ORIGINAL ARTICLE

Construct validation of the Nurse Cultural Competence Scale: a

hierarchy of abilities
Shoa-Jen Perng and Roger Watson

Aim. The aim of this study was to describe the development of a Nurse Cultural Competence Scale using Mokken scaling.
Background. The psychometrics of the present cultural competence assessment tools has been questioned. The levels of com-
petence measured by existing tools are not capable of indicating individual differences.
Design. This study employed a cross-sectional design. A convenience sample of 172 on-the-job nursing students in a college of
technology in Taiwan was recruited.
Methods. Based on previous literature, the Nurse Cultural Competence Scale comprising 41 items was developed to measure the
concept of cultural awareness, cultural knowledge, cultural sensitivity and cultural skill. Mokken scaling analysis was con-
ducted to investigate the unidimensionality and hierarchical nature of the scale.
Results. From the 41 items entered into the Mokken scaling procedure, 20 form a strong Mokken scale. The 20 items form a
reliable and statistically significant scale which is negatively skewed. The ordering of the items from lowest to highest difficulty
shows a hierarchy.
Relevance to clinical practice. Nursing managers and educators may use this scale to assess the levels of cultural competence of
their members or students and then provide the education according to individual needs.

Key words: cultural competence, item response theory, Mokken scaling, nurses, nursing, Taiwan

Accepted for publication: 4 August 2011

Cultural competence is the ability necessary for profes-

Introduction
sional health personnel to provide safe and effective health
The trend towards globalisation and immigration increases services to clients with different cultural contexts. This kind
population diversity and this multiethnicity enriches aspects of ability is not inherent, but it can be developed (Baldwin
of society in many developed countries. Each population has 1999, Campinha-Bacote 2002). In nursing, many programs
its own particular norms and practices that guide their have been designed to prepare nurses to be culturally
lifestyles; therefore, a challenge arises for health care provid- competent. The majority of programs used self-reported
ers to learn to provide culturally sensitive care to clients from assessment tools to measure nurses’ knowledge, attitude or
diverse cultural backgrounds (Waite & Calamaro 2010). If behaviours regarding the culture and health of a specific or a
one can serve such clients while considering their languages general population (Capell et al. 2007, Wilson et al. 2010).
and traditions while simultaneously respecting their own However, the validity of these assessment tools has been
ways of taking care of their health, benefits should come from questioned. Capell et al. (2007) indicated that invalid tools
increasing clients’ satisfaction with quality of care (Servonsky lead to invalid scores and lack of clarity about levels of
& Gibbons 2005, Castro & Ruiz 2009) and the elimination competence obtained. In addition, levels of competence are
of inequalities in health care (Betancourt et al. 2005). usually presented with a mean score on a scale to indicate

Authors: Shoa-Jen Perng, PhD, RN, Associate Professor, Department Correspondence: Shoa-Jen Perng, Associate Professor, Department of
of Nursing, The Tzu-Chi College of Technology, Taiwan; Roger Nursing, The Tzu-Chi College of Technology, Taiwan.
Watson, PhD, RN, FAAN, Professor, Department of Nursing, The Telephone: +44 7808480547.
University of Sheffield, Sheffield, UK E-mail: jen@tccn.edu.tw

 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, doi: 10.1111/j.1365-2702.2011.03933.x 1
S-J Perng and R Watson

one’s general level of competence; nevertheless, which specific cultural knowledge, cultural skill, cultural encounters and
abilities one is able to achieve and which need to be cultural desire. Although these constructs are abstract and
developed is unknown. This is because the scale was focus on general phenomena, they are frequently adopted by
developed using a range items without considering their other researchers.
relative difficulty. Some researchers explored the construct of cultural com-
Several researchers have pointed to the need for a valid tool petence through the strategy of concept analysis (Burchum
to assess nurses’ cultural competence (Balcazar et al. 2009, 2002, Suh 2004, Zander 2007). There are some similarities
Fitzgerald et al. 2009). Towards this end, Mokken scaling and differences in this work. Suh (2004) identified the
could be used as an alternative strategy for constructing a attributes of cultural competence including ability, openness
construct valid hierarchical scale that could order scale items and flexibility and antecedents, including cultural awareness,
in terms of their difficulty and also order respondents to the cultural knowledge, cultural sensitivity, cultural skill and
scale. Therefore, the purpose of this study is to discuss the cultural encounters. Unlike Suh’s work, cultural aware-
development process of a Nurse Cultural Competence Scale ness, cultural knowledge, cultural skill, cultural understand-
(NCCS) using Mokken scaling. ing, cultural sensitivity, cultural interaction and cultural
proficiency have been identified as the attributes of culture
competence (Burchum 2002, Zander 2007). Many measures
Background
of culture competence were developed consistent with the
logic of the latter two authors.
The concept of cultural competence

Working across cultures in nursing has been described as

Measuring cultural competence
transcultural nursing, and several models have been pro-
posed to illustrate this concept (Andrews & Boyle 1999, The measures of cultural competence were classified into two
Campinha-Bacote 2002, Purnell 2002, Jirwe et al. 2006). types: culture-specific tools and culture-general tools (Capell
These models also provide a theory-based framework et al. 2007). The use of culture-specific tools is limited in
exploring clients’ cultural care needs and guiding nurses’ specific ethnic groups of clients and the Cultural Self-Efficacy
practice. Jirwe et al. (2006) used document analysis to Scale is an example (Bernal & Froman 1993). Several
analyse the core components of nine frameworks regarding measures were developed as culture-general tools that can
cultural competence. Four main themes were identified: an be applied with different groups of clients, such as the
awareness of diversity among human beings; an ability to Inventory to Assess the Process of Cultural Competence-
care for individuals; non-judgmental openness for all indi- revised (Campinha-Bacote 2002) and the Cultural Compe-
viduals; and enhancing cultural competence as a long-term tence Assessment (Schim et al. 2003). Some tools were
continuous process. specifically designed to measure the cultural competence of
The definition and meaning of cultural competence are still nursing students, including the Transcultural Self-Efficacy
debated. Andrews and Boyle (1999) claimed that cultural Tool (Jeffreys & Smodlaka 1999), the Cultural Awareness
competence was a process referring to nurse’s ability for Scale (Rew et al. 2003) and the student version of the
critical thinking and learning in cognitive, affective and Inventory to Assess the Process of Cultural Competence
psychomotor domains. Two other models also defined (Fitzgerald et al. 2009). Therefore, several measures have
cultural competence as a dynamic term referring to the been developed; however, the reliance on self-report mea-
ongoing process of a nurse provide care consistent with sures for cultural competence assessment is a common
client’s cultural context (Campinha-Bacote 2002, Purnell weakness because the reliability and validity of these
2002). The Purnell model of cultural competence delineated measures were not rigorously examined (Stanhope et al.
12 domains under the context of person, family, community 2005).
and global society for assessing client’s cultural backgrounds: The psychometric issue the researchers mostly questioned
overview/heritage, communication, family roles and organi- was whether the measures could capture the meanings of
sation, workforce issues, bio-cultural ecology, high-risk cultural competence. For example, Capell et al. (2007)
behaviours, nutrition, pregnancy and childbearing practices, claimed that cultural sensitivity was more appropriated to
death rituals, spirituality, health care practice and health care indicate the characters of one being able to provide cultural
practitioner (Purnell 2002). The process of Cultural Compe- care congruently. Further, as mentioned earlier, most
tence in the Delivery Healthcare Service (Campinha-Bacote researchers asserted that the cultural competence practice
2002) was comprised of five constructs: cultural awareness, is dynamic and described its stages from gaining knowledge

 2012 Blackwell Publishing Ltd

2 Journal of Clinical Nursing
Original article Construct validation of the NCCS

to being proficient. However, measuring the level of

Methods
cultural competence was difficult because its definition is
not clear (Johnson & Munch 2009). Further empirical
Design and participants
research is needed to clarify these issues.
This study employed a cross-sectional design. A conve-
nience sample including all the ‘on-the-job’ nursing
Mokken scaling
students (n = 172) available in a college of technology in
There is increasing interest, as demonstrated by a series of Taiwan was recruited and the response rate was 97%
recent publications (Watson 1996, Watson et al. 2007, (n = 169). Approval to conduct the study was obtained
2008a,b, Lin et al. 2008, Bedford et al. 2010a,b, Deary et al. from the college. All the participants were fully informed
2010, Thompson & Watson 2010), in whether items are about the study and gave their written consent. The
ordered in scales, and Mokken scaling is a method for participants were all women. Their average age was
establishing if items in a scale conform to a cumulative, 33Æ32 (SD 5Æ50) years old, and the average period of being
hierarchical structure. The method is evolved from Guttman a nurse was 11Æ79 (SD 5Æ14) years. Most of them (11Æ97%)
scaling (Stouffer et al. 1950) but, unlike the deterministic worked in the hospital, 33 (19Æ71%) of them could speak a
Guttman model, Mokken scaling is a stochastic non- foreign language. Some of them (68Æ3%) had the experi-
parametric method (Sijtsma et al. 1990) with a range of ence of caring for foreigners and only one had the
diagnostics which indicate the extent to which a set of items experience of studying abroad.
is scalable (H or Loevinger’s coefficient), whether they
conform to models of montone homogeneity and double
Instrument
monotonicity (MMH and DMM, respectively) and whether
items show invariant item ordering (IIO). Based on the literature (Ahmann 2002, Burchum 2002,
The essential idea behind a cumulative hierarchical scale is Campinha-Bacote 2002, Jeffreys 2002), we developed a
that the items in it are ordered consistently and sensibly. For NCCS including four domains: cultural awareness, cultural
example, using the example of Watson et al. (2008a), if a knowledge, cultural sensitivity and cultural skill. Cultural
scale contained items enquiring about the height of respon- awareness refers to the nurses’ consciousness of the
dents in 10 cm increments from 100–200 cm, you would similarities and differences between individual and oth-
expect those who were tallest to respond positively to the ers’ cultural context, and recognition of one’s own
larger values on the scale than respondents who were less tall. prejudice; ten items measured this domain. Cultural
Someone measuring 190 cm they would respond positively to knowledge refers to the nurses’ knowledge of obtaining
all increments up to 190 cm; someone measuring 170 cm information about diverse groups and their culture, such as
would respond positively to all increments up to 170 cm but health beliefs, cultural values; nine items measured this
none of the increments above that. In this example, height domain. Cultural sensitivity refers to the nurses’ appreci-
can be considered to be the latent trait which is not being ation of the client’s beliefs, valuing their culture and
measured directly but indirectly by asking individuals to respecting its influence on client’s behaviours; eight items
indicate their height on the scale. measured this domain. Cultural skills refer to the nurses’
Loevinger’s coefficient measures the extent to which ability to carry out the cultural assessment for client,
items are consistently ordered relative to one another communicate with client by using resources and provide
(Niemöller & van Schuur 1983) and H > 0Æ3 is the appropriate care without individual prejudice; 14 items
minimum value indicating that a set of items may conform measured this domain.
to a Mokken scale. MMH refers to the extent to which The NCCS used a five-point Likert scale with response
items respond monotonously, or increase consistently, in categories of strongly agree, agree, no comment, disagree
the presence of the latent trait (Mokken & Lewis 1982). and strongly disagree. Total scores for 41 items ranged from
This relationship is described by an item response function, 0–205. Face validity was established through reviews by
and DMM refers to the extent to which items do not four experts including two nursing researchers, a nurse
intersect (Mokken & Lewis 1982). Finally, IIO refers to the manager and a health educator. An initial exploration of
extent to which items are ordered in the same way for all reliability was conducted by examining internal consistency
respondents (Sijtsma & Junker 1996), and this is indicated on a pilot test sample of 47 on-the-job nursing students.
by coefficient HT which should exceed 0Æ30 before IIO is Resulting Cronbach’s Alpha for four scales ranged from
indicated. 0Æ78–0Æ96.

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Journal of Clinical Nursing 3
S-J Perng and R Watson

Mokken scaling analysis competence using the MSP. The Cultural Capacity Scale
differs from other cultural competence assessment tools on
Mokken scaling analysis was conducted using two pieces of
the characteristic of unidimensionality and a hierarchy of
software: the commercially available Mokken scaling procedure
items.
(MSP) for Windows (Molenaar & Sijtsma 2000) and the public
In terms of unidimensionality, Mokken scaling analysis
domain statistical software R using the Mokken package (van
was considered to be an appropriate strategy, better than
der Ark 2007). Data (n = 169) on the Cultural Competence
factor analysis, to assess the unidimensionality of a set of
scales, saved in SPSS (XiShu Software, New Taipei City,
items (Gillespie et al. 1987). In this study, the Cultural
Taiwan), were saved as a tab-delimited file with the spread-
Capacity Scale shows the scalability of items along the scale.
sheet option turned off and imported into the MSP. All 41 items
The items retained in the scale reflect one’s abilities that can
were analysed together for Loevinger’s coefficient and MMH
be externally demonstrated during practice, such as explana-
and DMM. The latter were examined using the ‘Crit’ diagnostic
tion of cultural knowledge, use of communication skills,
in MSP; Crit < 80 for both MMH and DMM indicate that
offering care and teaching others regarding the clients from
items should be included in the final scale. The MSP uses a
diverse cultural backgrounds. The items that indicate one’s
Bonferroni method at each iteration in the procedure to avoid
internal abilities, such as possessing positive perceptions or
Type I error (Molenaar & Sijtsma 2000) and provides a p value
attitudes toward the beliefs and behaviours of clients from
for the analysis and also a reliability estimate (Rho) which is
diverse cultural backgrounds, were not retained in the scale.
analogous to Cronbach’s alpha (Sijtsma & Junker 1996). In
Consequently, the cultural competence scales more precisely
addition, distribution properties of the resulting scale are
confirms the construct validity of cultural competence with
provided including mean score, standard deviation, skewness
high reliability.
and kurtosis. The items obtained from the MSP analysis were
In terms of hierarchy, the score on the Mokken scale will
imported into R by converting the SPSS data to an Rdata file and
indicate the extent to which the levels of cultural compe-
then analysing the items retained in the Mokken scale for IIO
tence are present. Someone scoring high on ‘… teach and
using the method manifest procedure in R.
guide other nursing colleagues about the differences and
similarities of diverse cultures’ would also perform well on
‘… teach and guide other nursing colleagues about plan-
Results
ning nursing interventions for clients from diverse cultural
The results of the Mokken scaling analysis are shown in backgrounds’; on the contrary, someone scoring low on ‘…
Table 1. From the 41 items entered into the MSP, 20 form a teach and guide …planning nursing interventions…’ would
strong Mokken scale (H = 0Æ67) (H > 0Æ5 indicates a string score lower on ‘… teach and guide …the differences and
Mokken scale). The 20 items form a reliable (Rho = 0Æ97) similarities of diverse cultures’. From the results of such a
and statistically significant (p < 0Æ001) scale which is neg- hierarchical scale, we can assess one’s level of cultural
atively skewed. The ordering of the items from lowest to competence and provide educational interventions or
highest difficulty (difficulty increases inversely with mean resources for nurses. However, as noted in the Results
item score) shows a hierarchy indicating that respondents section, the Mokken scale obtained did not demonstrate
more readily endorse items related to their own skills such as IIO. This does not invalidate the use of the scale for the
using communication skills and identifying care needs ordering of individuals on the basis of their mean total
through to teaching colleagues about cultural aspects of care scale responses; however, it indicates that across the range
and using examples to illustrate aspects of cultural care. The of the latent trait (cultural competence), not all of the
items retained in the scale do not show IIO. respondents respond to the items in the scale in the same
The final Mokken Scale, so called Cultural Capacity Scale, order. In other words, while the item characteristic curves
was comprised of six items from Cultural Knowledge Scale, for the items in the Mokken scale show monotone
two items from Cultural Sensitivity Scale and 12 items from homogeneity, some of these may intersect. Further studies
Cultural Skill Scale. None of the items from the Cultural are needed to develop and test items that follow the model
Awareness Scale were incorporated into the final Mokken scale. of double homogeneity.

Discussion Conclusion
The study describes the development and testing a con- In summary, this study presents the development process of
struct valid scale for assessing nurses’ levels of cultural the NCCS. Through the use of Mokken scaling analysis, a

 2012 Blackwell Publishing Ltd

4 Journal of Clinical Nursing
Original article Construct validation of the NCCS

Table 1 Mokken scaling of all items in the Cultural Competence scale (n = 169)

Item Mean H Item label Scale

37 1Æ99 0Æ72 I can teach and guide other nursing colleagues about the differences and similarities of diverse cultures CSk
40 2Æ03 0Æ76 I can teach and guide other nursing colleagues about planning nursing interventions for clients from CSk
diverse cultural backgrounds
13 2Æ04 0Æ63 I can use examples to illustrate communication skills with clients of diverse cultural backgrounds CK
39 2Æ06 0Æ74 I can teach and guide other nursing colleagues about the communication skills for clients from CSk
diverse cultural backgrounds
33 2Æ07 0Æ74 I can explain the influences of cultural factors on one’s beliefs/behaviour towards health/illness to CSk
clients from diverse ethnic groups
31 2Æ08 0Æ67 To me collecting information on each client’s beliefs/behaviour about health/illness is very easy CSk
38 2Æ11 0Æ71 I can teach and guide other nursing colleagues about the cultural knowledge of health and illness CSk
41 2Æ14 0Æ72 I can teach and guide other nursing colleagues to display appropriate behaviour, when they CSk
implement nursing care for clients from diverse cultural groups
16 2Æ15 0Æ61 I am familiar in health- or illness-related cultural knowledge or theory CK
32 2Æ18 0Æ65 I can explain the influence of culture on a client’s beliefs/behaviour about health/illness CSk
15 2Æ21 0Æ63 I can list the methods or ways of collecting health-, illness-, and cultural-related information CK
18 2Æ23 0Æ63 I can compare the health or illness beliefs among clients with diverse cultural background CK
19 2Æ23 0Æ68 I can easily identify the care needs of clients with diverse cultural backgrounds CK
35 2Æ28 0Æ72 When implementing nursing activities, I can fulfil the needs of clients from diverse cultural backgrounds CSk
17 2Æ30 0Æ66 I can explain the possible relationships between the health/illness beliefs and culture of the clients CK
34 2Æ31 0Æ69 I can establish nursing goals according each client’s cultural background CSk
26 2Æ37 0Æ56 I usually actively strive to understand the beliefs of different cultural groups CSens
36 2Æ40 0Æ71 When caring for clients from different cultural backgrounds, my behavioural response usually CSk
will not differ much from the client’s cultural norms
28 2Æ43 0Æ68 I can use communication skills with clients of different cultural backgrounds CSk
25 2Æ46 0Æ49 I usually discuss differences between the client’s health beliefs/behaviour and nursing knowledge CSens
with each client

CSk, Cultural skills; CK, Cultural knowledge; CSens, Cultural sensitivity.

H = 0Æ67; p = 0Æ00014; Rho = 0Æ97; Mean = 44Æ08; Standard deviation = 13Æ52; Skewness = 0Æ42; Kurtosis = 0Æ00; HT = 0Æ11.

Cultural Capable Scale containing multidomains but brief individual differences in cultural competence of their mem-
and unidimensional was generated. bers or students and then provide education according to
individual needs.

Relevance to clinical practice

Contributions
Increasing cultural competence and providing culturally
congruent care in nursing can improve the quality of care Study design: P-SJ; data collection and analysis: P-SJ, RW and
and health outcomes (Ahmann 2002). Continuing education manuscript preparation: P-SJ, RW.
is needed to facilitate nursing students and nurses to acquire
the necessary knowledge, skills and attitudes. To provide
Conflict of interest
effective education program, nursing managers or educators
may use this culture-general scale to assess the levels and None.

References
Ahmann E (2002) Developing cultural van der Ark LA (2007) Mokken scale anal- work. Disability and Rehabilitation 31,
competence in health care settings. ysis in R. Journal of Statistical Software 1153–1160.
Pediatric Nursing 28, 133–137. 20, 1–19. Baldwin D (1999) Community-based
Andrews MM & Boyle JS (1999) Transcu- Balcazar FE, Suarez-Balcazar Y & Taylor- experiences and cultural competence.
tural Concepts in Nursing Care, 3rd Ritzler T (2009) Cultural competence: Journal of Nursing Education 38, 195–
edn. Lippincott, Philadelphia, PA. development of a conceptual frame- 196.

 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing 5
S-J Perng and R Watson

Bedford A, Watson R, Lyne J, Tibbles J, scales? Quality & Quantity 21, 393– program and an empirical application.
Davies F & Deary IJ (2010a) Mokken 408. Quality & Quantity 24, 173–188.
scaling and principal components Jeffreys MR (2002) A transcultural core Sijtsma K & Junker BW (1996) A survey of
analysis of the CORE-OM in a large course in the clinical nurse specialist theory and methods of invariant item
clinical sample. Clinical Psychology curriculum. Clinical Nurse Specialist ordering. British Journal of Mathemat-
and Psychotherapy 17, 51–56. 16, 195–202. ical and Statistical Psychology 49,
Bedford A, Watson R, Henry JD, Craw- Jeffreys MR & Smodlaka I (1999) Construct 79–105.
ford JR & Deary IJ (2010b) Mokken validation of the transcultural self-effi- Stanhope V, Solomon P, Pernell-Arnold A,
scaling analyses of the Personal cacy tool. Journal of Nursing Education Sands RG & Bourjollyet JN (2005)
Disturbance Scale (DSSI/sAD) in large 38, 222–227. Evaluating cultural competence among
clinical and non-clinical samples. Per- Jirwe M, Gerrish K & Emami A (2006) The behavioural health professionals. Psychi-
sonality and Individual Differences theoretical framework of cultural com- atric Rehabilitation Journal 28, 225–233.
50, 38–42. petence. The Journal of Multicultural Stouffer SA, Guttman L, Suchman EA,
Bernal H & Froman R (1993) Influences on Nursing and Health 12, 6–16. Lazarsfeld PF, Star SA & Clausen JA
the cultural self-efficacy of community Johnson YM & Munch S (2009) Funda- (1950) Measurement and Prediction,
health nurses. Journal of Transcultural mental contradictions in cultural com- vol. 4. Princeton University Press,
Nursing 4, 24–31. petence. Social Work 54, 220–231. Princeton, NJ.
Betancourt JR, Green AR, Carriilo JE & Lin L-C, Watson R, Lee Y-C, Chou Y-C & Suh EE (2004) The model of cultural com-
Park ER (2005) Cultural competence Wu S-C (2008) Edinburgh Feeding petence through an evolutionary
and health care disparities: key per- Evaluation in Dementia (EdFED) scale: concept analysis. Journal of Transcul-
spectives and trends. Health affairs 24, cross-cultural validation of the Chinese tural Nursing 15, 93–102.
499–505. version. Journal of Advanced Nursing Thompson DR & Watson R (2010) Mok-
Burchum JLR (2002) Cultural competence: 62, 116–123. ken scaling of the myocardial infarction
an evolutionary perspective. Nursing Mokken RJ & Lewis C (1982) A nonpara- dimensional assessment scale (MIDAS).
Forum 37, 5–15. metric approach to the analysis of Journal of Evaluation in Clinical Prac-
Campinha-Bacote J (2002) The process of dichotomous item responses. Applied tice 17, 156–159.
cultural competence in the delivery of Psychological Measurement 6, 417– Waite R & Calamaro C (2010) Cultural
healthcare services: a model of care. 430. competence: a systemic challenge to
Journal of Transcultural Nursing 13, Molenaar IW & Sijtsma K (2000) MSP5 for nursing education, knowledge
181–184. Windows: a Program for Mokken Scale exchange, and the knowledge develop-
Capell J, Veenstra G & Dean E (2007) Cul- Analysis for Polytomous Items. iec ment process. Perspectives in Psychiat-
tural competence in healthcare: critical ProGAMMA, Groningen. ric Care 46, 74–79.
analysis of the construct: its assessment Niemöller K & van Schuur W (1983) Sto- Watson R (1996) Mokken scaling procedure
and implications. The Journal of Theory chastic models for unidimensional scal- (MSP) applied to feeding difficulty in
Construction and Testing 11, 30–37. ing: Mokken and Rasch. In Data Analysis elderly people with dementia. Interna-
Castro A & Ruiz E (2009) The effects of and the Social Sciences (McKay D, tional Journal of Nursing Studies 33,
nurse practitioner cultural competence Schofield N & Whitely P eds). Frances 385–393.
on Latina patient satisfaction. Journal Pinter, London, pp. 120–170. Watson R, Deary I & Austin E (2007) Are
of the American Academy of Nurse Purnell L (2002) The Purnell model for personality trait items reliably more or
Practitioners 21, 278–286. cultural competence. Journal of Trans- less ‘difficult’? Mokken scaling of the
Deary IJ, Wilson JA, Carding PN, Mac- cultural Nursing 13, 193–196. NEO-FFI. Personality and Individual
Kenzie K & Watson R (2010) From Rew L, Becker H, Cookston J, Khosropour S Difference 43, 1460–1469.
dysphonia to dysphoria: Mokken scal- & Martinez S (2003) Measuring cultural Watson R, Deary IJ & Shipley B (2008a) A
ing shows a strong, reliable hierarchy of awareness in nursing students. Journal of hierarchy of distress: Mokken scaling of
voice symptoms in the Voice Symptom Nursing Education 42, 249–257. the GHQ-30. Psychological Medicine
Scale questionnaire. Journal of Psy- Schim SM, Doorenbos AZ, Miller J & 28, 575–579.
chosomatic Research 68, 67–71. Benkert R (2003) Development of a Watson R, Roberts (nee Shipley) B, Gow A &
Fitzgerald EM, Cronin SN & Campinha- cultural competence assessment instru- Deary IJ (2008b) A hierarchy of items
Bacote J (2009) Psychometric testing of ment. Journal of Nursing Measurement within Eysenck’s EPI. Personality and
the inventory for assessing the process 11, 29–40. Individual Differences 45, 333–335.
of cultural competence among health- Servonsky EJ & Gibbons ME (2005) Family Wilson AH, Sanner S & McAllister LE (2010)
care professionals – student version nursing: assessment strategies for A longitudinal study of cultural compe-
(lAPCC-SV). The Journal of Theory implementing culturally competent tence among health science faculty.
Construction & Testing 13, 64–68. care. Journal of Multicultural Nursing Journal of Cultural Diversity 17, 68–72.
Gillespie M, Tenvergert EM & Kingma J and Health 11, 51–56. Zander PE (2007) Cultural competence:
(1987) Using Mokken scale analysis to Sijtsma K, Debets P & Molenaar IW (1990) analyzing the construct. The Journal
develop unidimefiona.ross4@nhs.netion Mokken scale analysis for poly- of Theory Construction & Testing 11,
items in the NORC GSS form one or two chotomous items: theory, a computer 50–54.

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Original article Construct validation of the NCCS

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