th e C hi ne se v er sio n of Cu ltu ra l C om pe te nc e In ve nt or y fo r N ur se s (C C IN ) To d ev el op a nd te st th e ps yc ho m et ric p ro pe rt ie s of th e qu es tio nn ai re fo r m ea su rin g cu ltu ra l co m pe te nc e of n ur se s i n C hi na . 52 0 nu rs es . 29 st at em en ts co m pr isi ng 5 co ns tr uc ts : c ul tu ra l a w ar en es s, cu ltu ra l r es pe ct , c ul tu ra l un de rs ta nd in g an d cu ltu ra l s ki lls . Th e sc al e us es a fi ve -p oi nt L ik er t sc al e as th e m et ho d of a ss es sm en t. It is ba se d on m od el s de ve lo pe d by C am pi nh a- Ba co ta , Je ffr ey s a nd L ei ni ge r. Th e sc al e m ea su re s a ll di m en sio ns o f c ul tu ra l co m pe te nc e. C ru z, A gu in al do e t al ., 20 17 Sa ud i A ra bi a N ur se C ul tu ra l Co m pe te nc e S ca le (N C C S) To m ea su re c ul tu ra l co m pe te nc e in n ur sin g st ud en ts . 27 2 nu rs in g st ud en ts . 20 st at em en ts : c ul tu ra l a w ar en es s (9 ), cu ltu ra l k no w le dg e (4 ), cu ltu ra l s en sit iv ity (4 ), cu ltu ra l sk ill s ( 6) . Th e as se ss m en t i s b as ed on a fi ve -p oi nt L ik er t s ca le . Th e sc al e is ba se d on lit er at ur e re vi ew a nd C am pi nh a- Ba co te M od el o f C ul tu ra l C om pe te nc e an d Je ffr ey s’s C ul tu ra l C om pe te nc e an d C on fid en ce M od el . Cu ltu ra l k no w le dg e, de sir e fo r c ul tu ra l aw ar en es s a nd c ul tu ra l sk ill s. C ru z e t a l., 2 01 7 C hi le , I ra q, O m an , Ph ili pp in es , S au di A ra bi a, S ou th A fr ic a, S ud an a nd Tu rk ey Cu ltu ra l C ap ac ity Sc al e ( C C S) To a ss es s c ul tu ra l co m pe te nc e in n ur sin g st ud en ts fr om n in e co un tr ie s. 2, 16 7 nu rs in g st ud en ts . 20 st at em en ts : c ul tu ra l k no w le dg e (6 ), cu ltu ra l s en sit iv ity (2 ), cu ltu ra l s ki lls (1 2) . A ss es sm en t i s ba se d on a fi ve -p oi nt L ik er t s ca le . Th e qu es tio nn ai re w as cr ea te d on th e ba sis o f a lit er at ur e re vi ew . Th e co nc ep tu al m od el o f cu ltu ra l c om pe te nc e is no t s pe ci fie d. Cu ltu ra l k no w le dg e, se ns iti vi ty a nd c ul tu ra l sk ill s. D el ga do e t a l., 2 01 3 U ni te d St at es o f A m er ic a In ve nt or y fo r A ss es sin g th e P ro ce ss o f C ul tu ra l Co m pe te nc y (IA PC C an d IP A C C -R ) To e nh an ce a nd m ea su re cu ltu ra l c om pe te nc e in nu rs es . 98 n ur se s. Th e or ig in al 2 0- ite m qu es tio nn ai re h as b ee n co nv er te d to a 2 5- ite m q ue st io nn ai re b as ed on fi ve co ns tr uc ts o f c ul tu ra l co m pe te nc e: d es ire , a w ar en es s, kn ow le dg e, sk ill s a nd e nc ou nt er s w ith fo re ig n cu ltu re s. Th e qu es tio nn ai re u se s a fo ur -p oi nt Li ke rt sc al e. It is ba se d on C am pi nh a- Ba co te M od el o f C ul tu ra l C om pe te nc e. A ll di m en sio ns o f cu ltu ra l c om pe te nc e. H al te r e t a l., 2 01 5 U ni te d St at es o f A m er ic a Tr an sc ul tu ra l S elf - Effi ca cy T oo l ( TS ET ) To a ss es s t he im pa ct o f va rio us c ul tu ra l e du ca tio n pr og ra m m es . 26 0 nu rs in g st ud en ts . 83 st at em en ts w ith th re e su b- sc al es : c og ni tiv e, pr ac tic al a nd aff ec tiv e. A ss es sm en t i s b as ed o n a te n- po in t L ik er t s ca le . C on sis te nt w ith Ba nd ur 's th eo ry of so ci al le ar ni ng an d th e co nc ep ts o f tr an sc ul tu ra l n ur sin g. Cu ltu ra l s el f- effi ca cy . Co nt in ue s 54 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Au th or (s ), Ye ar , C ou nt ry In st ru m en t Pu rp os e Sa m pl e D es cr ip tio n of th e i ns tr um en t C on ce pt ua l m od el D im en sio ns o f c ul tu ra l co m pe te nc e H er re ro -H ah n et al ., 20 19 C ol om bi a Se lf- Effi ca cy S ca le (C SE S) To d es cr ib e th e le ve l of c ul tu ra l s el f- effi ca cy of C ol om bi an n ur sin g pr of es sio na ls an d de te rm in e th e m ai n in flu en ci ng fa ct or s. 21 1 nu rs es 26 st at em en ts cl as sifi ed in to 3 su bc at eg or ie s: kn ow le dg e of cu ltu ra l c on ce pt s, cu ltu ra l s ki lls , kn ow le dg e of c ul tu ra l p at te rn s in in di vi du al e th ni c g ro up s. Th e in st ru m en t i s b as ed o n a fiv e- po in t L ik er t s ca le . C on sis te nt w ith Ba nd ur 's th eo ry o f so ci al le ar ni ng a nd Le in in ge r's th eo ry o f tr an sc ul tu ra l n ur sin g. Cu ltu ra l s el f- effi ca cy . Ko ut a et a l., 2 01 6 C yp ru s Cu ltu ra l C om pe te nc e A ss es sm en t T oo l ( C C A To ol ) To p re se nt th e le ve l o f cu ltu ra l c om pe te nc e of nu rs es b ef or e an d aft er at te nd in g a w or ks ho p on cu ltu ra l c om pe te nc e. 17 0 co m m un ity nu rs es . A 2 5- ite m sc al e w ith th e fo llo w in g su b- sc al es : c ul tu ra l a w ar en es s, kn ow le dg e, se ns iti vi ty a nd co m pe te nc e of n ur sin g pr ac tic e. A ss es sm en t i s b as ed o n a fiv e- po in t L ik er t s ca le . M od el o f d ev el op m en t of c ul tu ra l c om pe te nc e ba se d on th e Pa pa do po ul os , T ilk i an d Ta yl or M od el . Cu ltu ra l a w ar en es s, kn ow le dg e an d cu ltu ra l se ns iti vi ty . N oj i e t a l., 2 01 7 Ja pa n Ca ffr ey C ul tu ra l Co m pe te nc e H ea lth Se rv ice s ( J- C C C H S) To a ss es s c ul tu ra l co m pe te nc e in n ur se s s o as to im pr ov e co m pr eh en siv e nu rs in g ca re . 7, 49 4 nu rs es fr om 1 9 ho sp ita ls. 28 st at em en ts m ea su rin g se lf- pe rc ep tio n, se lf- aw ar en es s a nd co m fo rt w ith c ul tu ra l c om pe te nc e sk ill s. A ss es sm en t i s b as ed o n a fiv e- po in t L ik er t s ca le . Th e in st ru m en t i s ba se d on a m od el w hi ch p ro po se s th e as se ss m en t o f cu ltu ra l c om pe te nc e as a n ou tc om e of tr ai ni ng b as ed o n a tw o- st ag e le ar ni ng pr oc es s: ac qu isi tio n of k no w le dg e an d ch an ge in at tit ud es an d be ha vi ou rs . Se lf- pe rc ei ve d kn ow le dg e, se lf- aw ar en es s a nd co m fo rt w ith c ul tu ra l co m pe te nc e sk ill s. Pa rk e t a l., 2 01 9 So ut h Ko re a Cu ltu ra l C om pe te nc e Sc al e f or K or ea n N ur se s ( K -C C SN ) To a ss es s t he im pa ct o f cu ltu ra l n ur sin g ed uc at io n. 69 n ur sin g st ud en ts . It co ns ist s o f 3 3 st at em en ts co ve rin g 4 ca te go rie s: cu ltu ra l aw ar en es s ( 6) , c ul tu ra l s ki lls (7 ), cu ltu ra l s en sit iv ity (1 2) , c ul tu ra l kn ow le dg e (8 ). It is ba se d on G ig er - D av id hi za r's m od el o f cu ltu ra l c om pe te nc e. Cu ltu ra l a w ar en es s, kn ow le dg e, se ns iti vi ty an d cu ltu ra l c om pe te nc e sk ill s. Sa fip ou r e t a l., 2 01 7 Sw ed en Cu ltu ra l A w ar en es s Sc al e ( C A S) To a ss es s s tu de nt s’ cu ltu ra l aw ar en es s i n re la tio n to th ei r e du ca tio n, ta ki ng in to a cc ou nt th ei r s oc io - de m og ra ph ic b ac kg ro un d. 21 5 nu rs in g st ud en ts . Th e 36 -it em sc al e w ith fi ve su b- sc al es : g en er al e du ca tio na l ex pe rie nc e (1 4) , c og ni tiv e aw ar en es s ( 7) , r es ea rc h iss ue (4 ), in te ra ct io n be ha vi ou r/ co m fo rt in in te ra ct io n (6 ), pa tie nt c ar e/ cl in ic al p ra ct ic e (5 ). A ss es sm en t is ba se d on a se ve n- po in t L ik er t sc al e. It is ba se d on a n an al ys is of th e "P at hw ay s" m od el a nd is lin ke d to th e Pu rn el l M od el fo r C ul tu ra l C om pe te nc e. Cu ltu ra l a w ar en es s. 55Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Revised (IAPCC-R) (revised version) by Campinha- Bacota consists of 25 statements designed to measure cultural competence in healthcare providers. The questionnaire, which uses a four-point Likert scale, Table 2: Quality of measurement properties of questionnaires included in the systematic literature review Instruments Reliability Validity Internal Consistency Test-Retest Number of Items Sampling Content Construct Validity CSES Cronbach Alpha = 0.978 (0.85−0.98) ND 26 (30) DMS/DZ Expert council 33−90% variance TSET Cronbach Alpha = 0.92−0.98 r = 0.64−0.75 in two weeks (test-retest) 83 Nursing students Expert council 62% variance IAPCC-R Cronbach Alpha = 0.75−0.93 Limitations stated for the original version of the questionnaire 25 DMS/DZ Expert council ND CAS Cronbach Alpha = 0.869 ND 36 Nursing students Expert council 51% variance CCCATool Cronbach Alpha = 0.82−0.91 ND 25 DMS/DZ Expert council 56% variance CDQNE Cronbach Alpha = 0.94 ND 72 Nurse educators Expert council ND J-CCCHS Cronbach Alpha = 0.756−0.892 ND 28 DMS/DZ Expert council 61% variance K-CCSN Cronbach Alpha = 0.900 (0.879− 0.921) r = 0.61−0.75 in thirteen weeks (test-retest) 33 Nursing students Expert council ND NCCS Cronbach Alpha = 0.95 ND 20 Nursing students Expert council 66% variance CCIN Cronbach Alpha = 0.94 r =0.86 in two weeks (0.75− 0.85) 29 DMS/DZ Expert council 63.46% variance CCS Cronbach Alpha = 0.96 IC = 0.88 in two weeks 20 Nursing students Expert council 20.4% variance Legend: CSES − Cultural Self-Efficacy Scale; TSET − Transcultural Self-Efficacy Tool; IAPCC and IPACC-R − Inventory for Assessing the Process of Cultural Competence; CAS − Cultural Awareness Scale; CCA Tool − Cultural Competence Assessment Tool; CDQNE − Cultural Diversity Questionnaire for Nurse Educators; J-CCCHS − Caffrey Cultural Competence Health Services; K-CCSN − Cultural Competence Scale for Korean Nurses; NCCS − Nurse Cultural Competence Scale; CCIN − Cultural Competence Inventory for Nurses (adapted for nursing staff in China); CCS – Cultural Capacity Scale; ND − not rated; DMS/DZ − registered nurse/graduate nurse/registered nurses; ZN − nursing Table 3: Validity and reliability of questionnaires according to the rating system developed by Terwee et al. (2007) Instruments Reliability Validity Internal consistency Test-retest Number of items Sampling Content Construct Validity CSES + ? + + + − TSET + − − + + − IAPCC-R + − + + + − CAS + ? − + + − CCCATool + ? + + + − CDQNE + ? − + + − J-CCCHS + ? + + + − K-CCSN + − − + + ? NCCS + ? + + + − CCIN + + − + + − CCS − + + + + − Legend: CSES − Cultural Self-Efficacy Scale; TSET − Transcultural Self-Efficacy Tool; IAPCC and IPACC-R − Inventory for Assessing the Process of Cultural Competency; CAS − Cultural Awareness Scale; CCA Tool − Cultural Competence Assessment Tool; CDQNE − Cultural Diversity Questionnaire for Nurse Educators; J-CCCHS − Caffrey Cultural Competence Health Services; K-CCSN − Cultural Competence Scale for Korean Nurses; NCCS − Nurse Cultural Competence Scale; CCIN − Cultural Competence Inventory for Nurses (adapted for nursing staff in China); CCS – Cultural Capacity Scale. (+) positive assessment; (-) negative assessment; (?) data not available 56 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. is based on the model of care by Campinha-Bacote (2002). The Caffrey Cultural Competence Healthcare Scale (CCCHS) was developed by Caffrey, Neander, Markle & Stewart (2005). This questionnaire measures self- perceived knowledge, self-awareness and depth of skills of cultural competence (Caffrey et., 2005; Loftin et al., 2013). The scale consists of 28 statements and uses a five-point Likert scale (Caffrey et al., 2005; Transcultural C.A.R.E. Associates, 2020). The CCCHS scale is intended for use before and after clinical training. One of the advantages of using the CCCHS scale lies in its ability to assess student improvement over time. However, its disadvantage is its inability to show the relationship between actual and simulated experiences (Loftin et al., 2013). The Cultural Awareness Scale (CAS) developed by Rew, Becker, Cookkston, Khospropour & Martinez (2003) was designed to measure cultural awareness in nursing students. The authors consider cultural awareness as the minimum level of cultural competence. The scale, which is based on the Pathways Model and is consistent with the Purnell Model of Cultural Competence, consists of 36 statements (Rew et al., 2003; Loftin et al., 2013). Students rank the statements on a seven-point Likert scale. The CAS scale has also been translated into Slovenian (Ličen, Karnjuš, & Prosen, 2020). The Cultural Competence Assessment Tool (CCA) was designed to assess cultural competence in healthcare providers, including nurses (Schim, Doorenbos, Miller, & Benkert, 2003). The CCA consists of 26 statements which are rated on a five- point Likert scale (Doorenbos, Schim, Miller, & Benkert, 2005). The Cultural Diversity Questionnaire for Nurse Educators (CDQNE) was developed to measure the cultural competence of nurse educators (Sealey, Burnett, & Johenson, 2006). The CDQNE consists of 72 statements rated on a five-point Likert scale (Transcultural C.A.R.E. Associates, 2020). The Chinese version of the Cultural Competence Inventory for Nurses – CCIN (tailored to nurses in China) was developed by Dr Duanying Cai from the Chiang Mai University (Transcultural C.A.R.E. Associates, 2020). The scale consists of 29 statements covering five dimensions: cultural awareness, cultural respect, cultural knowledge, cultural understanding, and cultural skills. The questionnaire uses a five-point Likert scale (Cai et al., 2017). The Nurse Cultural Competence Scale (NCCS) was developed by Perng & Watson (2012) and is based on models developed by Campinha-Bacote, Jeffreys and others. The scale includes four domains: cultural awareness, cultural knowledge, cultural sensitivity and cultural skills. The NCCS contains 41 statements and is based on a five-point Likert scale (Transcultural C.A.R.E. Associates, 2020). The Cultural Capacity Scale (CCS) consists of 20 questions related to cultural knowledge and cultural sensitivity (Perng & Waston, 2012). Among the questionnaires included in our research, the CCS is the only questionnaire developed to assess the need for training programmes for nurses (Transcultural C.A.R.E. Associates, 2020). The Cultural Competence Scale for Korean Nurses – CCSN, adapted for nurses in South Korea (Chae & Lee, 2014), is based on a theoretical model of culturally competent nursing by Rene Papadopoulos (2006) and interviews with nurses. The CCSN consists of four subscales measuring cultural awareness, cultural knowledge, cultural sensitivity, and cultural skills. The scale consists of 33 statements and uses a seven-point Likert scale (Oh, Lee, & Scheep, 2015; Ahn, 2017). Discussion We conducted a systematic literature review to identify and examine the questionnaires which measure or assess cultural competence in nursing and to investigate their contents, characteristics, and other components. Our literature review resulted in the selection of eleven questionnaires which we considered most appropriate for measuring cultural competence in nurses and nursing students. Our first research question was which questionnaire is the most suitable for measuring cultural competence in the field of clinical practice and nursing education in Slovenia. According to our findings, some questionnaires were not considered suitable for measuring cultural competence and cultural capacity in nurses and nursing students in Slovenia for various reasons: for example, the CSES questionnaire (Herrero-Hahn et al., 2019; Capell et al., 2007), the K-CCSN questionnaire (Chae & Lee, 2014) and the CCIN questionnaire (Cai et al., 2017). These questionnaires are adapted to measure the cultural competence of employees from specific cultures and are not suitable for measuring cultural competence in the Slovenian setting. Using a comprehensive analysis of the psychometric characteristics of questionnaires, such as validity and reliability, we identified the following questionnaires as the most suitable for measuring cultural competence in nurses: IPACC-R (Delgado et al., 2013), CCATool (Kouta et al., 2016), NCCS (Cruz et al., 2017), and CCS (Cruz, Aguinaldo et al., 2017). According to our findings, the following questionnaires are suitable for measuring cultural competence in nursing students: TSET (Halter et al., 2015), CCCHS (Noj et al., 2017), CAS (Safipour et al., 2017); and CDQNE (Baghadi & Ismaile, 2018) for measuring cultural competence in nurse educators. In the second research question, we investigated the common features/characteristics/components of questionnaires measuring cultural competence in 57Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. nurses and nursing students. We used the rating system developed by Terwee (2007). The questionnaires included in our analysis were found to have several common features. Most of these questionnaires are so-called general questionnaires, meaning that they measure cultural competence in nurses regardless of the differences in the patients' respective cultural groups (Delgado et al., 2013; Kouta et al., 2016; Cai et al., 2017; Cruz et al., 2017; Noj et al., 2017; Herrero- Hahn, 2019). The CSES questionnaire (Herrero-Hahn, 2019) belongs to a group of specific questionnaires. The internal consistency of the questionnaires included in the analysis was expressed by the Cronbach's alpha coefficient. The following seven questionnaires achieved a Cronbach's alpha of 0.90 or higher, indicating excellent reliability: CSES (Herreo- Hahn et al., 2019), TSET (Halter et al., 2015), CDQNE (Baghadi & Ismaile, 2018), K-CCSN (Chae & Lee, 2014), NCCS (Cruz et al., 2017), CCIN (Transcultural C.A.R.E. Associates, 2020), CCS (Cruz, Aguinaldo et al., 2017), IPACC-R R (Delgado et al., 2013) and J-CCCHS (Noj et al., 2017). Reliability in terms of construct validity was assessed using factor analysis. This analysis was conducted for eight questionnaires: CSES (Herreo-Hahn et al., 2019), TSET (Halter et al., 2015), CAS (Safipour et al., 2017), CCCATool (Kouta et al., 2016), J-CCCHS (Noj et al., 2017), NCCS (Cruz et al., 2017), CCIN (Cai et al., 2017), CCS (Cruz et al., 2020). For CSES (Herreo-Hahn et al., 2019), the variance explained by factor analysis varied widely: from 33% for nurse educators (Kardong-Edgren & Campinha- Bacote, 2008) to 90% for community nurses (Bernal & Forman, 1993). The explained variance of the model was 20% only for the CCS questionnaire (Cruz, Aguinaldo et al., 2017), while for six questionnaires – TSET (Halter et al., 2015), CAS (Safipour et al., 2017), CCATool (Kouta et al., 2016), J-CCSN (Noj et al., 2017), NCCS (Cruz et al., 2017), CCIN (Cai et al., 2017) — the explained variance of the model was more than 50%. Test-retest reliability data were also available for TSET (Halter et al., 2015), K-CCSN (Chae & Lee, 2014), CCIN (Cai et al., 2017) and CCS (Cruz, Aguinaldo et al., 2017). For CCIN (Park et al., 2019) and CCS (Transcultural C.A.R.E. Associates, 2020), the intraclass correlation coefficient of > 0.70 indicates high stability. The questionnaires included in the analysis were developed on the basis of literature review (Halter et al., 2015; Cruz et al., 2017; Noji et al., 2017) and cultural competence models and theories developed by many authors, e.g., Campinha-Bacote (Delgado et al., 2013; Cai et al., 2017; Cruz, Aguinaldo et al., 2017; Baghadi & Ismaile, 2018), Madeleine Leininger (Herrero-Hahn., et al., 2019), Larry D. Purnell (Safipour et al., 2017), Marianne Jeffreys (Cai et al., 2017; Cruz, Aguinaldo et al., 2017), Rena Papadopoulos (Kouta et al., 2016) and others. Limitations of this study include a limited number of databases, which means that some high-quality research was overlooked. Another limitation is the lack of Slovenian literature in the field of measuring cultural competence. Despite the fact that there are several instruments available for assessing the quality of research based on systematic literature review, we used the CASP instrument without prior analysis and comparison with other similar instruments. Conclusion Our systematic literature review showed that the IPACC-R, CCATool, NCCS and CCS questionnaires are among the most appropriate instruments for measuring nurses' cultural competence in Slovenia. The TSET, CCCHS and CAS questionnaires were found to be suitable for measuring cultural competence in nursing students. This systematic literature review represents only one form of measuring cultural competence in nursing, as despite its usefulness in practice, this method of quantitative assessment of cultural competence may not always be the most appropriate. We suggest that researchers in this field also use qualitative methods to measure cultural competence, which may be more complex to implement, but address a particular problem in more detail. Nevertheless, this systematic literature review represents the first such study in this field in Slovenia, and with the selection of analysed questionnaires therefore provides a good starting point for other researchers and further research. Slovenian translation/Prevod v slovenščino Uvod Danes številne države doživljajo naraščajočo kulturno raznolikost kot posledico migracij in globalizacije (Czaika & Haas, 2014; Regev, 2014). Demografske spremembe v prebivalstvu so skozi desetletja tudi našo državo spremenile v multikulturno družbo (Ličen, Karnjuš, Bogataj, Rebec, & Prosen, 2019). Vse večja diverzifikacija družb sicer ponuja številne priložnosti za družbeno in gospodarsko rast, vendar hkrati predstavlja tudi izziv za države gostiteljice (Abubakar et al., 2018; Handtke, Schilgen, & Mösko, 2019). Slednje lahko opazimo tudi v Sloveniji, saj podatki Statističnega urada Republike Slovenije prvega januarja 2019 kažejo, da tujci trenutno predstavljajo 6,6 % vseh prebivalcev Slovenije (Statistični urad Republike Slovenije, 2019). Z naraščanjem vpliva globalizacije opazimo vpliv kulture na determinante zdravja – kultura vpliva na pogled posameznika ali skupine na zdravje, dobro počutje, bolezen, mladost ter staranje (Halbwachs, 58 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. 2019). Velikokrat kultura posameznika oblikuje odnos do zdravja in lastnega telesa, vpliva na vlogo pacienta in na pričakovanja, ki jih pacient goji do zdravstva (Ličen et al., 2019). Zdravstveni delavci se zdaj bolj kot kadar koli prej zavedajo izzivov, s katerimi se soočajo pri zagotavljanju zdravstvenih storitev pri raznoliki populaciji. Kulturna kompetenca tako predstavlja okvir za razumevanje zdravstvenih razlik med rasnimi in etničnimi skupinami (Crenshaw et al., 2011; Handtke et al., 2019) ter upoštevanje kulturnih raznolikosti drugih delov populacije, kot so npr. ženske, starejši, raznolikost glede na spolno usmerjenost in spolno identiteto, invalidnost in pripadnost verskim manjšinam (Crenshaw et al., 2011; Ličen et al. 2019; Lipovec-Čebron & Huber, 2020). Kot rezultat teh opažanj se je tudi na področju zdravstva in zdravstvene nege pojavila potreba po usposabljanju na področju kulturnih kompetenc (Delgado et al., 2013). Čeprav obstaja več definicij, ki opredeljujejo izraz kulturne kompetence, vsaka poudarja potrebo, da se zdravstveni sistemi in izvajalci zavedajo kulturne raznolikosti in se odzivajo nanjo ter upoštevajo različna okolja, iz katerih prihajajo pacienti (Cai, 2016; Henderson, Horne, Hills, & Kendall, 2018). Prvo definicijo so podali avtorji Cross, Bazron, Dennis, & Isaacs (1989), ki so kulturne kompetence opredelili kot »skupek skladnega vedenja, stališč in politik, ki se združujejo v sistemu, agenciji ali med strokovnjaki in omogočajo temu sistemu, agenciji ali strokovnjakom, da učinkovito delujejo v medkulturnih situacijah«. Široko sprejeta definicija (National Center for Cultural Competence, n. d.) kulturne kompetence opredeljuje kot skupek znanj in veščin v odnosih z ljudmi, ki posamezniku omogoči, da izboljša svoje razumevanje, občutljivost, sprejemanje, spoštovanje in odzivanje na kulturne razlike in odnose, ki izhajajo iz njih. Kulturna kompetenca nam omogoča nudenje bolj kakovostne zdravstvene oskrbe ter pomaga, da bolje sodelujemo z ljudmi iz različnih kultur. Ker je razvijanje medkulturnih kompetenc dolgoročni proces, se zdi ključno, da se medkulturne vsebine vključijo v učni načrt zdravstvene nege že v zgodnji fazi. S tem lahko dosežemo ali vsaj omogočimo zgodnji pričetek razvoja medkulturnih kompetenc (Prosen, Karnjuš, & Ličen, 2017). Tudi merjenje kulturnih kompetenc med zaposlenimi v zdravstveni negi predstavlja temeljni korak k oceni strategij učenja kulturnih kompetenc, doseganju kulturne usposobljenosti na področju kulturnih kompetenc in izboljšanju kakovosti zdravstvene nege za vse bolj raznoliko populacijo (Cai, 2016; Ličen et al., 2017; Sharifi et al., 2019). Pomembno je poudariti, da raziskovalci pojem kulturne kompetence vidijo kot abstrakten in teoretičen koncept, ki ga je težko definirati in posledično težko razumeti ter proučevati (Diallo & McGrath, 2013). Medicinske sestre raziskovalke so razvile ukrepe za ocenjevanje znanja, veščin in stališč, povezanih s kulturno usposobljenostjo (Shen, 2015; Alizadeh & Chavan, 2016; Lin, Lee, & Huang, 2017). Nekatere raziskave so že opredelile 54 različnih vprašalnikov, ki se uporabljajo za ocenjevanje kulturnih kompetenc pri usposabljanju zdravstvenih delavcev in študentov zdravstvene nege (Loftin, Harin, Brenson, & Reyes, 2013; Shen, 2015; Lin et al., 2017). Namen in cilji Obstajajo številni vprašalniki in drugi instrumenti, ki merijo ali ocenjujejo kulturne kompetence v zdravstveni negi, zato je bil namen sistematičnega pregleda literature proučiti vsebino in lastnosti vprašalnikov, ki predstavljajo enega izmed možnih instrumentov za opredeljevanje doseganja kulturnih kompetenc, ter izbrati najprimernejše vprašalnike za ocenjevanje kulturnih kompetenc pri medicinskih sestrah in študentih zdravstvene nege. Cilj raziskave je bil na podlagi sistematičnega pregleda literature poiskati najbolj primeren in preverjen vprašalnik za merjenje kulturnih kompetenc, ki bi ga lahko uporabili na področju klinične prakse in izobraževanja za zdravstveno nego v Sloveniji. Na podlagi ciljev smo postavili naslednji raziskovalni vprašanji: – Kateri vprašalnik za merjenje kulturnih kompetenc, ki bi ga lahko uporabili na področju klinične prakse in izobraževanja za zdravstveno nego v Sloveniji, je najprimernejši? – Katere so skupne značilnosti/lastnosti/komponente vprašalnikov za merjenje kulturnih kompetenc med medicinskimi sestrami in študenti zdravstvene nege? Metode Izveden je bil sistematični pregled znanstvene literature. Metode pregleda V novembru 2019 smo opravili sistematični pregled literature v podatkovnih bazah Cumulative Index of Nursing and Allied Health Literature (CINAHL), Educational Resources Information Cenze (ERIC), EBSCO in ScienceDirect. Za iskalne izraze smo določili kombinacijo naslovov, uporabljenih fraz in prostega besedila ali ključnih besed v iskalniku Medical Subject Headings (MeSH). Želene rezultate smo dosegli z uporabo iskalnih izrazov v angleškem jeziku: transcultural nursing; culturally competent care; cultural competency; education, nursing; questionaire. Pri iskanju želenih rezultatov in zmanjšanju nepotrebnih virov smo si pomagali z Boolovimi operatorji IN (ang. AND) in ALI (ang. OR) v različnih 59Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. iskalnih kombinacijah: transcultural nursing OR culturally competent care OR cultural competency AND education nursing AND questionaire. Kot vključitvene kriterije smo upoštevali izvirne znanstvene članke z ustrezno tematiko, objavljene od leta 2010 do 2020. Kot izključitvene kriterije smo upoštevali pisma uredniku, protokole, strokovne članke, članke v jezikih, ki niso angleški, in članke, objavljene pred letom 2010, neustrezno populacijo ter nezadostne značilnosti/lastnosti/komponente za izbrane vprašalnike. Rezultati pregleda Brez vnaprej določenih kriterijev smo dobili 247 zadetkov. Od tega smo največ zadetkov dobili v podatkovni bazi CINAHL, in sicer 101 zadetek, naslednja podatkovna baza z največ zadetki je bila Identifikacija zadetkov: CINAHL + ERIC + EBSCO + ScienceDirect (n = 101 + 72 + 32 + 42 = 247) Zadetki po odstranitvi dvojnikov (n = 102) Pregled zadetkov na podlagi naslova in zadetkov (n = 102) Pregled polno dostopnih besedil glede na primernost (n = 64) Polno dostopna besedila, izključena z razlogom: populacija (n = 28), tema (n = 9), informacije o vprašalnikih (n = 16), skupaj 53 Raziskave, vključene v analizo (n = 11) Id en tif ik ac ija Pr eg le d Pr im er no st Vk lju če no st Slika 1: PRISMA diagram poteka sistematičnega pregleda literature 60 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. ERIC z 72 zadetki, v podatkovni bazi EBSCO je bilo 32 zadetkov, v podatkovni bazi ScienceDirect pa 42. Po uporabi kriterijev, kot so časovna omejitev, odstranitev dvojnikov, polna dostopnost besedila in članki v angleškem jeziku, se je število zadetkov zmanjšalo na 102. Nadalje smo odstranili še dodatnih 38 zadetkov na podlagi analize naslovov in/ali povzetkov člankov, 28 pa zaradi neustrezne populacije, ki ni vključevala zaposlenih v zdravstveni negi ali študentov. Ker pri analizi nismo mogli natančno razbrati značilnosti oziroma lastnosti ali komponent analiziranih vprašalnikov, je bilo dodatno izključenih še 16 člankov. Dodatnih devet člankov smo izključili, ker so vprašalniki merili druge kompetence v zdravstveni negi. Kot je razvidno iz Slike 1, smo v končni sistematični pregled literature vključili 11 člankov. Za prikaz poteka pregleda literature (Slika 1) smo uporabili pristop PRISMA (»Preferred Reporting Items for Systematic Reviews and Meta-Analyses«) (Moher, Liberati, Tettzlaf, & Altmanet, 2009). Ocena kakovosti pregleda in opis obdelave podatkov Enajst člankov, vključenih v sistematični pregled literature, je izpolnjevalo vse postavljene vključitvene kriterije. Članke, ki so bili v skladu z namenom in ciljem raziskave, smo kritično ovrednotili s pomočjo orodja CASP (ang. Critical Appraisal Skills Programme), in sicer s kontrolnim seznamom CAPS za sistematični pregled literature (CAPS, 2014). S tem orodjem smo dobro polovico vključenih raziskav ocenili kot dobre (Halter et al., 2015; Kouta et al., 2016; Cai et al., 2017; Safipour et al., 2017; Herrero- Hahn et al., 2019; Park et al., 2019), nekatere raziskave pa kot odlične (Delgado et al., 2013; Cruz et al., 2017; Noji et al., 2017; Cruz, Aguinaldo et al., 2017; Baghadi & Ismaile, 2018). V vseh člankih, vključenih v analizo, je skupno sodelovalo 11.937 sodelujočih, od tega 8.493 diplomiranih medicinskih sester, 2.983 študentov zdravstvene nege ter 461 učiteljev in mentorjev zdravstvene nege. Kot kritično oceno za merjenje kakovosti analiziranih vprašalnikov smo uporabili tako imenovani bonitetni sistem ocenjevanja (Terwee et al., 2007). Ta ocenjuje merilne lastnosti, kot sta veljavnost (notranja skladnost, ponovno testiranje in število trditev) in zanesljivost (vzorčenje, vsebine, konstruktna veljavnost), vprašalnikov v treh kategorijah ocenjevanja: »pozitivno« (+), »negativno« (−) in »ni nobenih informacij« (?). Navzkrižna primerjava je bila uporabljena za ponovno preverjanje informacij o merilnih lastnostih analiziranih vprašalnikov, vključenih v analizo. Avtorji članka smo o informaciji razpravljali po branju in povzemanju psihometričnih informacij o vprašalnikih ter pregledu njihove vsebine. Zadetke smo nadalje uvozili v program Zotero, raziskovalno orodje, ki hkrati omogoča organiziranje, shranjevanje virov, upravljanje in citiranje referenc. Rezultati V Tabeli 1 smo podrobneje opisali ključne značilnosti raziskave in značilnosti oziroma lastnosti vprašalnikov, ki ocenjujejo in merijo kompetence pri medicinskih sestrah in študentih zdravstvene nege. Tabela 2 prikazuje kakovost merilnih lastnosti analiziranih vprašalnikov po oceni z bonitetnim sistemom ocenjevanja po Terweeju et al. (2007). Kratice in imena merilnih orodij, navedenih v Tabeli 2, ohranjamo v angleškem jeziku. V legendi smo avtorji članka vprašalnike prevedli v slovenski jezik; ne gre za splošno priznan prevod originalnih poimenovanj vprašalnikov. Tabela 3 prikazuje podatke o veljavnosti in zanesljivosti vprašalnikov za merjenje kulturnih kompetenc po bonitetnem sistemu ocenjevanja (Terwee et al., 2007). Eden izmed vprašalnikov za merjenje kulturnih kompetenc je tako imenovana lestvica kulturne samoučinkovitosti (ang. Cultural Self-Efficacy Scale − CSES). CSES sta razvila avtorja Bernal in Forman leta 1987 (Bernal & Forman, 1993). CSES meri zaupanje Latinoameričanov, ameriških staroselcev in predstavnikov azijskih otočkov v odnosu do izvajalcev zdravstvene nege (Hagman, 2004). Lestvico sestavlja 30 trditev, ki so bile razvite na podlagi raziskave ustrezne literature in predstavljajo ključne koncepte, znanja in spretnosti v transkulturni zdravstveni negi. Lestvica vsebuje tudi 16 vedenjskih izjav, s katerimi anketiranci ocenijo lastno učinkovitost znotraj petstopenjske lestvice Likertovega tipa (Hagman, 2004, 2006). Orodje za merjenje transkulturne samoučinkovitosti (ang. Transcultural Self-Efficacy − TSET) sta razvila in psihometrično ocenila Jeffreysova in Smodlaka (Jeffreys & Smodlaka, 1996; Jeffreys, 2000). Vprašalnik je sestavljen iz 83 trditev, razdeljenih na tri sklope, ki ocenjujejo kognitivno, praktično in čustveno dimenzijo kulturnih kompetenc (Jeffreys, 2000; Lim et al., 2004). TSET uporablja desetstopenjsko Likertovo lestvico. Vprašalnik je bil zasnovan kot diagnostično orodje za merjenje in oceno dojemanja lastne učinkovitosti pri študentih zdravstvene nege pri oskrbi pacientov iz različnih okolij (Jeffreys, 2000). Lestvica za ocenjevanje procesa kulturnih kompetenc med zdravstvenimi delavci (revidirana verzija) avtorice Campinha-Bacote (ang. Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised − IAPCC-R) je sestavljena iz 25 trditev, namenjenih merjenju kulturnih kompetenc izvajalcev zdravstvene nege. Vprašalnik temelji na modelu oskrbe (Campinha- Bacote, 2002). Ocenjevanje IAPPC-R temelji na štiristopenjski Likertovi lestvici (Campinha-Bacote, 2002). 61Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Ta be la 1 : P rik az v pr aš al ni ko v, ki m er ijo k ul tu rn e k om pe te nc e p ri m ed ici ns ki h se str ah in št ud en tih zd ra vs tv en e n eg e Av to r, le tn ic a, dr ža va In st ru m en t N am en V zo re c O pi s i ns tr um en ta K on ce pt ua ln i m od el D im en zi je k ul tu rn e ko m pe te nc e Ba gh ad i & Is m ai le , 20 18 Zd ru že ni A ra bs ki Em ira ti Cu ltu ra l D iv er sit y Q ue sti on na ire fo r N ur se E du ca to rs – C D Q N E/ Vp ra ša ln ik ku ltu rn e ra zn ol ik os ti za m ed ic in sk e se st re v iz ob ra že va nj u O ce ni ti st op nj e ku ltu rn ih k om pe te nc uč ite lje v na vi so ko šo lsk em št ud ijs ke m p ro gr am u. 46 1 uč ite lje v zd ra vs tv en e ne ge . 72 tr di te v, ki m er ijo 5 k on st ru kt ov ku ltu rn ih k om pe te nc : ž el jo , oz av eš če no st , z na nj e, sp re tn os ti in sr eč an je . Z a oc en je va ln o m et od o up or ab lja p et st op en jsk o Li ke rt ov o le st vi co . Te m el ji na m od el u ku ltu rn ih ko m pe te nc p o C am pi nh a- Ba co te . V se d im en zi je ku ltu rn ih k om pe te nc . C ai e t a l., 2 01 7 K ita jsk a Th e C hi ne se ve rs io n of C ul tu ra l Co m pe te nc e In ve nt or y fo r N ur se s (C C IN )/ Le st vi ca ku ltu rn ih k om pe te nc m ed ic in sk ih se st er Ra zv iti in p re iz ku sit i ps ih om et rič ne la st no st i vp ra ša ln ik a za m er je nj e ku ltu rn ih k om pe te nc za m ed ic in sk e se st re n a K ita jsk em . 52 0 m ed ic in sk ih se st er . 29 tr di te v, ki za je m a 5 ko ns tr uk to v: ku ltu rn o oz av eš ča nj e, ku ltu rn o sp oš to va nj e, ku ltu rn o ra zu m ev an je in k ul tu rn e ve šč in e. Za oc en je va ln o m et od o up or ab lja pe ts to pe nj sk o Li ke rt ov o le st vi co . Te m el ji na m od el ih C am pi nh a- Ba co te , Je ffr ey so ve in L ei ni ge rja . M er i v se d im en zi je ku ltu rn ih k om pe te nc . C ru z, A gu in al do e t al ., 20 17 Sa vd sk a A ra bi ja N ur se C ul tu ra l Co m pe te nc e S ca le (N C C S) /L es tv ic a ku ltu rn ih k om pe te nc za m ed ic in sk e se st re O ce ni ti ku ltu rn e ko m pe te nc e št ud en to v zd ra vs tv en e ne ge . 27 2 št ud en to v zd ra vs tv en e ne ge . 20 tr di te v: k ul tu rn o oz av eš ča nj e (9 ), ku ltu rn o zn an je (4 ), ku ltu rn a ob ču tlj iv os t ( 4) , k ul tu rn e ve šč in e (6 ). O ce nj ev an je te m el ji na pe ts to pe nj sk i L ik er to vi le st vi ci . Te m el ji na p re gl ed u lit er at ur e in n a po dl ag i m od el a ku ltu rn ih k om pe te nc p o C am pi nh a- Ba co te te r m od el a ku ltu rn ih k om pe te nc in za up an ja p o Je ffr ey se je vi . Ku ltu rn o zn an je , že lja p o ku ltu rn i oz av eš če no st i i n ku ltu rn e ve šč in e. C ru z e t a l., 2 01 7 Č ile , I ra k, O m an , Fi lip in i, Sa vd sk a A ra bi ja , J už na A fr ik a, S ud an in Tu rč ija Cu ltu ra l C ap ac ity Sc al e ( C C S) /L es tv ic a ku ltu rn e zm og lji vo st i O ce ni ti ku ltu rn e ko m pe te nc e št ud en to v zd ra vs tv en e ne ge iz de ve tih d rž av . 2. 16 7 št ud en to v zd ra vs tv en e ne ge . 20 tr di te v: k ul tu rn o zn an je (6 ), ku ltu rn a ob ču tlj iv os t ( 2) , k ul tu rn e ve šč in e (1 2) . O ce nj ev an je te m el ji na p et st op en jsk i L ik er to vi le st vi ci . Vp ra ša ln ik je n as ta l n a po dl ag i p re gl ed a lit er at ur e. Ko nc ep tu al ni m od el k ul tu rn e ko m pe te nt no st i n i n av ed en . Ku ltu rn o zn an je , ob ču tlj iv os t i n ku ltu rn e ve šč in e. D el ga do e t a l., 2 01 3 Zd ru že ne d rž av e A m er ik e In ve nt or y fo r A ss es sin g t he Pr oc es s o f C ul tu ra l Co m pe te nc y (IA PC C an d IP A C C -R )/ Le st vi ca za oc en je va nj e pr oc es a ku ltu rn ih k om pe te nc m ed zd ra vs tv en im i de la vc i ( re vi di ra na ve rz ija ) Po ve ča ti in o ce ni ti ku ltu rn e ko m pe te nc e m ed ic in sk ih se st er . 98 m ed ic in sk ih se st er . Iz vi rn a le st vi ca z 20 tr di tv am i je b ila sp re m en je na n a le st vi co s 2 5 to čk am i, ki te m el ji na p et ih ko ns tr uk tih k ul tu rn ih k om pe te nc : že lji , z av ed an ju , z na nj u, sp re tn os ti in sr eč an ju s tu jo k ul tu ro . T em el ji na št iri st op en jsk i L ik er to vi le st vi ci . Te m el ji na m od el u ku ltu rn ih ko m pe te nc p o C am pi nh a- Ba co te . V se d im en zi je ku ltu rn ih k om pe te nc . H al te r e t a l., 2 01 5 Zd ru že ne d rž av e A m er ik e Tr an sc ul tu ra l S elf - Effi ca cy to ol (T SE T) / O ro dj e za m er je nj e tr an sk ul tu rn e sa m ou či nk ov ito st i O ce ni ti vp liv ra zl ič ni h ku ltu rn ih iz ob ra že va ln ih pr og ra m ov . 26 0 št ud en to v zd ra vs tv en e ne ge . 83 tr di te v s t re m i p od le st vi ca m i: ko gn iti vn e, pr ak tič ne in a fe kt iv ne . Za o ce nj ev al no m et od o up or ab lja de se ts to pe nj sk o Li ke rt ov o le st vi co . Sk la dn o z B an du rje vo te or ijo so ci al ne ga u če nj a in k on ce pt i tr an sk ul tu rn e zd ra vs tv en e ne ge . Ku ltu rn a sa m ou či nk ov ito st . Se n ad al ju je 62 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Av to r, le tn ic a, dr ža va In st ru m en t N am en V zo re c O pi s i ns tr um en ta K on ce pt ua ln i m od el D im en zi je k ul tu rn e ko m pe te nc e H er re ro -H ah n et al ., 20 19 Ko lu m bi ja Se lf- Effi ca cy Sc al e ( C SE S) / Le st vi ca k ul tu rn e sa m ou či nk ov ito st i O ce ni ti za up an je pa ci en to v do lo če ni h m an jši ns ki h sk up in v iz va ja lc e zd ra vs tv en e ne ge . 21 1 m ed ic in sk ih se st er 26 tr di te v, ra zv rš če ni h v 3 po dk at eg or ije : p oz na va nj e ku ltu rn ih k on ce pt ov , k ul tu rn e ve šč in e, po zn av an je k ul tu rn ih vz or ce v pr i d ol oč en ih e tič ni h sk up in ah . L es tv ic a te m el ji na pe ts to pe nj sk i L ik er to vi le st vi ci . Sk la dn o z B an du rje vo te or ijo so ci al ne ga u če nj a in L ei ni ng er je vo te or ijo tr an sk ul tu rn e zd ra vs tv en e ne ge . Ku ltu rn a sa m ou či nk ov ito st . Ko ut a et a l., 2 01 6 C ip er Cu ltu ra l c om pe te nc e A ss es sm en t T oo l (C C A T oo l)/ In st ru m en t z a oc en je va nj e ku ltu rn ih k om pe te nc Pr ed st av iti st op nj o ku ltu rn ih k om pe te nc m ed ic in sk ih se st er p re d de la vn ic o o ku ltu rn ih ko m pe te nc ah in p o nj ej . 17 0 pa tr on až ni h m ed ic in sk ih se st er . Le st vi ca s 25 tr di tv am i s po dl es tv ic am i: ku ltu rn a oz av eš če no st , z na nj e, ob ču tlj iv os t in k om pe te nt no st p ra ks e zd ra vs tv en e ne ge . Z a oc en je va ln o m et od o up or ab lja p et st op en jsk o Li ke rt ov o le st vi co . M od el ra zv oj a ku ltu rn e ko m pe te nt no st i p o Pa pa do po ul os ov i, Ti lk ije vi in Ta yl or je vi . Ku ltu rn a oz av eš če no st , zn an je in k ul tu rn a ob ču tlj iv os t. N oj i e t a l., 2 01 7 Ja po ns ka Ca ffr ey C ul tu ra l Co m pe te nc e H ea lth Se rv ice s ( J- C C C H S) / Le st vi ca k ul tu rn ih ko m pe te nc v zd ra vs tv en em va rs tv u O ce ni ti ku ltu rn e ko m pe te nc e m ed ic in sk ih se st er za iz bo ljš an je ce lo vi te zd ra vs tv en e ne ge . 7. 49 4 m ed ic in sk ih se st er iz 1 9 bo ln išn ic . 28 tr di te v za m er je nj e sa m oz az na va nj a, sa m oz av ed an ja in u do bj a s s pr et no st m i k ul tu rn e ko m pe te nt no st i. Za o ce nj ev al no m et od o up or ab lja p et st op en jsk o Li ke rt ov o le st vi co . Te m el ji na m od el u, k i pr ed la ga o ce nj ev an je ku ltu rn ih k om pe te nc k ot iz id a iz ob ra že va nj a na po dl ag i d ve h fa z u čn eg a pr oc es a: p rid ob iv an je zn an ja te r s pr em em be o dn os a in ve de nj a. Sa m oz az na no zn an je , sa m oz av ed an je in ud ob je s sp re tn os tm i ku ltu rn ih k om pe te nc Pa rk e t a l., 2 01 9 Ju žn a Ko re ja Cu ltu ra l C om pe te nc e Sc al e f or N ur se (K -C C SN )/ Le st vi ca za m er je nj e ku ltu rn ih k om pe te nc za m ed ic in sk e se st re Pr ev er iti u či ne k te ča ja ku ltu rn e zd ra vs tv en e ne ge . 69 št ud en to v zd ra vs tv en e ne ge . Se st av lje n iz 3 3 tr di te v, ki za je m aj o 4 ka te go rij e: k ul tu rn o oz av eš ča nj e (6 ), ku ltu rn e ve šč in e (7 ), ku ltu rn a ob ču tlj iv os t ( 12 ), ku ltu rn o zn an je (8 ). Te m el ji na G ig er - D av id hi za rje ve m m od el u ku ltu rn e ko m pe te nt no st i. Ku ltu rn a oz av eš če no st , z na nj e, ob ču tlj iv os t i n ve šč in e ku ltu rn ih ko m pe te nc . Sa fip ou r e t a l., 2 01 7 Šv ed sk a Cu ltu ra l A w ar en es s Sc al e ( C A S) / Le st vi ca k ul tu rn e oz av eš če no st i Pr ou či ti ku ltu rn o oz av eš če no st št ud en to v v po ve za vi z i zo br až ev an je m o b up oš te va nj u nj ih ov eg a so ci al no -d em og ra fs ke ga oz ad ja . 21 5 št ud en to v zd ra vs tv en e ne ge . Le st vi ca s 36 tr di tv am i in p et im i p od le st vi ca m i: sp lo šn oi zo br až ev al ne iz ku šn je (1 4) , k og ni tiv na o za ve šč en os t (7 ), vp ra ša nj a ra zi sk ov an ja (4 ), ve de nj e/ ud ob je p ri in te ra kc iji (6 ), os kr ba p ac ie nt ov /k lin ič na pr ak sa (5 ). O ce nj ev an je te m el ji na se de m st op en jsk i L ik er to vi le st vi ci . Te m el ji na a na liz i m od el a »P at hw ay s« in je p ov ez an s P ur ne llo vi m m od el om ku ltu rn ih k om pe te nc . Ku ltu rn a oz av eš če no st . 63Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Lestvico kulturnih kompetenc v zdravstvenem varstvu (ang. The Caffrey Cultural Competence Healthcare Scale − CCCHS) so razvili Caffrey, Neander, Markle & Stewart (2005). Ta vprašalnik je zasnovan za merjenje samozaznanega znanja, samozavedanja in spretnosti rabe kulturnih kompetenc (Caffrey et al., 2005; Loftin et al., 2013). Lestvica je sestavljena iz 28 trditev, ki temeljijo na samooceni na podlagi lestvice tipa Likert (Caffrey et al., 2005; Transcultural C.A.R.E. Associates, 2020). Predvidena uporaba CCCHS je pred kliničnim usposabljanjem in po njem. Močna stran lestvice CCCHS je njena zmožnost ocenjevanja izboljšav študentov skozi čas; njena šibka lastnost pa je pomanjkljiva sposobnost prikaza odnosa med dejanskimi in simuliranimi izkušnjami (Loftin et al., 2013). Lestvica kulturne ozaveščenosti (ang. The Cultural Awareness Scale − CAS), ki so jo razvili Rew, Becker, Cookkston, Khospropour, & Martinez (2003), je bila zasnovana za merjenje kulturne ozaveščenosti študentov zdravstvene nege. Avtorji so menili, da je kulturna zavest minimalna raven kulturne kompetentnosti. Lestvica, ki temelji na modelu »poti« (ang. Pathways model) in je skladna s Purnellovim modelom kulturnih kompetenc, je sestavljena iz 36 trditev (Rew et al., 2003; Loftin et al., 2013). Trditve študenti ocenjujejo na podlagi sedemstopenjske Likertove lestvice. Lestvica CAS je bila prevedena tudi v slovenski jezik (Ličen, Karnjuš, & Prosen, 2020). Instrument za ocenjevanje kulturnih kompetenc (ang. The Cultural Competence Assessment − CCA) je bil zasnovan za oceno kulturne kompetentnosti izvajalcev zdravstvenih storitev, vključno z medicinskimi sestrami (Schim, Doorenbos, Miller, & Benkert, 2003). CCA je vprašalnik s 26 trditvami, ki jih anketiranci ocenjujejo glede na petstopenjsko lestvico tipa Likert (Doorenbos, Schim, Miller, & Benkert, 2005). Tabela 2: Prikaz kakovosti merilnih lastnosti vprašalnikov, vključenih v sistematični pregled literature Instrumenti Zanesljivost Veljavnost Notranja skladnost Ponovno testiranje Število trditev Vzorčenje Vsebine Konstruktna veljavnost CSES Cronbach alfa = 0,978 (0,85−0,98) ND 26 (30) DMS/DZ Strokovni svet 33−90 % variance TSET Cronbach alfa = 0,92−0,98 r = 0,64−0,75 v dveh tednih (test-retest) 83 Študenti ZN Strokovni svet 62 % variance IAPCC-R Cronbach alfa = 0,75−0,93 Izvirna različica vprašalnika je navedena z omejitvami 25 DMS/DZ Strokovni svet Ni podatka CAS Cronbach alfa = 0,869 ND 36 Študenti ZN Strokovni svet 51 % variance CCCATool Cronbach alfa = 0,82−0,91 ND 25 DMS/DZ Strokovni svet 56 % variance CDQNE Cronbach alfa = 0,94 ND 72 Učitelji ZN Strokovni svet ND J-CCCHS Cronbach alfa = 0,756−0,892 ND 28 DMS/DZ Strokovni svet 61 % variance K-CCSN Cronbach alfa = 0,900 (0,879− 0,921) r = 0,61−0,75 v trinajstih tednih (test-retest) 33 Študenti ZN Strokovni svet ND NCCS Cronbach alfa = 0,95 ND 20 Študenti ZN Strokovni svet 66 % variance CCIN Cronbach alfa = 0,94 r =0,86 v dveh tednih (0,75−0,85) 29 DMS/DZ Strokovni svet 63,46 % variance CCS Cronbach alfa = 0,96 IC = 0,88 v dveh tednih 20 Študenti ZN Strokovni svet 20,4 % variance Legenda: CSES − Cultural Self-Efficacy Scale/Lestvica kulturne samoučinkovitosti; TSET − Transcultural self-efficacy tool; IAPCC and IPACC-R − Inventory for Assessing the Process of Cultural Competency/Lestvica za ocenjevanje procesa kulturnih kompetenc med zdravstvenimi delavci; CAS − Cultural Awareness Scale/Lestvica kulturne ozaveščenosti; CCA Tool − Cultural competence Assessment Tool/Instrument za ocenjevanje kulturnih kompetenc; CDQNE − Cultural Diversity Questionnaire for Nurse Educators/Vprašalnik kulturne raznolikosti za medicinske sestre v izobraževanju; J-CCCHS − Caffrey Cultural Competence Health Services/Lestvica kulturnih kompetenc v zdravstvenem varstvu; K-CCSN − Cultural Competence Scale for Nurse/Lestvice za merjenje kulturnih kompetenc za medicinske sestre; NCCS − Nurse Cultural Competence Scale/Lestvica kulturnih kompetenc za medicinske sestre; CCIN − Cultural Competence Inventory for Nurses/Lestvica kulturnih kompetenc medicinskih sester (prilagojena za zaposlene v zdravstveni negi na Kitajskem); CCS − Cultural Capacity Scale/Lestvica kulturne zmogljivosti; ND − ni ocenjeno; DMS/ DZT − diplomirana medicinska sestra/diplomirani zdravstvenik; ZN − zdravstvena nega 64 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Vprašalnik kulturne raznolikosti za medicinske sestre v izobraževanju (ang. The Cultural Diversity Questionnaire for Nurse Educators − CDQNE) je bil razvit za merjenje kulturnih kompetenc medicinskih sester v izobraževanju (Sealey, Burnett, & Johenson, 2006). CDQNE je sestavljen iz 72 trditev, ki jih anketiranci ocenjujejo na podlagi petstopenjske Likertove lestvice (Transcultural C.A.R.E. Associates, 2020). Lestvico kulturnih kompetenc medicinskih sester (prilagojena za zaposlene v zdravstveni negi na Kitajskem) (ang. The Chinese version of Cultural Competence Inventory for Nurses – CCIN) je razvil dr. Duanying Cai z univerze Chiang Mai (Transcultural C.A.R.E. Associates, 2020). Orodje je sestavljeno iz 29 trditev, ki vključujejo pet dimenzij: kulturno zavest, kulturno spoštovanje, kulturno znanje, kulturno razumevanje in kulturne veščine. Ocenjevanje trditev temelji na petstopenjski Likertovi lestvici (Cai et al., 2017). Lestvico kulturnih kompetenc za medicinske sestre (ang. The Nurse Cultural Competence Scale − v nadaljevanju NCCS) sta razvila Perng & Watson (2012) in temelji na modelu Campinha-Bacote, Jeffreysove in drugih. Lestvica vključuje štiri področja kulturne zavesti, kulturnega znanja, kulturne občutljivosti in kulturne spretnosti. NCCS vsebuje 41 trditev in temelji na ocenjevanju po petstopenjski lestvici tipa Likert (Transcultural C.A.R.E. Associates, 2020). Orodje za samoocenjevanje z naslovom »Lestvica kulturne zmogljivosti« (ang. Cultural Capacity Scale − CCS) je sestavljeno iz 20 vprašanj, ki se nanašajo na kulturno znanje in na kulturno občutljivost (Perng & Waston, 2012). Med vprašalniki, vključenimi v našo raziskavo, je vprašalnik CCS edini, ki je nastal z namenom oceniti potrebo po izobraževalnih programih usposabljana za medicinske sestre (Transcultural C.A.R.E. Associates, 2020). Lestvica za merjenje kulturnih kompetenc za medicinske sestre (prilagojena za zaposlene v zdravstveni negi v Južni Koreji) (ang. The Korean version of Cultural Competence Scale for Nurses − CCSN) (Chae & Lee, 2014) temelji na teoretičnem modelu kulturnih kompetenc avtorice Rene Papadopoulos (2006) in intervjujih z medicinskimi sestrami. CCSN je sestavljen iz štirih podlestvic, ki merijo kulturno zavedanje, znanje, občutljivost in kulturno spretnost. Lestvico sestavlja 33 trditev, ki jih anketiranci ocenjujejo na podlagi sedemstopenjske Likertove lestvice (Oh, Lee, & Scheep, 2015; Ahn, 2017). Diskusija Sistematični pregled literature je bil opravljen z namenom poiskati in raziskati merske vprašalnike, ki merijo ali ocenjujejo kulturne kompetence v zdravstveni negi, ter proučiti njihovo vsebino, lastnosti in ostale komponente, ki sestavljajo vprašalnike. Na podlagi analizirane literature smo na koncu izbrali enajst vprašalnikov, ki so najbolj primerni za merjenje kulturnih kompetenc pri medicinskih sestrah in študentih zdravstvene nege. Tabela 3: Prikaz veljavnosti in zanesljivosti vprašalnikov po bonitetnem sistemu ocenjevanja po Terweeju et al. (2007) Instrumenti Zanesljivost Veljavnost Notranja skladnost Ponovno testiranje Število trditev Vzorčenje Vsebine Konstruktna veljavnost CSES + ? + + + − TSET + − − + + − IAPCC-R + − + + + − CAS + ? − + + − CCCATool + ? + + + − CDQNE + ? − + + − J-CCCHS + ? + + + − K-CCSN + − − + + ? NCCS + ? + + + − CCIN + + − + + − CCS − + + + + − Legenda: CSES − Cultural Self-Efficacy Scale/Lestvica kulturne samoučinkovitosti; TSET − Transcultural self-efficacy tool; IAPCC and IPACC-R − Inventory for Assessing the Process of Cultural Competency/Lestvica za ocenjevanje procesa kulturnih kompetenc med zdravstvenimi delavci; CAS − Cultural Awareness Scale/Lestvica kulturne ozaveščenosti; CCA Tool − Cultural competence Assessment Tool/Instrument za ocenjevanje kulturnih kompetence; CDQNE − Cultural Diversity Questionnaire for Nurse Educators/ Vprašalnik kulturne raznolikosti za medicinske sestre v izobraževanju; J-CCCHS − Caffrey Cultural Competence Health Services/ Lestvica kulturnih kompetenc v zdravstvenem varstvu; K-CCSN − Cultural Competence Scale for Nurse/Lestvice za merjenje kulturnih kompetenc za medicinske sestre; NCCS − Nurse Cultural Competence Scale/Lestvica kulturnih kompetenc za medicinske sestre; CCIN − Cultural Competence Inventory for Nurses /Lestvica kulturnih kompetenc medicinskih sester (prilagojena za zaposlene v zdravstveni negi na Kitajskem); CCS − Cultural Capacity Scale/Lestvica kulturne zmogljivosti. (+) pozitivna ocena; (−) negativna ocena; (?) podatki niso dostopni 65Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Pri prvem raziskovalnem vprašanju nas je zanimalo, kateri vprašalnik, ki bi ga lahko uporabili na področju klinične prakse in izobraževanja za zdravstveno nego v Sloveniji, je najprimernejši za merjenje kulturnih kompetenc. Na podlagi analizirane literature v naši raziskavi lahko trdimo, da zaradi različnih vzrokov nekateri vprašalniki niso primerni za merjenje kulturnih kompetenc in kompetentnosti medicinskih sester in študentov zdravstvene nege pri nas: na primer vprašalnik CSES (slov. lestvica kulturne samoučinkovitosti) (Herrero-Hahn et al., 2019) (Capell et al., 2007), vprašalnik K-CCSN (slov. lestvica za merjenje kulturnih kompetenc za medicinske sestre (Chae & Lee, 2014) in vprašalnik CCIN (slov. lestvica kulturnih kompetenc medicinskih sester (Cai et al., 2017). Navedeni vprašalniki so prilagojeni za merjenje kulturnih kompetenc pri zaposlenih iz določenih kultur in niso primerni za merjenje kulturnih kompetenc v našem okolju. S pomočjo izčrpne analize o psihometričnih lastnostih vprašalnikov, kot sta veljavnost in zanesljivost, smo ugotovili, da med najprimernejše vprašalnike za merjenje kulturnih kompetenc med zaposlenimi v zdravstveni negi sodijo: IPACC-R (slov. lestvica za ocenjevanje procesa kulturnih kompetenc med zdravstvenimi delavci – revidirana verzija) (Delgado et al., 2013), CCATool (slov. instrument za ocenjevanje kulturnih kompetenc) (Kouta et al., 2016), NCCS (slov. lestvica kulturnih kompetenc za medicinske sestre) (Cruz et al., 2017), CCS (slov. lestvica kulturne zmogljivosti) (Cruz, Aguinaldo et al., 2017). Med vprašalnike, ki so primerni za merjenje kulturnih kompetenc pri študentih zdravstvene nege, spadajo: TSET (slov. orodje za merjenje transkulturne samoučinkovitosti) (Halter et al., 2015), CCCHS (slov. lestvica kulturnih kompetenc v zdravstvenem varstvu) (Noj et al., 2017), CAS (slov. lestvica kulturne ozaveščenosti) (Safipour et al., 2017); za merjenje kulturnih kompetenc pri medicinskih sestrah v izobraževanju pa CDQNE (slov. vprašalnik kulturne raznolikosti za medicinske sestre v izobraževanju) (Baghadi & Ismaile, 2018). Pri drugem raziskovalnem vprašanju smo raziskovali skupne značilnosti/lastnosti/komponente vprašalnikov za merjenje kulturnih kompetenc med medicinskimi sestrami in študenti zdravstvene nege. Pri tem smo si pomagali s tako imenovanim bonitetnim sistemom ocenjevanja (Terwee, 2007). Med analiziranimi vprašalniki je bilo ugotovljenih več skupnih podobnosti. Večina vprašalnikov je bila tako imenovanih splošnih vprašalnikov, kar pomeni, da so merili kulturne kompetence medicinskih sester ne glede na razlike med kulturnimi skupinami, iz katerih prihajajo pacienti (Delgado et al., 2013; Kouta et al., 2016; Cai et al., 2017; Cruz et al., 2017; Noj et al., 2017; Herrero-Hahn, 2019). Vprašalnik CSES (slov. lestvica kulturne samoučinkovitosti) (Herrero-Hahn, 2019) spada v skupino specifičnih vprašalnikov. Vključeni analizirani vprašalniki so notranjo skladnost izrazili s pomočjo Cronbachovega alfa koeficienta. Pri sedmih vprašalnikih je Cronbach alfa dosegel vrednost, ki nakazuje odlično zanesljivost – 0,90 ali višje: CSES (slov. lestvica kulturne samoučinkovitosti) (Herreo-Hahn et al., 2019), TSET (slov. orodje za merjenje transkulturne samoučinkovitosti) (Halter et al., 2015), CDQNE (slov. vprašalnik kulturne raznolikosti za medicinske sestre v izobraževanju (Baghadi & Ismaile, 2018), K-CCSN (slov. lestvica za merjenje kulturnih kompetenc za medicinske sestre (Chae & Lee, 2014), NCCS (slov. lestvica kulturnih kompetenc za medicinske sestre) (Cruz et al., 2017), CCIN (slov. lestvica kulturnih kompetenc medicinskih sester, prilagojena za zaposlene v zdravstveni negi na Kitajskem) (Transcultural C.A.R.E. Associates, 2020), CCS (slov. lestvica kulturne zmogljivosti) (Cruz, Aguinaldo et al., 2017), IPACC-R R (slov. lestvica za ocenjevanje procesa kulturnih kompetenc med zdravstvenimi delavci – revidirana verzija) (Delgado et al., 2013) in J-CCCHS (slov. lestvica kulturnih kompetenc v zdravstvenem varstvu) (Noj et al., 2017). Zanesljivost z vidika konstrukcijske veljavnosti je bila ocenjena s pomočjo faktorske analize. Ta je bila opravljena pri osmih vprašalnikih: CSES (slov. lestvica kulturne samoučinkovitosti) (Herreo-Hahn et al., 2019), TSET (slov. orodje za merjenje transkulturne samoučinkovitosti) (Halter et al., 2015), CAS (slov. lestvica kulturne ozaveščenosti) (Safipour et al. 2017), CCCATool (slov. instrument za ocenjevanje kulturnih kompetenc) (Kouta et al., 2016), J-CCCHS (slov. lestvica kulturnih kompetenc v zdravstvenem varstvu) (Noj et al., 2017), NCCS (slov. lestvica kulturnih kompetenc za medicinske sestre) (Cruz et al., 2017), CCIN (slov. lestvica kulturnih kompetenc medicinskih sester, prilagojena za zaposlene v zdravstveni negi na Kitajskem) (Cai et al., 2017), CCS (slov. lestvica kulturne zmogljivosti) (Cruz et al., 2020). Variabilnost faktorske analize pri CSES (slov. lestvica kulturne samoučinkovitosti) (Herreo-Hahn et al., 2019) pa se je močno razlikovala: od 33 % pri medicinskih sestrah v izobraževanju (Kardong-Edgren & Campinha-Bacote, 2008) do 90 % pri patronažnih medicinskih sestrah (Bernal & Forman, 1993). Le pri vprašalniku CCS (slov. lestvica kulturne zmogljivosti) (Cruz, Aguinaldo et al., 2017) je bila variabilnost modela pojasnjena z 20 %, pri šestih vprašalnikih – TSET (slov. orodje za merjenje transkulturne samoučinkovitosti) (Halter et al., 2015), CAS (slov. lestvica kulturne ozaveščenosti) (Safipour et al., 2017), CCATool (slov. instrument za ocenjevanje kulturnih kompetenc) (Kouta et al., 2016), J-CCSN (slov. lestvica kulturnih kompetenc v zdravstvenem varstvu) (Noj et al., 2017), NCCS (slov. lestvica kulturnih kompetenc za medicinske sestre) (Cruz et al., 2017), CCIN (slov. lestvica kulturnih kompetenc medicinskih sester, prilagojena za zaposlene v zdravstveni negi na 66 Avdylaj, L., & Ličen, S. (2022)/Obzornik zdravstvene nege, 56(1), pp. 49–69. Kitajskem) (Cai et al., 2017) – pa je bila variabilnost modela pojasnjena z več kot 50 %. Prav tako so bili podatki o verifikaciji za zanesljivost ponovnega testiranja na voljo za TSET (slov. orodje za merjenje transkulturne samoučinkovitosti) (Halter et al., 2015), K-CCSN (slov. lestvica za merjenje kulturnih kompetenc za medicinske sestre, prilagojena za zaposlene v zdravstveni negi v Južni Koreji) (Chae & Lee, 2014), CCIN (slov. lestvica kulturnih kompetenc medicinskih sester, prilagojena za zaposlene v zdravstveni negi na Kitajskem) (Cai et al., 2017) in CCS (slov. lestvica kulturne zmogljivosti) (Cruz, Aguinaldo et al., 2017). V primeru CCIN (Park et al., 2019) in CCS (Transcultural C.A.R.E. Associates, 2020) je bil koeficient intraklasne korelacije > 0,70, kar kaže na visoko stabilnost. Analizirani vprašalniki so bili razviti in temeljijo na pregledu literature (Halter et al., 2015; Cruz et al., 2017; Noji et al., 2017) ter na podlagi modelov in teorij o kulturnih kompetencah številnih avtorjev, kot so: Campinha-Bacote (Delgado et al., 2013; Cai et al., 2017; Cruz, Aguinaldo et al., 2017; Baghadi & Ismaile., 2018), Madeleine Leininger (Herrero-Hahn., et al., 2019), Larry D. Purnell (Safipour et al., 2017), Marianne Jeffreys (Cai et al., 2017; Cruz, Aguinaldo et al., 2017), Rena Papadopoulos (Kouta et al., 2016) in drugi. Med omejitve v naši raziskavi spada omejeno število baz podatkov, kar pomeni, da smo določene kakovostne raziskave spregledali. Dodatno omejitev predstavlja pomanjkanje slovenske literature s področja merjenja kulturnih kompetenc. Kljub temu da za oceno kakovosti raziskav na podlagi sistematičnega pregleda literature obstaja več orodij, smo v naši raziskavi uporabili orodje CASP brez predhodne analize in primerjave z ostalimi tovrstnimi orodji. Zaključek Sistematični pregled literature je pokazal, da so med najbolj primernimi vprašalniki za merjenje kulturnih kompetenc pri medicinskih sestrah v Sloveniji vprašalniki IPACC-R, CCATool, NCCS in CCS. Za merjenje kulturnih kompetenc pri študentih zdravstvene nege so primerni vprašalniki TSET, CCCHS in CAS. Ta sistematični pregled literature predstavlja le eno izmed oblik merjenja kulturnih kompetenc v zdravstveni negi, saj gre za metodo kvantitativnega merjenja kulturnih kompetenc, ki je sicer zelo praktična, a ne vedno najbolj primerna. Predlagam, da raziskovalci s tega področja uporabijo tudi kvalitativne metode za merjenje kulturnih kompetenc, ki so sicer bolj kompleksne za izvedbo, vendar določen problem obravnavajo natančneje. Kljub temu ta sistematični pregled literature predstavlja prvo tovrstno raziskavo na tem področju v Sloveniji, kar je dobro izhodišče za druge raziskovalce pri izboru analiziranih vprašalnikov za nadaljnje raziskave. Conflict of interest/Nasprotje interesov The authors declare that no conflict of interest exists./Avtorja izjavljata, da ni nasprotja interesov. Funding/Financiranje The study received no funding./Raziskava ni bila finančno podprta. Ethical approval/Etika raziskovanja The study was conducted in accordance with the Helsinki-Tokyo Declaration (World Medical Association, 2013) and the Code of Ethics for Nurses and Nurse Assistants of Slovenia (2014)./Raziskava je pripravljena v skladu z načeli Helsinško-tokijske deklaracije (World Medical Association, 2013) in v skladu s Kodeksom etike v zdravstveni negi in oskrbi Slovenije (2014). Author contributions/Prispevek avtorjev The first author conducted the research and prepared the first draft of the article. The co-author contributed in drafting the methodological concept of the research, prepared a critical review of the article and completed the final version of the article./Prvi avtor je opravil raziskavo in pripravil prvi osnutek članka. 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