FIVE A Guide for Interpreting Learners’ Transcultural Self-Efficacy (TSE) Perceptions, Identifying At-Risk Individuals, and Avoiding Pitfalls Making sense of transcultural self-efficacy (TSE) perceptions must be grounded in self-efficacy theory, follow statistical principles and techniques, and be considered in relation to the Cultural Competence and Confidence (CCC) model. Interpretation must be realistic. An overconfident or inefficacious approach in data interpretation should be avoided, because both approaches can interfere with the best interpretation that will have the most practical significance and usability. SNAPSHOT SCENARIO During a conference presentation, two researchers share their study results involving the Transcultural Self-Efficacy Tool (TSET) administered before and after a cultural competence teaching–learning strategy implemented with: (a) undergraduate and graduate nursing students and (b) staff education at several health care institutions. Later that day, several novice and experienced researchers reflect and dialogue about the conference. Excerpts are listed here: Norella: It seems as though the TSET may be the right questionnaire for me to administer in my doctoral dissertation study. I’m not clear about how to best interpret the TSET data published in dissertations, master’s theses, and journal articles. Fabiola: What’s clear to me is that the TSET has consistently demonstrated high validity and reliability among various populations and settings, both academic and health care institutions. In addition, it was developed and evaluated based upon recommendations and rationale in the self-efficacy, educational, psychology, and transcultural nursing literature. The TSET design was detailed and I want my future study to be detailed and well-designed. Libby: For the last few months, I’ve been reviewing the cultural competence and transcultural self-efficacy literature and want to design a perfect study but I still don’t know where to start. Maurice: There is no perfect research study; however, a researcher should take the time to critically appraise all aspects (strengths and weaknesses) of various designs, sample size, and other components. Generally, I know it’s important to review the detailed recommendations from the author of a questionnaire and relate it to the underpinnings of the conceptual framework to see if it substantiates the model’s propositions. The conference presenters demonstrated empirical support related to the CCC model. Wanda: I haven’t read much about the TSET, but I’m wondering whether I need to administer the entire TSET. I wonder if I could save time and administer only a part or parts of it. Fabiola: Based on the initial TSET design and CCC model, I realize it’s important to administer the entire TSET. Each of the three subscales, Cognitive, Practical, and Affective, tap each of the learning domains necessary for optimal cultural competence. All the items were reviewed and validated by the content validity experts. The comprehensiveness of the questionnaire and the rationale for the subscales and 10-point scaling and other design details add to the TSET’s strengths. I’m currently conducting a postdoctoral study that measures transcultural self-efficacy (TSE) outcomes with the TSET. Norella: It sounds like knowing general concerns about any research study is an important beginning step. Then, I should go into more specifics about self-efficacy and transcultural self-efficacy as well as review the details about the questionnaire. Wanda: Yes, and I’m also wondering how I can avoid pitfalls in TSE research appraisal, design, implementation, interpretation, and application. Empirical support for self-efficacy as a predictor of cultural competence is more difficult to establish than conceptually acknowledging that self-efficacy plays a vital role in cultural competence development and culturally congruent care actions. Theoretical background information must be carefully considered when interpreting findings and demonstrating empirical support. For example, the CCC model (see Figure 3.1) illustrates the proposed connections between the foundational concepts. Chapter 3 details major components underlying the conceptual model, incorporating the main theoretical tenets of Bandura’s self-efficacy theory (1–4). Finally, Figure 3.2 depicts the directional pathways involved in TSE, cultural competence development, and culturally congruent care actions, further expanding upon theoretical background information. Because the evaluation of self-efficacy relies on respondents’ self-perceptions, there will always be some error associated with self-report measures; however, the only way that self-efficacy can be measured is with a self-report measurement tool. Despite the limitations that self-report measurement tools present, efforts can be made to increase the usability and interpretation of results by using a valid measurement tool and by customizing various steps and components of the research process to appropriately complement each other. Avoiding pitfalls in the initial research design will improve the interpretation of findings. Similarly, avoiding pitfalls in the interpretation of findings will enhance the study’s validity and future usability and generalizability. Making sense of TSE perceptions is a key component in this interpretive process. This chapter guides educators and researchers in the interpretation of TSE perceptions and in avoiding pitfalls in research design and interpretation. The identification of at-risk individuals through the interpretation of findings is highlighted. INTERPRETATION What do I need to look for when interpreting data so that I can make valid empirical conclusions? What are the main theoretical underpinnings I need to be aware of to connect data validly with the underlying conceptual framework? Making sense of TSE perceptions must be grounded in self-efficacy theory. A quick overview of essential theoretical elements will aid in interpretation. One must know what to look for, what data findings suggest, and how to subsequently formulate valid empirical conclusions. Several main theoretical features emphasizing connections to data interpretation are presented. A key concept in Bandura’s (2) social cognitive theory is that learning and motivation for learning is directly influenced by self-efficacy perceptions, which are domain- and task-specific. Individuals with strong self-efficacy perceptions in a specific domain think, feel, and act differently from those who are inefficacious or those who are overly confident. Therefore, when interpreting findings, one will look for ways to differentiate between individuals who demonstrate strong (resilient) self-efficacy, low self-efficacy (inefficacious), or supremely high self-efficacy (overconfidence). For example, TSE perceptions as measured by the TSET can be differentiated by self-efficacy strength (SEST) subscale scores, comparison of factor mean scores, and/or grouping into low, medium, and high groups based on the selected grouping methodology. (See Chapter 4 for details on the TSET and Items 1 and 2 in the Jeffreys 2016 Toolkit.) Strong (resilient) self-efficacy enhances sociocognitive functioning in several ways: (a) new or difficult tasks are viewed as challenges that are accepted willingly; (b) great preparatory efforts are exhibited; (c) strong goal commitment and persistence behaviors are enhanced; (d) failures and setbacks are attributed to insufficient effort; and (e) more energy is expended to overcome failures, hardships, setbacks, and potential stressors in an effort to achieve goals (4). A strong (resilient) self-efficacy to withstand failures combined with some uncertainty (task perceived as a challenge rather than self-doubts about capability) will encourage preparatory efforts and thus enhance performance outcomes (1, 3). It is presumed that such individuals are highly motivated and actively seek help to maximize their transcultural nursing skills and cultural competence development. Based on the proposed pathways (see Figure 3.2), resilient individuals would be the most likely to persist in cultural competence development and the most likely to achieve culturally congruent care actions. At-Risk Individuals Who are at-risk individuals? In contrast, the inefficacious individual (one with low confidence levels) is at risk for lowered persistence, motivation, and goal commitment. He or she may give up when obstacles or hardships are encountered. Such individuals may easily become discouraged if they do not quickly grasp new concepts, skills, or knowledge. That is, they may view transcultural learning tasks as overwhelming and as insurmountable obstacles, threats, and hardships to be avoided. Consequently, decreased effort may be engaged, and lowered persistence with transcultural nursing skills may ensue. Low self-efficacy can affect cultural competence development directly, if individuals give up without even trying and then avoid cultural assessments, or indirectly, through poor nursing outcomes and/or through negative psychological outcomes. Poor nursing outcomes (achievement of negative client health outcomes) may be caused by culturally incongruent care. Such individuals become increasingly overwhelmed, focused on failure, dissatisfied, and stressed (see Figure 3.2). Interpretation of data to identify inefficacious individuals is therefore crucial. In addition, individuals with low self-efficacy benefit the most with diagnostic-specific interventions designed to enhance self-efficacy and other academic and psychological outcomes (5–8). Early identification of inefficacious students followed by diagnostic-prescriptive interventions can help students maximize strengths, minimize weakness, and facilitate success (6, 9–17). Because inefficacious individuals often lose motivation and are reluctant to actively seek assistance, the educator plays a key role in initiating actions with inefficacious individuals. (The broad term educator is used to describe any qualified individual in a position to provide transcultural educational interventions. Examples include qualified health professions faculty, clinical educators, preceptors, nurse managers, mentors, certified transcultural nurses, nurses with advanced certificates in cultural competence, and nursing organizational leaders.) Although self-efficacy appraisal is task-specific, repeated failures and negative psychological outcomes decrease self-efficacy for learning and performing the necessary tasks for becoming a culturally competent registered nurse, thereby lowering persistence and commitment behaviors overall. Other at-risk individuals are those who are supremely efficacious (overly confident). Supremely efficacious individuals may be totally unaware of their weaknesses, underestimate the task or its importance, overlook the task, overestimate their abilities, and overrate their strengths (1). Consequently, overly confident individuals may not see the need for adequate preparation, restructuring of priorities, or time management to accommodate transcultural tasks. Therefore, such individuals may not be adequately prepared. Cultural competency development is affected indirectly through poor skill outcomes and negative psychological outcomes. Poor, weak, or unsuccessful performances can lead to feeling overwhelmed, surprised or shocked, dissatisfied, and stressed. Unfortunately, some supremely efficacious individuals may not even be aware that culturally incongruent care actions have impacted adversely on a client’s emotional and physical health outcomes. Because supremely efficacious individuals often lack motivation for the task and see no need to seek assistance, the educator plays a key role in initiating actions with overly confident individuals. Early identification of supremely efficacious individuals can help individuals realistically appraise one’s strengths and weaknesses and recognize the need for adequate preparation for the achievement of successful outcomes. Because students (especially beginning students) may not know what to expect in nursing (or any other health profession), they may need much guidance in ongoing self-appraisal. Realistic self-efficacy appraisal allows one to seek action to enhance strengths and remedy weaknesses. Unfortunately, supremely efficacious individuals may not be restricted to beginning students, but may encompass nurses and other health care professionals at various career stages. What is the importance of early identification of supremely efficacious or inefficacious individuals? Curricular, Employee, and Continuing Education Program Appraisal Although the identification of at-risk individuals followed by teaching interventions is one proposed purpose of interpreting self-efficacy perceptions, interpretation may also be done to guide curricular and program innovations. (Program refers to hospital/agency employee orientation programs, in-service education, and continuing education.) For example, if first semester baccalaureate nursing students complete the TSET and consistently report lower confidence for five particular items on the Cognitive Subscale, this flags that these empirical findings should be further explored. Soliciting qualitative comments may add richness to the data and allow greater insight. Examining the first semester nursing course in relation to these items/topics may uncover an educational gap, suggesting supplementary educational strategies to enhance transcultural nursing skills specifically in these topics. Administration of the Cultural Competence Clinical Evaluation Tool (CCCET) may further identify areas of strengths and weaknesses, and provide evidence of the opportunities available to interact with culturally diverse clients within a particular area of practice (see Chapter 6). Yet, if it makes sense that first semester students would have lower confidence for a cluster of items, then this helps validate the measurement tool and lends greater support for overall study results. For example, if students report lower confidence for topics not covered in the current course or in any previous courses, it makes conceptual sense that students would have lower confidence. However, if students just completed a course focused on maternal and child health, yet reported lower confidence for TSET Cognitive Subscale items “pregnancy,” “birth,” and “growth and development,” there would be cause for concern. The same example could apply for new nurse orientation to the maternity unit. Exploring underlying course, curricular, and program objectives and desired outcomes would be necessary. Using a longitudinal study design will permit the examination of within-group changes over time, providing data on the impact of subsequent courses and other educational experiences throughout the curriculum or program. AVOIDING PITFALLS As with all data interpretation, but especially with data involving self-report measurement tools and the measurement of constructs that are difficult to measure, data interpretation must be viewed cautiously. Interpretation must be realistic. An overconfident or inefficacious approach in data interpretation should be avoided, because both approaches can interfere with the best interpretation that will have the most practical significance and usability. Consciously recognizing study limitations and avoiding overgeneralization of results will help keep overconfidence in check. Acknowledging the positive findings rather than negating all results because of slight imperfections in study design or other limitations is another consideration. Recognizing that statistically insignificant results can have practical significance and recognizing that statistically significant results do not always yield meaningful findings or practical significance are equally important. The following sections discuss strategies for avoiding pitfalls in research design and interpretation. Recognize Limitations Related to Measurement Level What limitations generally exist related to measurement level? How do these limitations pertain to self-efficacy measurement and the TSET? Self-efficacy measurement tools are reported to provide data at the ordinal or interval level of measurement. Ordinal measurement shows relative rankings whereby the intervals between numbers on the scale are not necessarily equal. At the interval level of measurement, distances between the numbers are equal. In both ordinal and interval measurement there is no absolute zero point. Generally, interval-level data permit more sophisticated statistical analyses (parametric statistics versus nonparametric statistics); however, within the social sciences there is much controversy about classification of the level of measurement and the appropriateness of selected statistical analyses (18–20). Individual consideration and the acknowledgment of study limitations are the recommended actions (18, 19). Typically, self-efficacy studies have reported mean and standard deviations (3, 21). The mean is a measure of central tendency and the standard deviation is a measure of variability associated with interval-level data; however, when reported with ordinal-level data, limitations in interpretation must be acknowledged. When interpreting data, one must be aware that individuals who select a “3” response on a 10-point self-efficacy rating scale are not necessarily half as confident as individuals who select a “6” response. What can be interpreted is that the former individuals are less confident than the latter group as measured by that particular rating scale. Similarly, an individual with a mean subscale score of 7.0 is not exactly “twice” as confident as an individual scoring a mean of 3.5 (see “Educator-in-Action” vignette). The best approach may be to adhere to the conventional analyses used in self-efficacy studies (interval level), interpret findings cautiously by acknowledging study limitations, repeat studies and compare results, and observe other outcome measures to substantiate findings. Because it is impossible to measure self-efficacy at such an exact level that distinguishes self-efficacy perceptions equally between individuals and between questionnaire response choices, researchers must go beyond this limitation to appreciate and value the findings generated in self-efficacy studies. Striving to control for other possible extraneous variables through a well-planned research design will enhance the validity and generalizability of findings (22). Pre-Test Before Educational Intervention What advantages does pre-test administration offer when evaluating educational interventions? What disadvantages exist if pre-tests are not conducted prior to initiating an education intervention? How do these advantages and disadvantages pertain to the TSET? When evaluating the effectiveness or impact of a specific educational intervention, the comparison of baseline data with outcome data strengthens the study. Using a pre-test and post-test approach with a longitudinal sample will enhance the interpretability of findings. Administration of a self-efficacy measurement tool (e.g., the TSET) prior to the initiation of any specific transcultural teaching intervention, followed by a post-test administration immediately after the intervention, will permit the most control and decrease the risk of extraneous variables affecting results. Without a pre-test, the researcher/educator cannot be sure that the educational intervention caused any change in the targeted population. Because it will be difficult to evaluate changes in cultural competency in the clinical area (see Chapter 3), it will be increasingly important to evaluate changes in TSE. According to Bandura (2, 4), changes in transcultural self-efficacy through the use of pre-test and post-test become more important to measure, especially when other performance outcome indicators may be difficult to evaluate. The underlying premise is that self-efficacy is a mediator and predictor of outcome performance behaviors and outcomes (23–28). Observe for Curricular/Program Consistency What impact can curricular/program consistency or inconsistency have on evaluating the impact of educational experiences? What impact can this have on TSET data interpretation between pre-test or post-test and/or within and between cross-sectional samples? Consistency in educational experiences between time of pre-test and post-test is especially important when evaluating the impact of a curriculum or workshop series using an integrated approach to cultural competence development. The premise underlying a series of educational experiences (such as in a curriculum or clinical agency workshop series) is that each educational experience will build upon previous learning. Learning experiences carefully coordinated to complement each other by weaving together learning in the cognitive, practical, and affective domains are most desirable. Active learning experiences designed to build on previous learning add to depth and synthesis. Learners who are passive tourists, spectators, or mentally inattentive will not be actively engaged in the process of becoming culturally competent. To accomplish the learning of cultural competence at higher depth and synthesis, careful thought and consideration must take into account the feasibility of offering sequenced, high-quality, learner-centered experiences. Sequencing courses, requiring prerequisites and corequisites that make sense conceptually, and avoiding class waivers simply for pure convenience, will optimize the learning experience and help control for extraneous variables. Ideally, educators who wish to measure the impact of transcultural nursing integrated throughout a curriculum (series of courses or educational experiences) should administer a pre-test to all students similarly on their first class session of the first foundational transcultural nursing course and before exposure to transcultural educational interventions. Within the health care institution (HCI), providing a foundation for cultural competence development during the initial employee orientation program (EOP) should be followed by a carefully planned sequence of employee in-service programs and unit-based educational initiatives (see Chapters 13, 14, and 15). In academia, if some students are waived from taking the first foundational transcultural course to take several other courses first because of scheduling or other noneducational requests, the evaluation of TSE will be confounded by curricular inconsistency and by the weakening of transcultural concepts throughout. One desired outcome supporting sequencing of courses is that all students will have had the same exposure to transcultural concepts, skills, and theory. More enlightened learners within a class can reach higher (optimal) levels of cultural competence development by sharing insights with each other at a higher level of synthesis. Learners without a common foundational experience will not have this advantage. Course expectations with mixed learner groups will have different, less-effective educational outcomes because learning must be adjusted to accommodate learners without the prerequisite knowledge, skills, and values (see Table 7.2). Determine Sufficient Sample Size
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