1. Introduction
The coronavirus disease 2019 (COVID-19) pandemic poses a tremendous public health challenge worldwide. The pandemic has had global effects, leading to unprecedented high-pressure environments in health systems and high stress for health professionals. Issues such as patent exemptions, compulsory licenses, technology transfers, and vaccine hubs have become key points of discussion on the development and supply of vaccines [
1]. The pandemic has affected the global economy, labor market, and other facets of individual and societal lives [
2]. In the context of COVID-19, the imbalance between the need to ensure routine care despite limited medical resources and the need to combat infectious diseases have raised ethical and clinical management issues [
3]. However, these issues are not limited to the current COVID-19 pandemic. When the pandemic is over, these global health issues will become more important; moreover, as more people participate in the global health network, there may be conflicts of interest among individuals [
1]. The United Nations (UN) formulated 17 Sustainable Development Goals (SDGs) between 2016 and 2030. Among them, SDG 3 aims to ensure healthy lives and promote well-being for all age groups [
4]. Subsequently, the International Council of Nurses (ICN) recommended that the nursing associations of all countries be familiar with the contents of the SDGs that included the most important common goals of the UN and ICN [
5].
Currently, global health is an emerging field that reflects the health and well-being of the global population. Thus, it is important to prepare the next generation of nurses as global health advocates [
6]. Nurses are in direct contact with patients and provide care to them on the front lines [
7]. As a result, nurses take care of inpatients and deal directly with the disease-prone population and their complications or mortality [
8]. Nurses require cultural competency throughout this process. Cultural competency is the ability to understand the cultures of different minority groups and respond to their unique needs, establish and maintain relationships with people from different cultural backgrounds, avoid misunderstandings with people of other cultures while communicating efficiently, and to collaborate with individuals across cultures [
9].
Improving cultural nursing competency can increase trust in the relationships developed between patients and nurses, facilitate health and disease observation and control, and increase the provision and safety of equal and appropriate health services [
10]. Therefore, it is important that nurses who provide care to multicultural patients understand and respect diverse cultures and beliefs and have the competency to provide meaningful care to patients of different cultures through effective interactions [
11].
However, in a study of nursing students in Korea, 51.8% of the students had no experience related to other cultures during their undergraduate years, and only 36.1% of the students had the rare opportunity to interact with other cultures within Korea [
12]. When nurses encounter multicultural patients in clinical practice, they must provide their patients with optimal care based on their understanding of different cultures. Nevertheless, in general, the care that Korean nurses provide to patients of different cultures tends to be similar to the care they provide to Korean patients [
13]. In contrast, patients from other countries and ethnicities have mentioned inequalities in delivery and access to healthcare services [
14]. According to a study that analyzed education programs related to the internationalization of medical personnel, education programs in Korea lacked programs on internationalization competency that could strengthen the cultural awareness of medical and health personnel [
15]. However, in other countries, when a global health competency program was continuously implemented, knowledge of and technical competency in global health were 66.76% and 61.4%, respectively [
6], suggesting that continuous education was necessary.
Therefore, it is necessary to continuously apply and develop programs to improve the global health and cultural competencies of nurses. To achieve this, global health, cultural competency, and their influencing factors in future medical professionals and nursing students must be assessed to provide basic data for developing adequate programs. Factors that affect global health and cultural competencies include metacognition, which is the ability to understand and manipulate one’s cognitive processes [
16]; global health and cultural nursing confidence; and other aspects such as overseas volunteer experience, foreign language skills, and foreign friends that may induce familiarity with different cultures.
This study aimed to identify factors affecting the global health and cultural competencies of nursing students and to provide basic data for the development of programs to enhance these abilities.
4. Discussion
This study evaluated the global health and cultural competencies of nursing students and identified the influencing factors. First, global health competency had a mean score of 2.63 points (1–4 points), while cultural competency had a mean score of 3.21 points (1–5 points), which was slightly higher than the mean. This finding was similar to that of a previous study on the self-assessment of global health competency. In that study, knowledge and skill competencies for global health were 66.76% and 61.4%, respectively [
6]. Since the beginning of the COVID-19 pandemic, the importance of understanding the world, global health, and interest in health inequality has been emphasized. The lack of information on viruses and diseases, uncertainty in treatment, and lack of vaccines are examples of these effects [
2]. Therefore, to develop educational programs and interventions for the improvement of global health and cultural competencies, influencing factors were investigated.
First, cultural competency significantly affected global health competency, with an explanatory power of 23.1%. Global health competency encompasses understanding the burden of disease and health determinants, in addition to having core public health skills and soft skills [
3]. It comprehensively covers various aspects of global health. However, cultural competency, which is the ability to provide care in harmony with a patient’s culture [
20], was the only factor influencing global health competency. This suggests that the capacity to provide culturally sensitive care is the basis for global health competency. In previous studies, three areas of educational requirements were related to global health competency: (1) the relationship between health and access to clean water, sanitation, and nutrition; (2) cultural competency; and (3) understanding the relationship between health and human rights [
6]. Our results align with the literature on the relationship between global health and cultural competencies [
6] and further demonstrate that cultural competency is a significant factor affecting global health competency.
In a conceptual analysis, cultural competency is analyzed as the combination of cultural awareness, knowledge, sensitivity, skill, proficiency, and dynamicity [
26]. This analysis implies that being aware of cultural competency and accepting and respecting the culture, health demands, culturally specific understandings of disease and health, and cultural differences to prevent other environmental factors from having significant effects on participants are the basis of global health competency [
27].
Cultural competency—the ability to understand the characteristics of other cultures to not indiscriminately apply individual values or judgments, and to interact appropriately and effectively with people of other cultures [
28]—plays a role in improving health competency; this suggests that specific knowledge, education, and having a basic understanding of and accepting other cultures, are all important factors.
In a previous study evaluating the effects of overseas programs on nursing students [
12], understanding global health was the competency that most participants expected to learn during the program. However, the greatest achievement after participation was the expansion of human relationships. This indicates that global health is promoted not only by overseas programs but also by appropriate activities and programs that can improve global health competency.
Cultural nursing confidence and metacognition were factors affecting the cultural competency of nursing students, with an explanatory power of 34.3%. This finding aligns with that of a previous study [
29] in which cultural nursing self-efficacy was found to be an important factor for cultural competency. Cultural nursing self-efficacy was a mediating factor that allowed cultural competency development to continue despite obstacles or stress [
29]; thus, cultural nursing self-efficacy is also essential to improve cultural nursing confidence. Similarly, a study on cultural competency suggested a need for interventions that acknowledge the value of cultural awareness-based approaches, while also exploring the utility of more comprehensive cultural competence and safety approaches [
30]. Altogether, these findings show that factors related to cultural competencies are complex. Short-term general culture-related education did not enhance cultural nursing self-efficacy. In contrast, to improve cultural nursing confidence, long-term systematic education that connects culture and nursing is necessary [
31].
In this study, metacognition was a factor influencing cultural competency. Metacognition is the capacity to analyze one’s thoughts [
16], to know and control one’s thinking processes, and to apply previously acquired knowledge, skills, and experience through appropriate strategies [
32]. In particular, it is an important variable in learning and problem solving. It selects an appropriate strategy for the task; establishes, selects, and applies related knowledge and problem-solving strategies; evaluates the effects of the applied strategy; and regulates the performance process [
33]. As cultural competency is the ability to understand the effects of culture and to provide care according to a patient’s culture [
19], metacognition—which acts as a central factor in understanding, self-learning, communication, and problem-solving processes—may also be applied to improve cultural competency. Therefore, it is important to include elements that can improve metacognition in programs aimed at enhancing cultural competency.
In our study, the factors, age, gender, English language ability, grades, foreign friends, foreign residence for more than one month, overseas volunteer experience, and international health experience, were not factors affecting global health and cultural competencies. This finding suggests that experiencing foreign cultures and meeting others from different cultures are insufficient for promoting global health and cultural competencies. This conclusion aligns with that of previous research, indicating that short-term immersion and volunteer experience in foreign countries led to individuals’ growth while their understanding of the culture did not change [
34]. As suggested in a study of internationalization programs for nursing students [
12], curriculum internationalization that provided opportunities to meet nursing students from different cultures could play an important role in filling the gap between theory and practice. However, systematic programs with group activities based on such opportunities and writing a reflection journal are needed to improve related competencies. Feedback from students on international programs includes the importance of improving foreign language skills [
12]. However, foreign language ability does not affect global health and cultural competencies. This means that foreign language ability or foreign experiences may help to improve global health and cultural competence, but they do not directly affect these competencies.
It is important not only to provide information on foreign cultures and increase awareness but also to educate students on how to accept differences using cultural competency. In one study, global health education improved global health competency in nursing students [
35], indicating that global health competency can be improved through well-structured education. Experience of foreign cultures and the level of foreign language ability do not increase global competency, but these factors may create opportunities or means for communication. This reflects an intersection of metacognition and cultural nursing confidence that understands and interprets a situation comprehensively, allowing individuals to acknowledge and accept cultural differences.
In a modern globalized society, increased access to information does not improve global health competency. In contrast, specific education on interpreting global health issues, accepting these issues like one’s own and comprehensively analyzing these issues is necessary. Based on the findings of this study, it is necessary to apply an intervention program that can improve cultural competency through the enhancement of cultural nursing confidence and metacognition, subsequently improving global health competency.
The limitations of this study and suggestions for future research are as follows: First, several variables, other than the ones mentioned in this study, should be considered as factors affecting global health competency. Second, this was a cross-sectional study; thus, causal relationships couldnot be determined. Lastly, since this study had a small sample size as compared with other global health-related studies, care must be taken not to overestimate when interpreting the results. This study should be replicated by including different variables that align with the recent changes in the world, in terms of influencing factors. In the future, since cultural nursing confidence can be measured as a subdomain of cultural nursing competency, it is recommended to use the cultural nursing competency tool that includes cultural nursing confidence rather than the general cultural competency tool targeting nursing students.