Objectives: Patients from different social environments and cultural backgrounds have different nursing needs. If nurses ignore the cultural differences of patients, it is easy to lead to the strained nurse-patient relationship, affect the nursing effect and cause harm to patients. Critical cultural competence (CCC) can help nurses to meet the nursing needs of patients from different cultural backgrounds, which is beneficial to building a harmonious nurse-patient relationship and improving the quality of nursing. Almutairi, et al designed the Critical Cultural Competence Scale (CCCS) which can be used to evaluate accurately nurses' CCC. No studies have reported the development of a critical cultural competence measurement tool for nurses or the introduction of foreign scales in China. This study aims to conduct Chinese and cross-cultural debugging and test the reliability of the English version of the CCCS in order to form CCCS suitable for Chinese cultural background and provide an effective evaluation tool for investigating the current situation of clinical nurses' CCC.
Methods: This study used Brislin's back-translation model to translate and back-translation the English version of CCCS. The Chinese version of CCCS was then created through cross-cultural debugging by expert consultation and a pre-survey with a sample size of 30 clinical nurses. From August to October 2019, 580 clinical nurses were surveyed using a whole group sampling method. The participants were randomly divided into 2 groups with a 7꞉3 ratio. One group (n=406) was used for exploratory factor analysis and reliability analysis, while the other group (n=174) was used for confirmatory factor analysis. Six experts used the scale-level content validity index (S-CVI) and the item-level content validity index (I-CVI) to assess content validity. In the exploratory factor analysis, items were screened using the critical ratio method, and were tested using the KMO (Kalser-Meyer-Olkin) index, Bartlett's sphericity test, and principal component analysis. In the confirmatory factor analysis, average variance extracted (AVE), goodness of fit index (GFI), adjusted goodness of fit index (AGFI), and root mean square error of approximation (RMSEA) were used to assess the degree of fit of the constructed model. For the total scale and the 4 subscales, the Cronbach's α coefficient, split-half reliability, and retest reliability were used to assess the scale's reliability.
Results: The S-CVI was 0.930, while the I-CVI ranged from 0.833 to 0.944. For all items, the critical ratio exceeded 3, and the difference between the high and low subgroups was statistically significant (P<0.05). Exploratory factor analysis revealed critical knowledge subscale had a KMO value of 0.676, with the total scale and other 3 subscales all having a KMO value >0.8 and a chi-square value of 814.32 to 12 442.45 for the Bartlett's spherical test, with degree of freedom ranging from 21 to 136 (P<0.001), indicating that all items were suitable for factor analysis. The principal component analysis showed that 17, 12, 7, and 7 items were extracted from the 4 subscales, with 4, 3, 2, and 2 components whose eigenvalues were more than 1, and the cumulative variance contribution was 66.0%, 54.3%, 56.6%, and 70.2%, respectively. The confirmatory factor analysis showed that the AVE of the 4 subscales were 0.637, 0.499, 0.560, and 0.565, GFI was 0.904, AGFI was 0.863, and RMSEA was 0.076. The Cronbach's α coefficient for the total scale and subscales ranged from 0.811 to 0.878, the split-half reliability ranged from 0.707 to 0.842, and the retest reliability was 0.827.
Conclusions: The Chinese version of the CCCS has good reliability and validity, and it can be used as a valid assessment tool for clinical nurses' critical cultural competence in China.
目的: 不同社会环境和文化背景的患者具有不同的护理需求。如果护士忽视患者的文化差异，就容易导致护患关系紧张，影响护理效果，甚至对患者造成伤害。评判性文化能力可以帮助护士满足不同文化背景下患者的护理需求，有利于构建和谐的护患关系，提高护理质量。Almutairi等编制的评判性文化能力量表(Critical Cultural Competence Scale，CCCS)可用于评估护士的评判性文化能力。国内尚未有研究报道护士评判性文化能力测量工具的开发或国外量表的引进。本研究旨在对英文版CCCS进行汉化、跨文化调适并检测其信效度，以期形成适合我国文化背景的CCCS，为临床护士评判性文化能力的现状调查提供有效的评估工具。方法: 根据Brislin经典回译模型对英文版CCCS进行翻译和回译，通过专家咨询法和对30名临床护士的预调查进行跨文化调适，形成中文版CCCS。采用整群抽样法于2019年8至10月对580名临床护士进行调查。按照7꞉3的比例随机分为两组，一组(n=406)用于探索性因子分析和信度分析，另一组(n=174)用于验证性因子分析。6名专家采用量表水平内容效度指数(scale-level content validity index，S-CVI)和条目水平内容效度指数(item-level content validity index，I-CVI)评定量表的内容效度。在探索性因子分析中，采用临界比值法对量表条目进行筛选，KMO(Kalser-Meyer-Olkin)值、Bartlett球形度检验、主成分分析法测验条目。在验证性因子分析中，采用平均方差提取值(average variance extracted，AVE)、拟合优度指数(goodness-of-fit index，GFI)、修正的拟合优度指数(adjusted goodness-of-fit index，AGFI)、近似误差平方根(root mean square error of approximation，RMSEA)评价所构建模型的拟合程度。采用总量表和4个分量表的Cronbach’s α系数、分半信度和重测信度评定量表的信度。结果: 总量表的S-CVI为0.930；I-CVI为0.833~0.944。所有条目的临界比值>3，高分组与低分组之间的差异具有统计学意义(P<0.05)。探索性因子分析显示：评判性知识分量表的KMO值为0.676，总量表和其他3个分量表的KMO值均>0.8，Bartlett球形检验的近似χ2值为814.32~12 442.45，自由度为21~136，P<0.001。这提示所有条目适合做因子分析。主成分分析显示：4个分量表分别抽取了17、12、7、7个成分，特征值>1的分别为4、3、2、2个，累计方差贡献率分别为66.0%、54.3%、56.6%、70.2%。验证性因子分析显示4个分量表的AVE为0.637、0.499、0.560、0.565；GFI为0.904，AGFI为0.863，RMSEA为0.076。总量表和分量表的Cronbach’s α系数为0.811~0.878，分半信度为0.707~0.842，重测信度为0.827。结论: 中文版CCCS的信度和效度良好，可作为我国临床护士评判性文化能力的有效测评工具。.
Keywords: Critical Cultural Competence Scale; clinical nurses; reliability; sinicization; validity.