Contributing to the ICNP ® : validating the term cultural diversity

Findings Validation and literature review provided sufficient support for the defined characteristics and the term was finally defined and submitted to ICN in November 2002 as: CULTURAL DIVERSITY is a type of CULTURE with the specific characteristics: co-existence of different groups, e.g. ethnic, religious, linguistic and other groups each with their own values and belief systems, traditions and different lifestyles.


Background
T he In te rn a tio n a l C la s s ific a tio n o f N u rsin g P ra c tic e (IC N P ® ) is a classification o f nursing phenom ena, ac tio n s and o u tc o m e s.T he IC N P ® p ro v id e s a te rm in o lo g y fo r n u rsin g p ra c tic e th a t s e rv e s as a u n ify in g framework into which existing nursing vocabularies and classifications can be cross-mapped to enable comparison of nursing data(IC N 2001a).
South A frica was one o f four African c o u n trie s (B o tsw a n a , South A frica, Swaziland, and Zimbabwe) funded by the W K Kellogg Foundation to participate in the ICNP® project, which started in 1999 and was concluded in M arch 2003.T h e re w as a p a ra lle l W K K e llo g g Foundation project in four Latin American countries (Brazil, Chile, Colombia, and M exico).T he p u rp o se o f the South African project was to identify and define terms used by nurses in primary health care services.The project consisted of two research groups from two different p ro v in c e s in S o u th A fric a , nam ely Gauteng and Eastern Cape.The purpose for selecting research groups in these two provinces was that one represents an urbanized com m unity and the other a more rural community.Although these communities will have some of the same needs, there are differences in their needs profiles and the terms identified by the tw o g ro u p s h a v e p ro v e n th e se differences (Geyer & Uys 2001).
The challenge to identify terms relevant to the South A frican situation and to develop a term that is relevant to the g lo b a l c o m m u n ity m ad e fo r som e in te re s tin g d is c u s sio n an d le a rn in g o p p o rtu n itie s .O ne o f th e te rm s d ev eloped by the G au ten g R esearch group was informal settlement.

Purpose
The overall purpose o f participating in the development o f the ICNP® was to e sta b lis h co m m o n te rm in o lo g y fo r describing nursing practice.A common term inology im proves com m unication among nurses and other members of the m u ltid is c ip lin a ry te a m , as w ell as provides standardized clinical data for d e s c rib in g an d a n a ly s in g n u rsin g practice.The specific aims of this study were to propose a definition of the term cultural diversity; to validate the term cultural diversity and to submit a term and definition for international utilisation to the International Council o f Nurses (ICN) for consideration for inclusion in the ICNP®.

Research design
This was a qualitative study w here a philosophical perspective was used to explore, explain and describe nursing practice (Polit, Beck & Hungler 2001).The research group members developed a d e fin itio n to d e s c rib e " c u ltu ra l d iv e rs ity " .T he d e fin itio n w as then validated amongst relevant stakeholders by determ ining the extent of agreement with the proposed definition.A combination of the m ethods proposed by the ICN was used for developing terms in the South African project (ICN 2001b).The procedure followed consisted o f a number o f steps followed by the research group participants.The research group selected a term, by p rio ritis in g te rm s lis te d by the participants.Using a score of 1 -5 (1 being the lo w est and 5 b e in g the h ig h e st priority), all terms were scored by the research group members to determine the order in which the terms were developed.The characteristics o f the selected term were then developed in a similar way.The list was carefully checked to ensure that th e c h a r a c te ris tic s w e re tru e c h a r a c te ris tic s and n o t c a u se s or c o n s e q u e n c e s.T h e re s e a rc h g ro u p scored the characteristics and only those with a score higher than 4 were included for the definition.A preliminary definition of the selected term was developed.A validation form was prepared explaining the process and providing the term and its characteristics for the opinion of other experts in the clinical field.
Before submitting the validation form to a wider stakeholder group, the form was piloted among nurses who are not part o f the research group.W here required, amendments were made to ensure clarity o f the expectations of the research group.O ther nurses involved in primary health care and community members exposed to informal settlements were requested to com plete the validation form.
The com pleted validation form s were returned to the research group where the data were analysed.A literature survey was performed to determine the support fo r th e su rv e y fin d in g s o f the characteristics o f the term.Based on the literature review and survey findings, the d efin ition w as finalized, the process summarized in the prescribed format and

Subjects and sampling
The Gauteng Research G roup consisted o f nine nurses with a prim ary health care b a c k g ro u n d .T h e se p a rtic ip a n ts volunteered for the project and complied w ith the p re d e te rm in e d c rite ria fo r participation.The criteria that the nurses complied with were a current position in primary health care (PHC), experience of at least two years in a PHC field and availability to participate in the research g ro u p a c tiv itie s .A ll p e rso n s, w ho indicated their interest to participate, were invited to become part o f the research group.The activities o f the research group were co-ordinated and recorded by a project co-ordinator and facilitated by a staff m em ber o f the D em ocratic Nursing O rganisation o f South Africa (DENOSA).
The sam ple for the v alid a tio n study co nsisted o f n u rse p ra c titio n e rs and co m m u n ity m e m b e rs.C o n v e n ie n ce sampling was used for the validation of the term and its characteristics (Polit, Beck & Hungler 2001).The validation forms were distributed by research group members within a prescribed time frame am o n g st n u rse p r a c titio n e r s and com m unity m em bers in the G auteng, N o rth W est and th e E a s te rn C ape provinces in South Africa.These were the areas w here the re se a rc h group participants had access and therefore the ability to ensure th at the p rescribed p ro c e sse s w as a d h e re d to and th a t persons who could not understand, read or write could be assisted.

Data collection
The research group p a rtic ip a n ts, the research project co -ordinator and the project facilitator conducted all the data collection during the different phases of the study.This included distribution and collection of the validation survey forms.

Ethical considerations
A ll resea rch group p a rtic ip a n ts had p e rm issio n from th e ir e m p lo y e rs to p a rtic ip a te in the p ro je c t. F o r the v a lid a tio n p ro c e ss p e rm issio n w as obtained from employers to have access to staff m em bers involved in service delivery.Each individual person who completed a validation form was informed o f the process and the reason for the stu d y .T h e y w ere a d v is e d th a t

Defining the term cultural diversity
The process of defining the term cultural diversity w as p erfo rm ed in different phases.Each phase is described below.

Selecting the term "cultural diversity"
The term, originally identified as "multi cultural" was identified by the research team in November 2000."Multi cultural" was initially listed together with 15 other terms as primary health care phenom ena im p o rta n t to n u rs in g p ra c tic e .To prioritise terms for the project, all terms were rated using a score o f T h e s u b s e q u e n t r e s e a rc h g ro u p activities involved developm ent of the three term s w ith the h ig h est scores, w h ic h in c lu d e d m u lti c u ltu ra l.In considering the literature available on " m ulti c u ltu ra l" th e re se a rc h g ro u p debated and agreed to change the term to "cultural diversity" .

Developing the initial definition
T h e re se a rc h te a m d e v e lo p e d the m ain characteristics of cultural diversity in July 2001.In s e le c tin g th e c h a r a c te r is tic s , e a c h research group m em ber was given an opportunity to list characteristics that describe the term.Thirtyone (31) characteristics w ere id e n tifie d .A fte r group discussion on each c h a ra c teristic, 21 w ere e x c lu d e d and 10 w ere retained as characteristics of cultural diversity.The research group consulted dictionaries and text books to clarify the rem ainder o f the identified characteristics and it was agreed that mixed values should be combined with belief systems and standards should be combined with norms (Table 1).
The research group rated each of the 8 characteristics using the same scale of 1-5.All the characteristics that obtained a mean score of four or more were included in the definition.Six characteristics of cultural diversity had a mean score >4 (Table 2).

Pilot testing of the validation form
A pilot test was conducted w ith the validation form in order to check whether participants understood and agreed with the content.For the pilot test each of the research group members distributed the validation form to two experts in the field who would not participate in the final data collection process.Pilot testing was conducted during August 2001 and all feedback about the forms was submitted to the project co-ordinator in September 2001.
Feedback from the pilot test did not id e n tify any a re a s th a t h a d to be addressed by the research group before

The initial definition
The identified characteristics were used to develop the initial definition, which was used for the validation form.To develop this definition the research group had to decide where the term would fit into the current ICN P® structure.The initial definition was the following: Cultural diversity is a type of CULTURE w ith the specific characteristics: co ex istence o f ethnic groups based on different customs and traditions and a m ixture of belief system s and values, norms and standards and different life styles.

Data analysis of validation forms
The

Literature overview
The

Finalisation of the definition of cultural diversity
In July 2002 the research group redefined the term cultural diversity based on the find in g s o f the v alid atio n study and discussion in the South African context.The initial definition indicated that for placement in the ICNP® Beta 2 version, the research group in itia lly th ought cultural diversity could be a type o f culture.After extensive discussion and literature review it was agreed that this rem ains a form o f culture.The final definition was as follows: CULTURAL DIVERSITY is a type of C U L T U R E w ith th e s p e c ific characteristics: co-existence of different groups, e.g.ethnic, religious, linguistic and other groups each with their own values and belief systems, traditions and different lifestyles.

Limitations of this study
T here are lim ita tio n s to this study.Although neighbouring countries were consulted, data was only collected within the areas w here the researchers were b a se d (G a u te n g , N o rth -W est and E astern C ape Provinces) providing a selective view.

Submission of the term to ICNP®
The process of the developm ent of the term cultural diversity was summarised on the prescribed form and submitted to ICN in November 2002.ICN distributes the term to experts in a related nursing practice area who volunteer to conduct further review.The ICNP® Evaluation C om m ittee then evaluates the expert review and considers inclusion in the ICNP®.

Inclusion of the term into the ICNP®
The research group has successfully developed and validated the term cultural diversity.In December 2003 the ICNP® E valuation C om m ittee in fo rm ed the research group participants that cultural diversity is one of 12 terms submitted by DENOSA that has been accepted for in clu sio n in the IC N P ® .W ith this announcem ent the research group has managed to achieve all the aims of the project.

Conclusion
Defining the term "cultural diversity" was a challenging exercise, especially in view of the fact that the definition had to be applicable internationally.Acceptance of the defined term is therefore meaningful for nursing and midwifery practice as it contributes to a standardized vocabulary for nurses and nursing globally -all who refer to cultural diversity, will have the same understanding wherever the term c u ltu ra l d iv e rsity (w ith its g en e ric characteristics) is used irrespective of where the term is used.
Reflecting on the process follow ed in defining the term, there are a few lessons to be learnt.The process for validation o f the term would have been enriched if more provinces in South Africa and other countries outside of Africa could have been used in the validation process.
Obtaining ethics approval for the project has proven to be problematic as all the research ethics com m ittees in South Africa are linked to universities.These committees were of the opinion that they could not execute any control over the project once approved, as DENOSA was not linked to the relevant universities in any way.These institutions therefore were not available to evaluate and provide ethics approval for the p roject.The ethical guidelines available to DENOSA were used to assist with compliance with the ethical principles for the study.While the e th ic a l g u id e lin e s d id p ro v id e assistance, there is a need for DENOSA to d e v e lo p an e th ic s c o m m itte e to consider non-university related nursing projects for ethical approval in future.
We wish to thank all who contributed to the dev elo p m en t o f the term .Many people have shared their expertise on "cultural diversity".We particularly wish to than k W.K K ello g g F o u n d a tio n , D E N O SA and the ICN fo r m aking participation in this project possible.The research group members are thanked for their time, effort, expertise and sometimes disagreements and debates that made the final subm ission of the term possible.The other Research Group members are: 1-5 (1 being the lo w est and 5 b e in g th e h ig h e st priority).A ccording to the scores the terms of preference, considered to be the m o st co m m o n p h e n o m e n a in PH C practice, were Hom e-based care (4.75); Multi Cultural (4.5); C om m unity based organizations (4.5); Traditional Healers (4 .37 ); T e e n a g e p re g n a n c y (4 .37 ); Rehabilitation (4.12) and Health Forum (4).

T
he research team developed a draft validation form.An option of "other" was added to the list o f 8 characteristics for th e re s p o n d e n ts to add o th e r characteristics that may have been left out by the research group.The form also made provision for persons to indicate who they were.
Each m em ber o f the research group re c e iv e d 5 v a lid a tio n fo rm s and conducted the data collection for the term v a lid a tio n b e tw e e n S e p te m b e r and N ovem ber 2001.One o f the research group participants was out of the country at this stage with the result that 40 forms were circulated for validation.The ten members of the Eastern Cape research group were also requested to complete a validation form.The research group m em bers co n d u cte d in te rv ie w s and co m p le ted the v a lid a tio n fo rm s, or ensured self-administration o f the form by the respondents.The ICN Consultant and n e ig h b o rin g A fric a n c o u n trie s in v o lv e d in the IC N P ® in -c o u n try projects were also consulted for their views on the term cultural diversity.
research group com pleted a review o f th e lite r a tu r e to v e rify th e characteristics included in the definition of the term cultural diversity.All research g ro u p p a r tic ip a n ts ; th e p ro je c t c o o rd in a to r an d th e f a c ilita to r w e re responsible for sourcing literature.The lite ra tu re c o n ta in e d b o th lo c a l and in tern atio n al so u rces.T he R esearch Group had a total o f 23 articles that were submitted at the M ay 2002 m eeting for consideration and evaluation to finalize the term and definition.Literature were numbered as they were received and were therefore not in an alphabetical order at the time o f the literature validation.T able 5 p ro v id e s an e x p o s itio n o f lite ra tu r e s u p p o rt fo r e a c h o f th e characteristics; the top row consists of the reference articles as they are listed below the table and the X show s the characteristics confirm ed in the stated article.Discussion of the validation and literature study T h e lite r a tu r e stu d y p ro v id e d th e follow ing inform ation that supported each o f the characteristics o f the term.W ith regard to C O -E X IST E N C E OF DIFFERENT ETHNIC GROUPS more than 50% of the literature referred to more than ju st ethnic groups.Two members of th e g ro u p re a s o n e d th a t th e g ro u p should keep to ethnic groups but the rest agreed that cultural diversity included more than just ethnic diversity.On the majority vote it was decided to refer to other groups.The m ajority suggested that a few examples should be included.S u g g e s te d e x a m p le s w ere e th n ic , religious, linguistic and socio-economic groups but one m em ber did not agree w ith the inclusion o f socio-econom ic groups and to refrain from controversy it w as d ecided to in clude only neutral groups but leave it open-ended by saying "and other groups" T h e p ro p o sa l to in c lu d e d iffe re n t customs and traditions were considered.The majority supported that customs be o m itte d and o n ly be d e s c rib e d as different traditions.It w as a g re e d to o m it n o rm s and standards because it was already omitted in the validation and if the term was placed as part of the family of norms and attitudes it was already included.The potential positions for placement of the term "cultural diversity" in the Beta version that were elim inated included n u rs in g p h e n o m e n o n (n o t s p e c ific e n o u g h ); health sy stem (lac k ed the c o m p o n en ts n ec essary to c la ssifie d under it); value belief (pertained to the individual) and community composition (disregarded).The majority supported the motion to classify it as a type of culture.
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Table 2 : Initial characteristics of cultural diversity
p a r tic ip a tio n w as v o lu n ta ry and anonymous.Persons who did not wish to participate w ere not discrim inated against (DENOS A 1998).

Table 4 Results obtained from the validation form s
•Disagree because lifestyle can be more related to econmics than to culture (1)