Comparative Study on the Intercultural Sensitivity of Japanese and Korean Nursing Students

study


Introduction
Intercultural sensitivity (IS) is defined as the ability to understand cultural differences positively [1], and is considered important when working with people from different cultures. IS is especially important for helping human service professionals including nurses to build better relationships with people from culturally diverse backgrounds [2]. As a result of increasing diversity, growing number of people with diverse background are visiting hospital settings in Japan and other Asian countries, where a historically mono-cultural society and has been progressively transitioning into more culturally diverse, and nurses as a front-line practitioner often find it difficult to fully understand their symptoms and conditions due to language barriers and different cultural background [3]. Previous studies have reported that Japanese nurses do not demonstrate their usual professional autonomy when caring for non-Japanese patients, and that IS affects their ability to demonstrate autonomy as a nursing professional [4].
Kılıçand Sevinç [6] reported that nursing students with higher IS have better communication skills and can enhance their IS through foreign language learning and the experience of living abroad. If IS can be improved through learning and having certain experiences, then Japanese nurses need to improve their IS starting from the time they are nursing students to provide the same level of care to both foreign and Japanese patients by exercising their autonomy. Enhancing IS of nurses and providing culturally sensitive care is one of the key factors in reducing inequalities in health care services [5]. However, at present, few studies on IS for nursing students in Japan and other Asian countries have been reported.

Data collection
Purposive sampling was used to collect data between June 1 and August 10, 2018. A survey was conducted using a self-administered anonymous questionnaire. The questionnaire consisted of 13 items, including attributes based on previous studies [4][5][6] and 24 items from the Intercultural Sensitivity Scale (ISS) [1,8]. For the 13 attributes, an English version was created first; then, Japanese and Korean versions were created by Japanese and Korean researchers, respectively, based on the English version. The consistency of the Japanese and Korean versions was checked by the Korean and Japanese researchers in terms of English and with the assistance of a Japanese graduate student who was fluent in Korean, and then back-translated into English to ensure the accuracy and cultural appropriateness of the translation. For the ISS, we used the Japanese version [4] and the Korean version [9]. This scale consists of five factors: interaction engagement (7 items), respect for cultural differences (6 items), interaction confidence (5 items), interaction enjoyment (3 items), and interaction attentiveness (3 items). Each item was rated on a 5-point Likert-type scale ranging from strongly disagree (scored as 1) to strongly agree (scored as 5). The total possible IS score was 120. The Cronbach's alpha of the scale was reported in original English version as 0.88 [8].
At the Japanese university, the co-researcher, who had no conflict of interest with the research participants, directly explained the survey contents to the participants orally and in writing, and then distributed the questionnaires during a break after the lectures. The researchers set up collection boxes at appropriate locations on campus and asked the participants to place the questionnaires in sealed envelopes and drop them in the collection boxes. The collection boxes were sealed so that only the researchers could collect and access the questionnaires after they had been dropped off. At the Korean university, the questionnaires were distributed and collected through the person in charge at the reception desk.

Analysis methods
The ISS was scored and tabulated for all 24 items and five subscales based on a 5-point scale (from 1 for "completely disagree" to 5 for "very much agree"). Microsoft Excel and IBM SPSS Statistics 22.0 (Tokyo, Japan) were used for tabulation and analysis. The significance level was set at p<0.05.

Ethical considerations
A request letter was attached to the questionnaire when it was distributed to the participants. The request letter described the purpose of the study, that participation was voluntary, that they could discontinue participation at any time without penalty, that the study was not related to academic performance in any way, that the data would not be used for any purpose other than research, that the data would be kept in a locked storage room in the laboratory and shredded and destroyed at the end of the study, that their anonymity would be protected, that the analysis would be coded so that no individual or university could be identified, and that the results of the study would be made public in an anonymous manner. Responding to the questionnaire was taken as consent.

Demographics and backgrounds of the participants in Japan and Korea
The number of questionnaires distributed was 159 in Japan and 220 in Korea, and the number (percentage) of questionnaires collected was 107 (48.6%) in Korea and 144 (90.6%) in Japan. Table 1 shows the results regarding the attributes of the participants. No significant differences in the distribution of each item were observed between Japan and Korea in terms of sex and grade.
A significant difference was found in the distribution of frequencies between Japan and Korea for the following items: 85 (59.0%) and 86 (80.4%) respondents in Japan and Korea, respectively, answered "Yes" for overseas travel experience, 115 (79.9%) and 54 (50.5%) answered "Yes" for the experience of interacting with foreigners, 110 (76.4%) and 98 (91.6%) answered "Yes" for the experience of receiving multicultural education, 13 (9.0%) and 56 (52.3%) answered "Yes" for the experience of working with foreign patients in practical training, and 121 (84.0%) and 104 (97.2%) answered "Yes" for opportunities to interact with foreign patients when working as a nurse in the future.
Regarding the ability to speak English (as a foreign language), 53 (36.8%) of the respondents in Japan answered that they could not speak English very well, while 57 (53.3%) of the respondents in Korea answered that they could speak English in simple conversations.

Sensitivity to different cultures among Japanese and Korean nursing students
The mean ± standard deviation total ISS scores were 78.55±8.7 for Japanese nursing students and 81.52±10.4 for Korean nursing students. The mean subscale scores are shown in Table 2. The mean scores for Total (t=2.379, p=.018), Interaction Confidence (t=6.847, p<.001), and Interaction Attentiveness (t=2.710, p=.007) were significantly higher in Korean than in Japanese nursing students (Table 2).

Interaction experience with foreigners and ISS
When the mean ISS scores were compared based on whether the respondents had experience interacting with foreigners (by country), Japanese nursing students showed significantly higher mean scores for Interaction Confidence (t=2.450, p=.017) and Interaction Attentiveness (t=1.999, p=.049), while Korean nursing students showed significantly higher mean scores for Total (t=2.108, p=.038); in both cases, all students in the group with interaction experience had higher mean scores (Table 3).
When the mean ISS scores were compared based on whether the participants had experience interacting with foreign patients in their practice (by country), Japanese nursing students showed a significant difference in Interaction Enjoyment (t=2.300, p=.037), while Korean nursing students showed a significant difference in Total (t=2.631, p=.010), Interaction Engagement (t=2.476, p=.015), and Interaction Attentiveness (t=2.113, p=.037); all had higher mean scores in the group that had experience working with foreign patients (Table 4).

English-speaking ability and ISS
With regard to English-speaking ability, we analyzed the participants' responses on a 6-point scale (from 1, "very fluent" to 6, "not fluent at all") and classified them into two groups: those with 1-3 points were considered "fluent" and those with 4-6 points were considered "not fluent". When the mean ISS scores were compared between the two groups (per country) in regard to English-speaking ability, Japanese nursing students scored higher for Total (t=4.191, p<.001), Interaction Engagement (t=4.257, p<.001), and Respect for Cultural Differences (t=2.148, p=.037); Interaction Confidence (t=3.026, p=.004) and Interaction Enjoyment (t=3.275, p=.002) were significantly different. In Korea, significant differences were found for Total (t=2.453, p=.016), Interaction Engagement (t=3.352, p=.001), and Interaction Confidence (t=2.918, p=.005), and the mean score was higher in the group that answered that they could speak in both Japanese and Korean (Table 5).
No significant differences in mean ISS scores were seen between those who had traveled abroad and those who had not, those who had the opportunity to receive multicultural education and those who had not, and those who thought they would have the opportunity to work with foreign patients in the future when they worked as nurses and those who thought they would not, in both countries.

Sensitivity to different cultures among Japanese and Korean nursing students
When the total ISS scores were compared between Japan and Korea, the total mean score for the Korean nursing students was significantly higher than that of the Japanese nursing students, suggesting that Korean nursing students are more culturally sensitive. Considering each subscale, the mean scores for Interaction Confidence and Interaction Attentiveness were significantly higher for Korean than for Japanese nursing students, suggesting that Korean nursing students are able to interact with foreigners with more confidence and understand events that occur as a result of differences in cultural backgrounds than are Japanese nursing students. Korean nursing students are therefore considered to be more confident than their Japanese counterparts when interacting with foreigners and more willing to understand events that occur because of differences in cultural backgrounds. IS is important in the areas of education and intercultural communication, especially in the medical profession [10,11]. Cultivating and enhancing the IS of nursing students, who will become nursing professionals in the future, is likely to have a positive impact on their ability to build relationships with patients from various backgrounds in clinical practice.

Influence of the experience of interacting with foreigners and working with foreign patients on IS
In this study, the mean total ISS score was higher in the group with experience interacting with foreigners in both Japan and Korea. In Japan, the mean score of the group with experience interacting with foreigners was significantly higher in Interaction Confidence and Interaction Attentiveness, while in Korea, a significant difference was found in the total mean score. In addition, the mean ISS score was significantly higher in both Japan and Korea for the group that answered "Yes" to the question "Have you had experience interacting with foreign patients in practice" than for the group that answered "No"; these results suggest that the experience of interacting with foreigners has an impact on IS. Göl & Özum mentioned that the total score of Intercultural Sensitivity Scale was higher among those nursing students who had encounters with people with different cultural backgrounds for any reason and those who wanted to work  [11,13,14].
In this study, no significant difference was found in the mean ISS score between the two groups for whether they would have opportunities to interact with foreign patients when working as a nurse in the future. However, a significant difference was seen in the distribution of frequencies between the two groups in Japan and Korea, and more than 97% of the students in Korea assumed that they would be providing nursing care for foreign patients in the future; this may be largely due to differences in social backgrounds. Ohnishi, Tanaka, Nishihara, lee, GO, & Morifuji found that Korean nursing students, regardless of their level of interest or international exchange experience, were aware of the need to provide medical health care services to foreigners, while majority of Japanese nursing students were not interested in this issue [15]. The proportion of foreigners in Korea has been increasing rapidly over the past decade, and as a result, it is likely that foreigners in Korea have been exposed to healthcare issues through not only formal educational institutions, but also the media and general sources [15]. In this study as well, more than 50% of the Korean students answered that they had experience working with foreign patients during their practical training, compared with less than 10% of the Japanese students. It can therefore be inferred that there are fewer opportunities to interact with foreign patients in clinical settings at general hospitals in Japan than in Korea, and this may be why Japanese students tend to limit their image of nursing to Japanese patients and think of nursing as being limited to Japanese people. By experiencing many opportunities to provide nursing care to foreigners while they are still nursing students, as is the case in Korea, Japanese students may be able to imagine the possibility of future relationships with foreigners and increase their readiness more concretely. As the number of non-Japanese patients is expected to increase in the future, training that prepares students for situations in which foreigners are the target, such as having opportunities to interact with foreigners in clinical practice and conducting exercises with simulated foreign patients, needs to be incorporated into undergraduate education.

Influence of English-speaking ability on IS among nursing students
In this study, the mean scores for Total, Interaction Engagement, and Interaction Confidence were significantly higher in the group that answered "Yes" to English-speaking ability than in the group that answered "No" in both Japan and Korea. It is thought that having a high proficiency in a foreign language is linked to confidence in cross-cultural communication and building good relationships with intercultural partners. Language is a major factor in communication, so it is predictable that language influences IS. According to Meydanlioglu, Arikan, and Gozum, knowing the language of another culture can lead to a better understanding of the culture and enhance IS among students [5]. In this study, Japanese students showed a significant difference in total and mean ISS scores for four of the five subscales, indicating that the ability to speak English has an impact on IS. Kato mentioned that Japanese nursing students do not usually spend time learning English because of the overcrowded curriculum [16].However, one of the relatively direct consequences of learning more than one language is to become familiar with more than one culture in a progressive way, or at least to develop an awareness of such multiculturalism [17]. Successful language learning will change the way people look at themselves, their identity, and their culture, and this is because successful language learning also increases selfawareness and cultural awareness [17]. In this perspective, enhancing nursing education with programs that improve the students' foreign language ability will help them to successfully manage cultural differences and provide culturally appropriate care in their nursing practice.
Nurses must build relationships with patients and respond to their needs. When providing care to foreign patients, high language proficiency not only facilitates communication, but also enables the nurse to understand the culture of the foreign patient and respond to their needs as quickly as possible. Although foreign patients are not necessarily English speakers, their willingness to and attitudes toward learning English as a foreign language may have an impact on the improvement of IS. The importance of effective verbal and non-verbal cross-cultural communication cannot be overemphasized as it is the basis of establishing trust and obtaining accurate health assessments and providing instructions [18]. Learning a foreign language may be one of the measures to improve IS in order to provide safe and secure nursing care to foreign patients.

Conclusion
In this study, the mean ISS score was higher for Korean than for Japanese nursing students. In both countries, students who had experience interacting with foreigners or with foreign patients in clinical practice had higher IS compared with other students, suggesting that the experience of interacting with foreigners may have an impact on IS. More than half of the Korean students had experienced interactions with foreigners in clinical practice, compared with less than 10% of the Japanese students. Moreover, in both Japan and Korea, students who responded that they had the ability to speak English were more culturally sensitive. Increasing IS among nursing students is thought to lead to the provision of higher quality nursing care, regardless of the cultural background of the patient. These findings suggest the necessity of increasing opportunities to interact with individuals who have different cultural backgrounds through clinical practice and activities both on and off campus.

Study Limitations
This study did have some limitations. First, the number of survey areas and facilities in Japan and Korea were limited, and only a small number of participants were analyzed, so caution is warranted when generalizing the IS of Japanese and Korean nursing students to different cultures based on the results of this study. To confirm the results of this study, it will be necessary to expand the study area and numbers of target facilities and participants in a future study.