In the United States and Japan, as in many other countries, the nursing workforce does not mirror the ethnic, racial, and linguistic diversity found in the broader patient population. It is imperative to increase diversity in nursing to reduce health disparities and achieve health equity (Noone et al., 2020). To achieve the long-term goal of providing culturally competent care to patients with diverse values, beliefs, and behaviors (Spencer, 2020), strategies are needed in nursing education to create a culturally responsible learning environment that meets the complex needs of diverse student populations (Spencer, 2020).

Intercultural sensitivity, the capacity of a person to recognize cultural differences and respond appropriately during intercultural communication (Chen & Starosta, 2000), is necessary to understand and care for patients from different cultures. To increase intercultural sensitivity in students, many universities offer overseas study programs. However, financial obstacles often prevent students from studying abroad, and COVID-19 put an end to many study-abroad programs. A pedagogical approach using collaborative online international engagement can enable nursing students to study abroad virtually (Rubin, 2017).

Collaborative online international learning (COIL) allows students and instructors to come together across cultures to learn, discuss, and collaborate by using various communication technologies (Rubin, 2017). The COIL pedagogy has shown to be relevant to nursing. Bragadottir and Potter (2019) reported their experience with COIL embedded into graduate nursing courses at universities in the United States and Iceland. Describing a COIL experience for undergraduate nursing students at universities in the US and the Philippines, de Castro et al. (2019) reported that both groups found COIL to be a meaningful way to enhance intercultural sensitivity. We also reported our first experience with COIL, where a post-COIL student survey indicated an overall increase in intercultural sensitivity (Niitsu et al., 2023). However, more evidence, especially quantitative data, is needed to support the impact of COIL on intercultural understanding. The purpose of our study was to examine whether COIL is an effective pedagogy to increase intercultural sensitivity in undergraduate nursing students in the United States and in Japan. We hypothesized that intercultural sensitivity would increase after COIL. This study was approved as exempt by the internal review board of the University of Washington and was approved by the medical research ethics committee at the Tokyo Medical and Dental University.

METHOD

The study design was quasi-experimental. At the beginning of the spring 2021 term, undergraduate students enrolled in nursing courses at the American university (n = 48) and the Japanese university (n = 8) received an invitation to complete a pretest, the Intercultural Sensitivity Scale (ISS) (Chen & Starosta, 2000). Students also provided demographic information. At the end of the term, after they participated in COIL activities, students were invited to complete the ISS as a posttest.

Drawing on previous studies, Chen and Starosta (2000, p. 4) conceptualized intercultural sensitivity as the "ability to develop a positive emotion towards understanding and appreciating cultural differences that promotes appropriate and effective behavior in intercultural communication." They surveyed 414 college students and, based on factor analysis, extracted five affective factors of intercultural competency or domains: 1) interaction engagement, 2) respect for cultural differences, 3) interaction confidence, 4) interaction enjoyment, and 5) interaction attentiveness. The 24-item instrument uses a 5-point Likert scale, with scores ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores range from 24 to 120, with higher scores indicating greater intercultural competency. The ISS has appropriate concurrent validity with related instruments and high internal consistency ([alpha] = .84; Chen & Starosta, 2000). Validity and reliability of the Japanese version have also been confirmed (Kuwano et al., 2016). We obtained permissions from both the creator and translator to use the instrument. In our data, the pretest Cronbach's [alpha] was .83 at the US university and .67 at the Japanese university. We used IBM SPSS Statistics Version 28 to analyze the data. After confirming normal distribution of the scores by Shapiro-Wilk's test (p > .05), changes in ISS scores from pretest to posttest were analyzed using paired t-test.

RESULTS

All US students (n = 48) completed the pretest; 91.7 percent (n = 44) completed the posttest. Seven of the eight students at the Japanese university who completed the pretest also completed the posttest (87.5 percent). The average age of US students was 33.3 (n = 46, SD = 7.6, range 21 to 51 years). Most (83.3 percent, n = 40) identified as women; 12.5 percent (n = 6) identified as men, and two indicated another gender identity. Nearly half (n = 22, 45.8 percent) identified as White, 13 (27.1 percent) identified as Asian, and 9 (16.7 percent) identified as Black/African American. All students at the Japanese university were 19 years old, identified as women, and were ethnically Japanese.

Among the 44 US students, total scores increased significantly (pretest, M = 97.9, SD = 9.0; posttest, M = 102.8, SD = 8.4), t(43) = -4.1, p < .001, d = 0.62. Scores increased significantly in all domains except interaction confidence (p = .07). Total ISS scores increased significantly for the seven Japanese students (pretest, M = 88.4, SD = 6.8; posttest, M = 91.9, SD = 5.3), t(6) = -2.9, p = .03, d = 1.09. There were no statistically significant differences in the paired t-test for each domain of ISS; scores increased for interaction engagement, respect for cultural differences, and interaction confidence.

DISCUSSION

Richards and Doorenbos (2016) reported no significant improvement in intercultural sensitivity for US students after a three-week study abroad program in India. In contrast, our finding after implementation indicates that COIL is effective for increasing intercultural sensitivity in undergraduate nursing students. At least three articles report positive associations between COIL and cultural understanding in nursing students. Based on survey data analysis, Bragadottir and Potter (2019) reported COIL enhanced global awareness and cultural sensitivity in nursing students in the US and Iceland. In our first COIL experience, we received positive feedback from students, indicating an increase in cultural awareness (Niitsu et al., 2023). Before and after students in the US and the Philippines took part in COIL, de Castro et al. (2019) asked them to complete an intercultural competence self-evaluation; the result was an increase (+7.4 points) in intercultural competence scores. Our study adds quantitative evidence supporting COIL as an effective pedagogy for nursing students.

Our finding of higher ISS total scores for American students than Japanese students is consistent with literature (Kuwano et al., 2016; Richards & Doorenbos, 2016). The United States was largely created by immigrants and shows increasing racial and ethnic diversity. Japan is traditionally a homogeneous country and students have few opportunities to interact with people from different cultures. The main limitation of this study is the lack of randomization and use of a control group. Although more rigorous design, including randomized controlled trials, would be ideal, such research is not practical; nursing students take other courses while taking a COIL-enhanced course. One way to address this limitation would be to create an experimental and control group (students in courses with and without COIL) and have both groups complete a pretest and posttest. More variables (e.g., other languages spoken fluently, other global learning courses taken) could be included for analysis.

The relatively small sample size, especially of Japanese students, may have skewed the data. Although positive findings emerged, they were very modest. Although the demographics of the student groups did not match, the mismatch in diversity was an opportunity for deepening awareness and intercultural learning.

Finally, we need to acknowledge the social movements happening during this COIL project: Black Lives Matter and anti-Asian racism and xenophobia. These historical events may have confounded our study. Students may have experienced heightened levels of harassment during the study period and/or participated in community action, directly influencing their intercultural sensitivity.

CONCLUSION

This study provides quantitative evidence that COIL is an effective pedagogy to increase intercultural sensitivity among undergraduate nursing students. We recommend fellow nurse educators to consider incorporating COIL in their courses. Because of the limitations in the current study design, more studies are needed to provide stronger evidence to support its effectiveness.

REFERENCES