Abstract
Introduction:
This study aimed to understand the impact of nursing students’ nursing professionalism, adjustment to college life, satisfaction with a major, and communication skills on cultural competence to develop future nursing education in a diversified and connected global world.
Methodology:
A descriptive correlational study was conducted on undergraduate nursing students at two Korean cities in 2019. Data from 177 students were analyzed via Pearson’s correlation and hierarchical regression analyses using SPSS version 25.0.
Results:
Health care issue awareness, nursing professionalism, and adjustment to college life significantly affected cultural competence, with an explanatory power of 26% (F = 11.73, p < .001).
Discussion:
This study strengthens the cultural competence of nursing students and presents key factors for caring for patients across various cultural backgrounds. Future-oriented integrated education and systematic curriculum based on factors influencing cultural competence should be prepared and provided.
Introduction
Rapid changes in the social environment, including the COVID-19 pandemic, digitalization, globalization, and climate change, present new challenges and opportunities for the educational environment and the future of nursing, underscoring the need for education on cultural competence. As health care issues are becoming increasingly interconnected globally, it is important to understand the environmental and health problems faced by patients from diverse cultural backgrounds, respect their cultures, and communicate effectively using various methods (Antón-Solanas et al., 2021; Armah et al., 2020).
Korea is on the verge of becoming an earnest multicultural society; hence, seeking a plan for professional nursing growth in cultural competence from a global perspective has become a priority. The “December 2023 Immigration and Foreign Policy Statistical Monthly Report” released by the Ministry of Justice’s Korea Immigration Service revealed that 2,507,584 foreigners lived in Korea in 2023, showing an increase of 11.7% compared to the previous year (Korea Immigration Service, Ministry of Justice, 2024). These facts suggest Korea is becoming more multicultural and multiracial, with a growing population of naturalized Korean citizens, second-generation Korean immigrants, and foreigners.
Cultural competence, which refers to the ability to provide care while respecting an individual’s culture based on an understanding of cultural traditions, beliefs, and values (Sharifi et al., 2019), is important in caring for various ethnic and cultural groups. Numerous studies on cultural competence have underscored the importance of cultural care, highlighting the efforts expended by nurses and nursing students to effectively interact with patients across various cultures, protect patients’ lives, and acquire cultural competence to promote human health beyond race, ethnicity, and country of origin (Kaihlanen et al., 2019; Tosun & BENEFITS Group, 2021; Young & Guo, 2020). To provide culturally appropriate care, professionalism based on professional nursing values must be formed (Poorchangizi et al., 2019; Rodríguez-Gázquez et al., 2021).
Successful adjustment to college life, in which nursing students actively interact with others and the environment, must be achieved to improve cultural competence based on nursing professionalism. In particular, various experiences in college life, including participation in major-related programs and activities, impact cultural knowledge and awareness, interpersonal relationships, communication, and critical thinking among undergraduate nursing students (Son & Kim, 2021; Walters et al., 2017). Based on their nursing majors, nursing students gain various experiences from participating in volunteer activities, multicultural programs, and overseas exchanges (Jeong, 2017; I. S. Lee & Song, 2019). The college life of nursing undergraduates based on diverse experiences is associated with satisfaction with their major (Cho, 2020; You, 2020), and satisfaction with their major is, in turn, associated with cultural competence (Jang & Seo, 2020). This bears further significance in influencing the formation of positive professional values for career paths and nursing roles (You, 2020), as well as professionalism and self-identity as a nurse (Cho, 2020).
Communication skills are essential for developing cultural competence. Those who understand both verbal and nonverbal factors of various cultures can provide appropriate nursing services by following nursing care guidelines when caring for patients across diverse cultural backgrounds (Brooks et al., 2019; Centers for Disease Control and Prevention, 2024). In particular, the lockdown to prevent the spread of COVID-19 has become a double burden for immigrants and refugees who have already experienced language barriers and cultural differences. Communication and language barriers occur because of immigrants’ digital information gaps, restricting access to medical services (Angawi, 2023). This COVID-19 situation highlights not only the importance of communication but also the need for nursing care with multidimensional communication skills. Therefore, multidimensional integrated education, which encompasses nursing expertise, adjustment to college life, satisfaction with one’s major, communication skills, and cultural competence, will broaden the understanding of changes worldwide, ultimately allowing nursing students to lead a new nursing paradigm beyond the existing framework for thinking about culture.
When designing future nursing education programs, a systematic approach should be employed to identify various influencing factors based on a theoretical model. In particular, Suh’s (2004) cultural competence model promotes an understanding of building a wide range of cultural competencies by presenting an overview of the four domains of an integrated cultural competence process and the three attributes of cultural competence. Suh’s (2004) model is useful for comprehensively understanding the factors influencing this study (namely, nursing professionalism, adjustment to college life, satisfaction with one’s major, and communication skills).
The present study aimed to understand the impact of nursing students’ nursing professionalism, adjustment to college life, satisfaction with one’s major, and communication skills on cultural competence and to identify factors influencing cultural competence in undergraduate nursing students. This study also proposed directions and plans for nursing education to cultivate cultural competence among future nursing experts.
Method
Study Design
This study adopted a cross-sectional and descriptive correlational design.
Sample and Setting
This study was conducted from October 2019 to December 2019. The study participants were conveniently recruited from students attending nursing colleges in two Korean cities. Students who understood the purpose and procedures of the study and agreed to participate voluntarily were included. Participants who did not complete the first semester after entering the nursing department were excluded. When six predictors with a significance level of 0.05 and a moderate effect size of 0.15 were included, the G*Power program (Faul et al., 2007) prescribed 146 as the minimum number of samples to maintain a power of 0.95. Based on the effect sizes and dropout rates in previous studies (N. Y. Lee et al., 2015), 190 individuals were surveyed, with an anticipated dropout rate of 30%, including response omissions; 177 questionnaires were collected, sufficient for statistical analysis.
Ethical Considerations
This study was approved by the Public Institutional Review Board (IRB) of the Ministry of Health and Welfare (IRB approval no. P01-201909-21-011). Written informed consent was obtained from voluntary study participants only after explaining the purpose, methodology, and procedures of the study.
Measures
Nursing Professionalism
Participants’ nursing professionalism was measured using a tool developed by Yeun et al. (2005), which consists of 29 items rated on a five-point Likert-type scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree.” The ratings ranged from 5 (lowest) to 145 (highest) for each question, with a higher score indicating a higher level of nursing professionalism. The internal consistency, reliability, and construct validity of this tool were verified (Yeun et al., 2005) with a Cronbach’s alpha of .92. Cronbach’s alpha for this study was .85.
Adjustment to College Life
The participants’ level of adjustment to college life was measured using S. Y. Park’s (2017) tool, which includes 34 questions on a five-point Likert-type scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree.” The ratings ranged from 5 (lowest) to 170 (highest) for each question, with a higher score signifying a higher level of adjustment to college life. The internal consistency, reliability, and construct validity of this tool were verified (S. Y. Park, 2017) with a Cronbach’s alpha of .92. Cronbach’s alpha for this study was .91.
Satisfaction With a Major
Participants’ satisfaction with their major was measured using H. S. Park’s (2015) tool, which consists of 17 items rated on a five-point Likert-type scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree.” The ratings ranged from 5 (lowest) to 85 (highest) for each question, with a higher score signifying a higher level of satisfaction with one’s major. The internal consistency, reliability, and construct validity of this tool were verified (H. S. Park, 2015) with a Cronbach’s alpha of .91. Cronbach’s alpha for this study was .88.
Communication Skills
Communication skills were measured using Hur’s (2003) tool, which consists of 45 items rated on a five-point Likert-type scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree.” The ratings ranged from 5 (lowest) to 225 (highest) for each question, with a higher score suggesting a higher level of communication skill. The internal consistency, reliability, and construct validity of this tool were verified (Hur, 2003) with a Cronbach’s alpha of .72. Cronbach’s alpha for this study was .72.
Cultural Competence
Participants’ cultural competence was measured using Han and Chung’s (2015) tool. This tool contains 27 items rated on a five-point Likert-type scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree.” The ratings for each question ranged from 5 (lowest) to 135 (highest), with a higher score implying a higher level of cultural competence. The internal consistency, reliability, and construct validity of this tool were verified (Han & Chung, 2015) with a Cronbach’s alpha of .91. Cronbach’s alpha for this study was .90.
Statistical Analysis
Data were analyzed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). (a) The general characteristics of the participants were analyzed using descriptive statistics, such as frequencies with percentages and mean with standard deviations. (b) Differences in cultural competence based on the participants’ general characteristics were examined using the t-test and analysis of variance (ANOVA), with the Scheffé test being employed as a post hoc test. (c) Participants’ nursing professionalism, adjustment to college life, satisfaction with their major, communication skills, and cultural competence were analyzed using means and standard deviations. (d) Correlations among variables were analyzed using Pearson’s correlation coefficient. (e) Factors influencing cultural competence were analyzed using hierarchical regression analysis.
Results
Differences in Cultural Competence According to General Characteristics
Table 1 presents the participants’ general characteristics, university locations, multicultural awareness, classes, cultural club activities, health care issue awareness, and knowledge of the laws related to foreign residents. Differences in cultural competence results, whether they were aware of health care issues (F = −4.01, p = .001) and whether they had knowledge of laws related to foreign residents (F = −2.46, p = .015), were found (Table 1).
Differences in Cultural Competence According to General Characteristics (N = 177).
Nursing Professionalism, Adjustment to College Life, Satisfaction with a Major, Communication Skills, and Cultural Competence
The participants’ mean scores for nursing professionalism, adjustment to college life, satisfaction with a major, communication skills, and cultural competence were 3.65 ± 0.36, 3.51 ± 0.42, 3.91 ± 0.45, 3.37 ± 0.22, and 3.37 ± 0.44, respectively (Table 2).
Levels of Nursing Professionalism, Adjustment to College Life, Satisfaction with a Major, Communication Skills, and Cultural Competence (N = 177).
Correlation among the Measures
Participants’ cultural competence was significantly and positively correlated with nursing professionalism (r = 0.39, p < .001), adjustment to college life (r = 0.38, p < .001), satisfaction with their major (r = 0.33, p < .001), and communication skills (r = 0.31, p < .001; Table 3).
Correlation among Nursing Professionalism, Adjustment to College Life, Satisfaction with a Major, Communication Skills, and Cultural Competence (N = 177).
Factors Affecting Cultural Competence
In Step 1, we regressed two variables with differences according to general characteristics (Model 1), health care issue awareness (β = 0.26, p < .001), and knowledge of laws related to foreign residents (β = 0.114, p = .130). In Step 2, we regressed the major variables—nursing professionalism, adjustment to college life, satisfaction with one’s major, and communication skills—against cultural competence (Model 2). The explanatory power of Model 2 was 26% (F = 11.73, p < .001), which established health care issue awareness (β = 0.21, p < .001), nursing professionalism (β = 0.27, p = .001), and adjustment to college life (β = 0.25, p = .03) as important variables (Table 4).
Factors Influencing Cultural Competence (N = 177).
Note. Dummy variable* (No: 0, Yes: 1).
Discussion
Differences in the participants’ cultural competence and general characteristics, including whether they were aware of health care issues, were observed. Our results suggest that the degree and level of exposure to health care–related situations and understanding health care laws and policies might produce differences in nursing students’ cultural competence. Inequality in the social determinants of health has caused significant inequalities in health outcomes among certain groups (International Council of Nurses [ICN], 2023; van Hout et al., 2024; World Health Organization, 2024), and discussions on health inequality and migrant health rights are active globally (Wurtz et al., 2024). Brottman et al. (2020) recommended using several educational strategies to develop knowledge, perceptions, attitudes, and skills as a result of a scoping review of diversity and inclusion education within health care, citing that comprehensive education and intervention need to develop fields that support culturally diverse patient populations. Therefore, various educational programs that reflect the current situation should be developed to understand these health care issues and related laws and to gain insight into multiculturalism.
The participants’ mean scores for nursing professionalism, adjustment to college life, satisfaction with a major, communication skills, and cultural competence were 3.65, 3.50, 3.91, 3.37, and 3.37 out of five points, respectively. Despite the different dates and locations of participation, the average scores of the major variables were similar to those in previous studies (Choi & Kim, 2018; S. M. Kim & Kim, 2018; Oh & Park, 2020; M. Park & Yoo, 2019). These results seem to be due to the Korean Accreditation Board of Nursing Education (KABONE) accreditation evaluation system. In 2005, KABONE adopted international standards for educational environments and program outcome-based curricula, such as adjustment to college life, satisfaction with a major, and communication skills, through accreditation evaluation. The adoption of international standards plays a role in training nurses to fulfill their social responsibilities by promoting competency-based nursing education, including cultural competence (KABONE, 2024). The Liaison Committee on Medical Education mandates education on cultural competence for certification (Mangold et al., 2019). Cultural competence is crucial for effectively providing culture-responsive medical services, reducing health inequality, challenging racism in health care, and improving patient safety, satisfaction, and health outcomes (Antón-Solanas et al., 2021). Therefore, integrated compulsory education is needed to improve content and cultural competence, including nursing professionalism, adjustment to college life, satisfaction with one’s major, and communication skills. Ličen and Prosen (2023) stated that it is important to prepare a nursing curriculum that integrates cultural content more, and it is necessary to introduce innovative education and learning methods to help them cope with various cultural experiences. Although not included in this study, various integrated educational methods that can enhance cultural adaptability and competence should be explored and the findings incorporated into the nursing curriculum. Such education will allow nursing students to view universality and specificity from a global perspective and expand their participation in various social activities to promote a healthy life for everyone and the well-being of all generations.
The factors influencing cultural competence were health care issue awareness, nursing professionalism, and adjustment to college life. The total explanatory power was 26%. Namely, students with health care issue awareness, a higher level of nursing professionalism, and well-adjusted to college life showed a higher level of cultural competence. Nursing students’ cultural competence is improved by the overall environment related to health care issues, knowledge about nursing and related careers, and their adjustment to various factors associated with college life. Hong and Han (2022) improved nursing professionalism among students by applying for multicultural education programs. Jang and Seo (2020) reported that nursing professionalism and cultural competence were correlated. These results highlight the importance of implementing educational programs to improve nursing professionalism and cultural competence. Chen et al. (2020) emphasized the importance of educational design and operations to improve cultural competence. Therefore, beyond the perspective of understanding cultural contexts specific to individual patients, educational content should be designed and developed to improve professionalism and cultural competence. Students should be educated on establishing professional values for nursing care through various curricula in college life.
Interestingly, communication skills, despite their theoretical importance, did not exhibit significant explanatory power for cultural competence in the results. This contrasts with the results reported by Alizadeh and Chavan (2015). These results may be attributable to the limitations of the measurements used in this study. Unlike the multicultural communication tools presented by Alizadeh and Chavan (2015), the communication tool utilized in this study measured therapeutic communication skills; it is thought that the effect of communication skills on cultural competence was not accurately reflected. Intercultural communicative competence is the practical ability to efficiently interact with people from different cultures as background knowledge and has an important influence on cultural competence. Based on the importance of intercultural communication, Anton-Solanas et al (2021) reported that nursing students perceived communication barriers as major barriers to safely caring for culturally diverse patients during clinical practice. Accordingly, various intervention studies should be conducted to improve undergraduate students’ intercultural communicative competence (Armah et al., 2020; Hong & Han, 2022). Furthermore, as intercultural communication competence is crucial for future professional nursing practice, experimental studies on this topic must be conducted using appropriate communication tools.
In addition, participants’ satisfaction with their major in this study did not affect their cultural competence. Although a comparison is impossible because no other studies have applied the same tools, the results differ from those of Jang and Seo (2020). In this study, satisfaction with one’s major was not significantly related to cultural competence in the regression analysis; however, satisfaction with one’s major and cultural competence was correlated. Further research is needed to determine which subfactors affect cultural competence by applying a nursing major satisfaction tool that sufficiently reflects the students’ region, generation, nursing major characteristics, and non-academic activities (e.g., multicultural volunteer work and cultural exchanges).
Finally, this study had low overall explanatory power for cultural competence. K. H. Kim (2020) and Kang et al. (2020) reported the influence of cultural empathy and global citizenship on cultural competence, respectively. Therefore, understanding the effects of factors not included in this study on cultural competence is necessary, and further studies investigating various factors (e.g., cultural sensitivity, empathy, global environment) not examined in this study should be conducted to identify factors that influence cultural competence. In addition, cultural competence models should also be studied by applying these various factors to the cultural-competency process model and cultural-nursing theory (Shen, 2015). This study will promote an understanding of building cultural competence, contribute to developing a cultural-competency system, and improve nursing quality.
Therefore, it is necessary to understand the effects of factors not included in this study on cultural competence, and studies that include various factors (e.g., cultural sensitivity and empathy) not examined in this study are needed to identify the factors that influence cultural competence.
This study has some limitations. Because data were collected over 3 months (from October to December 2019) prior to the first confirmed COVID-19 case in Korea on January 20, 2020, cultural competence reflecting the characteristics of students who experienced cultural changes in the post-COVID-19 era was not reflected. In addition, this study only targeted nursing students enrolled in two Korean cities. Furthermore, the researchers conveniently extracted the study sample, thereby limiting the expansion and interpretation of the study. Thus, repeated research with more participants should be conducted to generalize the study results.
Conclusion
This study revealed that health care issue awareness, nursing professionalism, and adjustment to college life significantly affected nursing students’ cultural competence. The factors influencing cultural competence were health care issue awareness, nursing professionalism, and adjustment to college life. Therefore, this study broadens the understanding of nursing professionalism, adjustment to college life, and cultural competence of Korean nursing students and provides basic data on multidimensional education development and design to cultivate transformative cultural competence.
Based on these results, educators must provide a systematic curriculum and integrated education to expand nursing students’ cultural competence and identify educational directions for participating in multicultural nursing activities to cultivate open-minded global insights.
Footnotes
Acknowledgements
The authors thank the professors (Denise Dunford, Paul Violanti, and Takesha Leonard) and the health care staff at Jericho Road Community Health Center (Buffalo, NY) for demonstrating the meaning, realization, role, and importance of multicultural nursing competency.
Author Contributions
Jiyoung Kim: Conceptualization; Data curation; Investigation; Validation; Writing—review & editing; Formal analysis.
Narae Heo: Conceptualization; Data curation; Investigation; Methodology; Validation; Writing—original draft; Writing—review & editing.
Consent to Participate
Written informed consent was obtained from voluntary study participants only after explaining the purpose, methodology, and procedures of the study.
Data Availability
All relevant data supporting the findings of this research are provided within the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval and Informed Consent Statements
Data collection was performed after the study was approved by the Public Institutional Review Board designated by the Ministry of Health and Welfare (IRB approval no. P01-201909-21-011).
