Reassembling cultural safety education for Korean medical students based on the actor-network theory: Situational analysis of discourses

Reassembling cultural safety education for Korean medical students based on the actor-network theory: Situational analysis of discourses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reassembling cultural safety education for Korean medical students based on the actor-network theory: Situational analysis of discourses HyeRin Roh, Kyung Hye Park, Jina Oh, Hyoseon Choi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3423047/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Conducting an education program on cultural safety (CS) based on the actor-network theory’s (ANT) translation strategy, this study aimed to investigate changes relating to situations, significant actors, and discourse positions among Korean medical students. This qualitative pre/post study used situational analysis. Participants included 294 fifth-year medical students who attended CS classes between 2017−2019. For successful translation, the CS classes empowered the students as active agents to have direct dialogues with international guests, designing all human and non-human actors in the classroom to support them. The authors collected and coded data from students’ reflective essays, and then conducted organised situational, relational, and positional mapping. Following the classes, the participants reflected more on CS-related situations and actors. They defined culturally safe care as making patients feel at home, tailoring care individually, and providing treatment indiscriminately. Instead of focusing on others, they recognised their own biases, influences of their cultures on patient care, and contradictions in the Korean healthcare system, realising the healer role of doctors and the importance of patient-centeredness. Further, we explored how the students’ confusion about appropriate levels of accepting patients’ cultures might be associated with notions regarding humility rooted in Korean culture. We found that the ANT and situational analysis are applicable in CS education and research, and could be considered in future studies. Grounded theory Situational analysis Social justice Equity diversity and inclusion (EDI) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction How would Korean medical students respond to cultural safety (CS), and what would change after CS education? Which factors and discourses related to culturally safe care (CSC) would emerge in Korean contexts, where doctors are primarily native Koreans, and patients may be from other countries? How could CS be translated into Korean contexts for equity, diversity, and inclusion? While most CS programs have targeted Indigenous Peoples in countries with colonial histories (Lavoie et al., 2022 ; Mehus et al., 2019 ; Pimentel et al., 2021 ; Pitama et al., 2018 ), literature has rarely reported on programs in countries that had been occupied, such as Korea. Some studies have documented a small number of Asian students’ reflections (Plaisime et al., 2023 ), but their main focus was white/Black-based racism, which does not apply to Korean contexts. Descriptions of Asian students in literature do not adequately represent individual Korean medical students to consider factors and discourses for successful CS programs in Korea. Compared to considerable research about CS courses (Kurtz et al., 2018 ), studies examining qualitative changes in students’ discourses in CS programs have also been scarce (Jowsey, 2019 ). Furthermore, some literature has reported students’ resistance towards CS education, highlighting the need for further research on the subject (Arieli et al., 2012 ; Bullon, 2013 ; Gonzalez et al., 2019 ; Micheal et al., 2021 ; Ona et al., 2020 ). We believe CS education is also necessary in Korea for promoting learners to reflect critically on their biases, the power relations between doctors and patients, and the underlying social structures influencing health inequities, which are the primary aims of CS education (Curtis et al., 2019 ; Jowsey, 2019 ; Papps & Ramsden, 1996 ; Ramsden, 2002 ). Korean doctors’ and patients’ responses towards CSC might be more complex, and CSC might be defined differently in Korea, due to the significant variance between Korean and Western culture and history. Exploring Korean students’ discourses would help CS educators understand individual Asian students’ attitudes towards CS in their classes and improve pedagogical strategies for students from non-Western backgrounds. It would also help educators design and implement contextualised CS education in their respective countries. As CS aims to decolonise Western medicine (Wong et al., 2021 ), CS education should also decolonise Western CS education, thus embracing the world. Actor-network theory The actor-network theory (ANT) (Callon, 1984 ; Latour, 2005 ; Law, 1992 ) can be an inspiring conceptual and theoretical framework for investigating Korean medical students' responses, factors, and discourses and their changes through CS programs. ANT criticises modernism’s dichotomy, which divides the constructs of spirit/material, human/nature, and western/non-western (Latour, 1993 ). Regarding the ontological question of what the world is like, ANT answers that the world is not divided in reality but constitutes the collective of humans and non-humans (Latour, 1993 ). With the ANT approach, everything ( actors in ANT), including humans and non-humans in the social and natural worlds, interacts in constantly changing networks (Latour, 2005 ; Law, 1992 ): Reality is not fixed and pre-formed but exists as specific, diversified, and relational individuals (Latour, 2005 ). ANT recognises human and non-human actors as equals and considers non-human actors a dynamic agency shaping the world (Callon, 1984 ; Latour, 2017). For example, material things in a classroom, such as platforms, projects, and slides, are significant actors , asymmetrically enhancing communications between professors and students (Law, 1992 ). ANT aims to show how the world, including knowledge and power, emerges, maintains, evolves, or disappears through actor-networks (Latour, 2005 ; Law, 1992 ). To the epistemological question of how we can know the outside world, ANT answers that the networks of human and non-human actors ’ interactions create knowledge. It explores black boxes , which are actor-networks that are simplified and stable but fold heterogenous complexities (Law, 1992 ). Black boxes are unfolded and reassembled with other actors to create a new actor-network through the following four phases of translation : Problematisation is when an actor defines the problem’s nature in a specific situation and suggests an alternative; interessement refers to locking other actors into the roles in the actor’s approach; enrolment defines and interrelates other actors’ roles; and mobilisation means actors connect across the network (Callon, 1984 ). Regarding learning, ANT has different perspectives from objectivism and constructivism (Table 1 ). Objectivism aims to transmit knowledge to achieve educational objectives through effective lectures, and constructivism aims to organise learning environments to support learners’ knowledge construction (Jonassen, 1997 ). Meanwhile, according to the ANT, learning occurs in translation through networks among human and non-human actors (Fenwick & Edwards, 2014 ). As networked communities encourage translation (Fox, 2005 ), the ANT suggests that educators should plan interactions and activities as part of the translation process (Fenwick & Edwards, 2014 ; Fountain, 1999 ). Table 1 The characteristic views of objectivism, constructivism, and actor-network theory Objectivism Constructivism Actor-network theory Knowledge Transmitted by instructors Constructed by individual learners Networked by human and non-human actors Learning Acquisition Experiences Translation Non-human actors Delivery tools Learning resources to support human actors Dynamic agency symmetrically as human actors The focus of instructional design Instructors’ activities Learning environments Building communities and discourses Detailed characteristics for this table are based on a synthesis of relevant literature (Jonassen, 1997 ; Fenwick & Edwards, 2014 ; Fox, 2005 ; Fountain, 1999 ). [Table 1 ] CS educators can apply the ANT in their classes for successful translation . The ANT can be helpful, because CS classes involve non-human actors , including biases, discourses, pedagogy, and classroom facilities, which are a significant part of these classes. Specific biases, preconceptions, and social structures are black boxes , and changing discourses and positionality would be new actor-networks . Exploring students’ black boxes and newly assembled actor-networks could enable educators to understand students’ attitudes towards CS and their transformation through CS education. The translation process may reduce the risks of emotional distress for all culturally dominant and minoritised groups and teachers. However, only a few medical education studies have used the ANT to explore CS-related issues (Bleakley, 2012 ; MacLeod et al., 2019 ). Therefore, applying the ANT, this study aimed to analyse changes in students’ discourses on CSC through CS education. The specific research questions are listed below. Which situations and related actors do the students consider for CSC before and after CS education? What black boxes related to CSC changed to new actor-networks after CS education? Which debates related to CS were predominant among medical students in a CS class? Methods Korean context Korea has been a single-ethnic country with a solid national identity for a long time. Korea had a history of successfully resisting several invasions by foreign troops, but never colonised other countries. However, Korea experienced forced cultural destruction under Japanese occupation for 35 years, from 1910 to 1945. Koreans had rarely encountered people of different appearances until the late 19th century when the French, US, and British powers attacked Joseon. Since the mid-2000s, Korea has experienced a significant influx of people from East Asia, Southeast Asia, and the United States. Additionally, there has been a notable increase in the number of North Korean defectors and Korean Chinese residing in the country. Currently, foreign residents constitute more than four per cent of the Korean population. Korea has its own language, Korean, and English is the main language taught as a foreign language. Traditionally, Neo-Confucianism, Buddhism, and Taoism were integrated into Korean culture, which enhanced self-cultivation and community cultures. Self-cultivation aims to recover one’s true nature through enlightenment free from unhealthy desires: ‘Do’ in Korean. Community cultures encourage humility, mutual respect, harmony, and embracement. A common cultural characteristic in Korean relationships is ‘jeong’, which refers to ‘uncalculated self-sacrifice and unconditional compassionate feelings or affects related to persons, objects, or things with which people may have relationships’ (Heo et al., 2016 , p. 327). Protestantism and Catholicism are also major religions in modern Korea, while more than half of the population does not believe in any religion. American missionaries mostly propagated Protestantism since the late 19th century. Korea adopted Western medicine in the early 20th century, but many traditional Korean medical clinics still exist. Korea has a National Health Insurance Service (NHIS), which allows people to access healthcare easily, quickly, and affordably. However, short clinical encounters and governments’ limited financial support are among the shortcomings of the NHIS (Moon, 2012 ). Research design and positioning To answer the research questions, we designed a qualitative pre/post study using students’ essays. We chose the ANT as our theoretical framework because its ontological and epistemological foundations support this research. For the research methodology, we employed the grounded theory based on the assumption that it would help provide a new understanding of the psychosocial phenomena and experiences of Korean medical students in CS classes. Among grounded theory methodologies, we chose Clarke’s situational analysis (SA), because SA adopts non-human actors in science and technology studies and attempts to overcome the limitations of previous grounded theories (Clarke et al., 2017 ). SA is a situation-centred approach, systematically aligning research participants’ interactions to complex social contexts and conditions (Clarke et al., 2017 ). It provides visual maps to understand significant elements in situations, relationships, social worlds, and discursive positions (Table 2 ) (Clarke et al., 2017 ; Clarke et al., 2022 ). Thus, SA would help us investigate human and non-human actors , actor-networks , and discourses. Table 2 Maps of situational analysis Type of maps Aims at Helps Situational map Shows all meaningful human and non-human actors in a specific situation Frame the situation, identify invisible but significant elements, and categorise them Relational map Specify complex relations among the principal elements Consider how the elements had complex networks with other particular elements and discourses Social worlds/arenas map Present powerful collective actors influencing discourses in arenas of commitment Explore social dimensions, including organisations and institutions, of the situation Positional map Represent the major discursive positions on particular issues Depict engaged discourses and debates Details for this table are based on a synthesis of relevant literature (Martin et al., 2016 ; Clarke et al., 2017 ; Clarke et al., 2022 ). [Table 2 ] The research team comprised CS education, ANT, and grounded theory methodology experts. Authors HR and KHP have expertise in CS education and are involved in the CS classes; thus, they provided CS expertise in designing the classes and interpreting the findings. HR and HC have ANT expertise, and their primary contribution was to ensure that the paper was written based on the ANT approach. JO and HC are grounded theory experts and were not involved in the CS classes. Instead, they ensured rigorousness in the grounded theory methodology employed and provided objective views to explore the data. Participants We implemented mandatory CS classes for fifth-year students at Inje University College of Medicine from 2017 to 2019 (Roh & Nirta, 2018 ). We decided to exclude classes that occurred in and after 2020 because online settings due to the pandemic significantly altered non-human actors . A total of 302 students (99, 95, and 108 in the years 2017, 2018, and 2019, respectively) enrolled in the CS classes. Among them, eight did not submit essays; thus, the total number of research participants was 294. They were ethnically and nationally Korean. Before the classes, we explained their aims, processes, and activities in detail and obtained all participants’ oaths of confidentiality. The school’s curriculum comprises six years of study: one and a half years of premedical, two and a half years of preclinical, and two years of clinical clerkships. As part of the integrated curriculum, students learn subjects relating to medical humanities and social sciences, including communication, ethics, professionalism, patient safety, and health systems. The participants had previously known about ‘diversity with tolerance’, but never encountered the concept of CS. CS classes based on the ANT translation process We established CS programs using the ANT translation process for a culturally safe class climate, considering human and non-human actors. The program was a 6-h course, which consisted of an initial 2-h session on problematisation and interessement , followed by a 4-h session on enrolment and mobilisation. We held the second session three days after the first, allowing the participants to prepare themselves for the second session. HR coordinated the classes, and KHP participated as an invited speaker in the program. As CS emphasises a partnership approach that empowers patients (Jowsey, 2019 ; Papps & Ramsden, 1996 ), we empowered participants as active agents in the class for culturally safe education. The CS class intended to separate traditional classroom actor-networks to reassemble new actor-networks about the roles of students, teachers, and material things. The participants experienced the role changes of professors, students, and patients. For example, HR, the professor, and invited speakers changed their roles from delivering knowledge to encouraging students’ translation about CS. They did not give formal lectures on the concepts of CS. Instead, they empowered the participants to change their roles from passive to active learners. International guests, usually listeners as patients in a clinic, changed their positions to speakers. The platform, microphones, loudspeakers, and lights, usually for teachers in the classroom, served patient guests and students who were traditionally underrepresented in ordinary hospitals and classrooms. In contrast, the lecture desk and screen in the centre of the usual lecture theatre remained behind the scenes (Figure. 1). [Figure 1 ] Problematisation HR posed current CS issues related to international patient care in Korean healthcare. First, she asked the participants to anticipate the challenges experienced by international patients and Korean doctors in Korean clinics, which was to empower the participants to reflect on CS issues. Next, she shared international residents’ increasing population status and healthcare usage in Korea to make the participants consider significant CS issues as they relate to Korean medical settings. She then showed a video clip presenting cases of culturally unsafe care to help the participants gain awareness of its seriousness. She also delivered the reality of international patients’ experiences in Korean clinics through academic evidence. Finally, she highlighted that she prepared the CS classes for patients and future doctors experiencing difficulties in CSC. Interessement HR invited two Korean physicians and one Australian nurse to ensure that the participants considered the CS issue in their practice. The invited speakers sincerely and empathetically shared their experiences of culturally unsafe care and demonstrated their learning journey with reflective practice. The Australian nurse also shared her international friends’ experiences as foreign patients in Korean clinics. Then, HR helped the participants reflect on the changes in their thoughts towards CS to encourage them to extend their role to care for international (not only Korean) patients. She also announced the parts that the participants should take in the second session. Enrolment To enrol the participants, HR empowered them to meet with the guests in person, in a culturally safe manner. HR assigned them the following three roles: host, question developer, and questioner. First, the host’s role was to welcome international patient guests warmly. Before the dialogue, she provided short orientations about common nonverbal rude manners to help the participants behave in a culturally safe way. Second, the role of the question developer was to formulate the questions using the question formulation technique (QFT) (Rothstein & Santana, 2011). Through small group discussions, the participants brainstormed questions on what they wanted to know regarding guests’ medical experiences, cultures, and expectations towards Korean doctors. Next, they modified their questions to express them in a more culturally safe way, both verbally and nonverbally and then prioritised them. Third, the questioner’s role was to ask the guests questions group by group. The participants collaboratively practised their questioning in a culturally safe way before the dialogue. The participants and guests used English, native languages, or Korean during dialogues, as they preferred (Roh & Nirta, 2018 ). The participants actively engaged in the roles assigned. Mobilisation To mobilise the participants into new actor-networks of CS, HR asked the guests to share the class experiences with take-home messages after finishing the dialogue: The guests thanked them for their hospitality. Then, HR encouraged them to reflect on their class experiences through small group discussions and writing essays. Additionally, they created action plans for personal and professional development for CSC, allowing them to advocate for the patients and doctors in a culturally safe way. Data collection and analysis We collected the participants’ essays before and after the classes. The following questions were posed to guide the students’ writing: 1) ‘What does CSC mean?’; 2) ‘What obstacles do you think international patients experience?’; 3) ‘What difficulties do doctors face when encountering international patients?’; and 4) ‘What and how will you prepare for CS?’. The participants wrote one- to two-page reflective essays in 30 min and submitted them to the research assistant, who transcribed them for analysis digitally. We focused on situations, actors , and discourses related to CS while excluding specific biases on particular demographics. Before SA, we performed the initial, focused, and theoretical coding based on the constructivist grounded approach (Charmaz, 2014 ) to ‘digest’ the data and grasp the students’ psychosocial processes during the classes. Subsequently, we constructed three maps using situation analysis. We chose an organised situational map for the situations with significant actors , a relational map for the actor-networks related to CSC, and a positional map for students’ major debates. We did not limit predefined situations or categories of actors and actor-networks and explored them freely from the data. We conducted a constant comparative analysis using memos during the coding and mapping processes. First, authors HR and KHP analysed the data independently and cross-checked the codes, categories, themes, quotes, and mapping. Then, authors JO and HS reviewed the initial results. Finally, all authors checked and discussed the results using maps to visualise the situation and discourses. We numbered the students of the pre-class in 2017 A, post-class in 2017 AA, pre-class in 2018 B, post-class in 2018 BB, pre-class in 2019 C, and post-class in 2019 CC. We used inclusive terminology while writing the paper, but have used the participants’ expressions in the Results section for authenticity. Rigour with reflexivity We checked the quality of this study according to conceptual depth criteria for grounded theory studies: range, complexity, subtlety, resonance, and credibility (Table 3 ) (Clark et al., 2022; Nelson, 2016). We presented quotations and visual maps to ensure the range and complexity criteria. Then, as suggested by Nelson, we carefully examined the language used by the participants and researchers with the help of memos during analysis, to take the subtlety criteria into consideration. We also utilised the ANT for the resonance criteria to ensure sufficient conceptual depth of the study and reflect on researchers’ positions. Table 3 Conceptual depth criteria for situational analysis Criteria Nelson’s definition* Specific examples Range ‘A wide range of evidence from the data to illustrate the concepts’. Meaningful codes, quotations, examples, or maps Complexity ‘The concepts must be demonstrably part of a rich network of other concepts and themes in the data within which there are complex connections’. Diagrams such as positional, social worlds, and situational maps in situational analysis Subtlety ‘Subtlety in the concepts is understood by the researcher and used constructively to articulate the richness in its meaning’. Memo writing to pay attention to the participants’ language and the language generated by researchers during the analysis Resonance ‘The concepts have resonance with existing literature in the area being investigated’. Theories in previous literature Credibility** ‘The concepts, as part of a wider analytic story, stand up to testing for external validity’. Systematic analysis, reflexivity*** Details for this table are based on a synthesis of relevant literature (Charmaz & Thornburg, 2021; Clarke et al., 2022 ; Nelson, 2016; Taylor & Francis, 2013 ). *Nelson (2016) has claimed that ‘saturation’ is a problematic concept and suggested alternative criteria for grounded theory approaches: Conceptual depth criteria. **Nelson (2016) suggests validity as one of the conceptual depth criteria, and Clarke et al. ( 2022 ) have changed it to credibility and trustworthiness. ***Charmaz & Thornburg (2021) suggest having sufficient data, systematic analysis, and reflexivity for credibility. Among them, we adopted systematic analysis and reflexivity for credibility criteria in this study because the range criteria include sufficient data concepts. [Table 3 ] For credibility, we tried to ensure systematic analysis and reflexivity (Charmaz & Thornberg, 2021 ; Taylor & Francis, 2013 ). We systematically constructed the initial, focused, and theoretical coding for a thorough investigation. We continuously reflected on our unconscious biases and discourses related to CS, CS education, and research methodologies to prevent our perspectives from blinding the actual findings. We found our black-boxed dichotomous ideas about educators/students, doctors/patients, and dominant/socially minoritised groups: ‘Doctors and students have culturally unsafe attitudes’, ‘Patients have culturally safe behaviours’, and ‘The first target of CS education is individual students, not systems or social structures in medicine and medical education’. We also reflected on our biases against Confucian Korean cultures due to our experiences of being discriminated against. We realised that our negative attitudes against Confucianism might hinder our analysis of the actual findings. We also discovered our biases against postmodern approaches. We found our preference for constructionist pedagogies and conventional grounded theory methodologies rather than the ANT and SA. However, we reviewed theories and methodologies to select the most appropriate ones, repeating reflections on our research aims and questions. Results Changes in situations and significant actors Before the classes, the situation the participants imagined was when doctors met foreign patients with interpreters in large hospitals (Appendix 1). Specifically, Korean doctors diagnosed and treated foreign patients with/without interpreters or carers in large Korean hospitals, culturally inappropriate settings full of Korean patients, carers, and healthcare professionals. Language barriers, religious customs, surrounding people’s discrimination, socioeconomic and biological factors of patients, and knowledge were significant actors . They assumed that the patients were foreigners with different languages, religions, and biological backgrounds. To them, patients’ culture might disrupt treatment: Their focus was the diseases. After the classes, the situation changed to when the participants, as doctors, meet patients regardless of their nationality in their clinics (Appendix 2). Specifically, as doctors, they met international and Korean patients, together with the patients’ different companions and healthcare workers in hectic Korean clinical settings. Influential actors were their biases with preconceptions, Korean clinical settings with cultural factors, doctors’ discriminative care with avoidance, and reflections with direct experiences. They assumed that the patients were from various cultural backgrounds, not focusing on whether they were foreigners or not; simply approaching them as individuals experiencing pain. They recognised that silent discourses, including biases, cultures of all, and surrounding structures, might hamper patients’ access to clinics. Furthermore, they expressed terms of situations and actors more clearly, richly, and authentically after the CS classes. For example, before the course, the participants merely commented on ‘carers’, but they used more specific terminology such as ‘husbands’ or ‘employers’ after the classes. Additionally, before the classes, they used terms such as ‘empathy’, which in Korea, is a concept students learn through academic lectures and texts. However, after the course, they used colloquial words widely used by Koreans in daily life, such as ‘soeong-sim- seong-eui’ (heartfelt sincerity). Black boxes related to CSC before the CS program Before the classes, the participants assumed that ‘culture’ was about nationality, language, and religion, and the service was for foreign patients. They believed ‘CSC’ to be a culturally customised treatment with humanistic approaches and the best medical practice that might enhance patients’ compliance for good clinical outcomes and prevent harm (Fig. 2 ). They weighed the importance of doctors’ curer role in treating diseases as scientists. They felt that they should study languages, acquire knowledge about cultures, and develop clinical competence in international patient care. [Figure 2 ] Culturally customised treatment The participants believed that doctors should customise medical treatments for foreign patients with tolerance and language proficiency for CSC. Meanwhile, they believed that ignoring patients' cultural customs and taboos in culturally inappropriate facilities would influence patients’ compliance. The participants regarded tolerance of cultural customs as significant, expecting tolerance to influence rapport building, enhance patients’ compliance, and produce good clinical outcomes. They thought that doctors should accept foreign patients as they are: the cultural customs of foreign patients’ nations and religions. They considered open-mindedness without prejudice as principal because ‘difference’ does not mean ‘wrong’. They believed that medical care should be holistic to understand patients based on their cultures. Thus, they felt that experiencing cultures through media, books, and travelling abroad would help reduce their prejudice. CSC is to accept that there are different cultures from mine and admit differences as different, not incorrect. Ways of thinking and cultures evolve differently because geographical and cultural environments differ. We should respect other cultures because I always become a stranger if I visit other cultural regions. If time permits, I could acquire knowledge about many cultural regions through travelling, books, and TV. When my understanding of other cultural regions increases, I think my understanding of multicultural patients will increase, and the doctor-patient relationship will improve. (A65) To get [good treatment outcomes] beyond rapport building and increase patients’ compliance, we should know how patients’ culture influences their health. For example, the treatment for Koreans taking Korean herbal medicine and Canadians not taking it would be different. (C16) The participants assumed that language proficiency was primary for culturally customised treatment. They considered English, interpreters, and nonverbal communication as alternative communication tools. This was because they thought that foreigners could not speak Korean and could only speak English. Furthermore, even though they could speak Korean, they would experience difficulty, because Korean medical terminology would be different and unfamiliar to language used in daily life. They considered the language barrier the most challenging obstacle for patients and doctors. They were concerned about doctors’ difficulties in diagnosis and treatment because they could not wholly understand the patients and build rapport due to language differences. Consequently, they felt that they should develop linguistic abilities, especially in English, and learn to utilise interpreters. Language issues are the most challenging. It would be tough for patients to correctly talk about their symptoms and conditions in incommunicable situations. Doctors may not take necessary histories well and have limited patient education. Even with an interpreter, communicating accurately would be hard because of the big risk of interpreters’ arbitrary distortion. I need to study foreign languages a lot. (B9) The participants focused on the cultural etiquettes and taboos related to the medical practice of the patients’ countries or religions to customise their treatment accordingly. They believed that patients had the right to be respected about their medical beliefs and precautions even though doctors could not understand them. They expressed that the inappropriate service systems and facilities in Korean hospitals, such as the lack of worship areas, might deepen patients’ discomfort, misunderstanding, and loneliness. Concerned that they might make cultural mistakes due to their lack of knowledge and inexperience of unfamiliar patients’ cultures, they were also worried about the increase of burden on doctors in terms of the additional time and effort needed to care for international patients than Korean patients. They believed that they should acquire knowledge on other cultures’ medical customs and related dos and don’ts and on the profiles of multicultural populations. CSC is to respect things I cannot accept by medical common sense, such as Jehovah’s Witnesses’ transfusion refusal or female Muslim patients’ unacceptance of body exposure to male doctors. Although such cultural customs may appear different and inconsequential to me, those customs might have a mountain of meanings, more valuable than their life, to them. (C91) The biggest problem is that doctors cannot rapidly solve patients’ difficulties and obstacles. It would be hard for doctors because they need time and effort to communicate with them, find new medicines, and understand their ways of thinking. Doctors also have difficulties relating to having to study more to receive such patients. (A55) A humanistic approach The participants considered that surrounding people’s and healthcare professionals’ discriminatory attitudes would influence patients’ compliance. They believed that doctors should empathise with foreign patients’ vulnerable circumstances, treating them as human beings. The participants assumed that the discriminatory gaze of surrounding people and healthcare professionals against the patients, seeing them as strangers in multi-person rooms and the wards, might be influential factors: Expulsion would enhance patients’ non-compliance, resulting in harmful practices. They thought that the patients might feel daunted, alienated, and unsatisfied due to close-minded people and healthcare professionals. Thus, they commented on the importance of a non-discriminatory gaze and not using discriminatory words. I anticipate that the patients would receive unwelcome glances from people who think conversations would be difficult. They might be inappropriately treated, have to wait longer to receive treatment, or be rejected. Additionally, it would be hard to ask questions or receive answers. (C46) The participants regarded empathising with vulnerable foreign patients’ circumstances and maladaptation to afford clinical care in unfamiliar clinical settings as meaningful to the humanistic approach. They assumed that foreign patients would struggle with issues such as poor financial status, no health insurance, and undocumented status. They also supposed that non-supportive systems and facilities (e.g. different clinical care payment processes, complex hospital facilities with confusing signs, transportation difficulties without adequate carer support) might worsen foreign patients’ experiences in Korean care systems, which might deepen their fear, tension, confusion, and discomfort. Thus, they thought that doctors should provide considerate care with a supportive approach and improve facilities for foreign patients by exploring their difficulties and finding solutions. They felt that they should acquire knowledge of different healthcare systems in patients’ countries and the supportive systems for multicultural patients in Korea. Not all, but many multicultural families in Korea have low incomes. Thus, they could not afford the treatment they wanted or could not receive health insurance benefits because of visa problems. (C6) If they are inpatients in hospitals, they need time to adapt to staying with Koreans and our diets, besides [Korean style of] clinical encounters, because of unfamiliar environments. Considering my language and behaviours, I will prepare to make them comfortable in an unfamiliar place. Also, I will get acquainted with social work/hospital systems aligned to their treatment. (B17) The best medical practice The participants believed that doctors should pursue the best medical practice in foreign patient care because the patients have the right to receive the best treatment. As they regarded correct diagnosis and treatment as vital, they focused on effectively dealing with unscientific patients with defensible strategies. The participants considered epidemiology and biological factors by detailed history taking as central to correct diagnosis and treatment. They were concerned about other diseases more prevalent among those with certain geographic and racial/ethnic characteristics, but rare in Koreans. They were also worried that different clinical features and physical structures might impact doctors’ accurate diagnosis. Additionally, genetic factors influencing enzyme activation, disease progress, and physiologic reactions to therapies might affect doctors’ decisions in choosing appropriate treatments and estimating prognosis. Therefore, they felt that they should learn about common diseases in patients’ countries and the various biological factors of patients to prevent misdiagnosis and treatment failure. They would have different DNA from Koreans. Consequently, their clinical features might differ slightly, prevalent diseases may differ, and appropriate medicines may differ. In the case of other races/ethnicities or nationalities, we should pay more attention to diagnosis/treatment. Increasing interest in racial studies focused on other countries would be desirable. (A40) The participants believed that doctors should allow patients’ opinions within medical principles to guide the best medical practices because doctors must adopt scientific approaches. They felt that doctors should judge correct treatment by ethical and legal standards for patient safety. They had strong repulsion against alternative remedies or treatment refusal but took them for granted because of the ethical code to respect patients’ self-determination. While regarding patients as active participants in clinical care, they were concerned about non-compliant patients who assert only their culture, ignore Korean cultures, and disrespect Korean doctors. Their experiences of being discriminated against in foreign countries encouraged them to worry about them. They valued informed consent with sufficient and understandable explanations. Although it might be impossible to persuade unscientific patients, they still felt they should convince them as best as possible to uphold medical principles. They considered building a trusting rapport and eloquence to prevail over patients as helpful strategies. They commented that they should acquire knowledge of ethico-legal evidence and communication skills. CSC is to understand patients but persuade them for their treatment within the boundaries that they do not disregard patients’ cultures, although the patients make decisions based on incomprehensible thoughts from doctors’ perspectives. CS is important because treatment, after all, is for patients. (C73) CSC is making patients follow doctors’ therapeutic decisions without reluctance and building rapport by respecting patients. It would be difficult to build a strong rapport with patients. I will prepare myself to admit and respect other cultures and develop eloquence to make patients understand and participate in [doctors’] treatments without discomfort. (C8) New actor-networks of CSC after the CS program After the classes, the participants recognised that ‘culture’ was beyond language, nationality, and specific religions, and CSC was for all, including Korean patients. They defined ‘CSC’ as making patients feel at home, tailoring care individually, and serving patients indiscriminately as ordinary Koreans for medical care accessibility (Fig. 3 ). They realised that doctors are healers who treat humans, not diseases; thus, respecting culture is meaningful in patient care. They concluded that medical care comprises more than just providing treatment. They felt that they needed reflections and practice for CS through direct experiences, including global ones. [Figure 3 ] Making patients comfortable The participants explained that CSC would make international patients feel comfortable, as they would feel back home. They realised that deep understanding with an openhearted and warm approach could make the patients feel that they are in a familiar environment. Conversely, they recognised that some unconscious non-verbal habits could unintentionally make patients feel unpleasant, which might prevent the patients from visiting clinics, although they could access clinics easily. They noticed similar unconscious patterns in themselves, which were influenced by their cultural backgrounds and preconceptions. Thus, for international patients’ comfort, they decided to sincerely understand patients’ perspectives, provide consolation and solicitude from their hearts, and reflect on their preconceptions and unconscious cultural habits influenced by their cultural backgrounds. The participants realised that deeply understanding international patients as they are and welcoming them as humans are fundamental to making them feel at home. They noticed that CS started by sincerely sensing the hearts of patients in their hearts. They discovered that deep awareness of patients’ perspectives could make them understand their illnesses, including emotions. They admitted that their perspectives could prevent them from understanding patients wholly. They recognised that patients’ culture signifies their life experiences and personal characteristics such as lifestyles. They decided to pay complete attention to patients to understand all about them as humans. CSC is thinking and understanding what patients set a high value on, how they have lived, and their ways of thinking and behaviours. It is seeing and respecting the inside, more than what meets the eye. Thus, it is of greater importance because ‘culture’ eventually represents patients. We meet ‘human beings’, not ‘diseases’. I will pay attention to patients with all my heart, seeing them as persons as they are. (BB66) The participants recognised that warm consolation with solicitude could make international patients feel more at home. They identified that togetherness with true hearts, not with communication guidelines or manuals, was essential. They found that they could share and ease the patients’ pain and sorrow with warm words of compassion because they empathised with ill patients’ feelings of fear and being lost in other lands. They discovered that providing comfort by putting themselves in patients’ positions and attentively listening to their voices could alleviate patients’ illness and sadness. While regretting that they had neglected the importance of rapport, they noticed that their cultural custom of no friendly expressions might prevent them from providing warm consolation and solicitude. Consequently, they decided to warmly express their compassion and share patients’ sufferings ‘from the bottom of their hearts and souls’ through practice and observing senior clinical teachers during clinical placements. What international patients need the most is doctors’ compassion and sincere care, not only verbal communication. It will enable humanistic communication, transcending cultural barriers. I may not know beforehand about all cultures, but I will try to provide humane solicitude and consolation. (CC11) The participants recognised that proper non-verbal habits from international patients’ perspectives were basic, while some cultural behaviours of doctors might evoke unpleasant feelings in patients. They discovered that nonverbal etiquette or manners of Korean traditions, regions, or personal habits (e.g. ‘awkward smile when feeling embarrassed’) might cause unintentional misunderstanding. They found that they had similar patterns during the dialogues with international guests. They realised that not only explicitly rude manners but also ordinary culturally different non-verbal behaviours with good intentions might hurt and upset international patients. Therefore, they were concerned about making unintentional mistakes because of their unconscious cultural non-verbal habits. They were motivated to explore widespread nonverbal patterns that could hurt the patients and learn culturally safe non-verbal etiquette to provide patients with a pleasant experience. I deeply felt that our unconscious behaviours and thoughtless smiles marked international patients for life. I should mind that my sayings and doings, which we take for granted, unintentionally hurt them. I usually murmured ‘foreigner’ when I saw them. I will mind my p’s and q’s and attitudes from now on. (CC52) Tailoring care individually The participants defined CSC as individually tailored services in culturally safe cultures and systems. They realised that considering patients as diverse individuals and respecting patients’ values with sufficient discussion could be fundamental to individualised care. Conversely, they recognised that uniform services with generalised stereotypes disrespected patients, a critical obstacle to accessing medical care in Korea. They noticed similar disrespectful attitudes with stereotyping in themselves. They also found influences of their cultures and prejudice, science-centred medical cultures, hierarchical Confucian cultures, contradictory Korean NHIS, and the myth of a single ethnicity in Korea. Thus, they were motivated to consider diversity and respect patients’ values by ensuring longer clinical encounters and flexible medical services. They decided to explore their stereotypes with preconceptions and Korean medical cultures through direct experiences and reflective exercises. The participants realised that considering persons as diverse individuals was foundational to individually tailored care, which implied respecting differences. They recognised that Korean patients were also unique individuals, meaning CS was for every patient, including Koreans. They discovered that each patient had different needs despite having the same diseases and nationalities, and they should consider all aspects of patients’ characteristics. They identified their prejudice against differences and preconceptions (e.g. ‘CS was for international patients’, ‘Koreans were the same’, and ‘culture was about nationality and religion’), which prevented them from considering patients’ individuality. Thus, they were inspired to go beyond acquiring knowledge about national or religious cultures. They decided to learn more about diverse cultures and directly interact with various people to gain experiences. I thought that CS covered international patients, but I noticed today that it also includes Koreans and those from other religions and sexual orientations. I should consider not only the national dimension of cultures but also everything about patients, always. (AA35) Before the classes, I considered nationality and race as different cultural customs. I learned today that people are different, not racially but individually. I should approach them differently according to individuality. I felt that directly meeting and experiencing is important to understand individual patients. (AA103) The participants also realised that respecting patients’ values could enhance individualised care. They found that forcing doctors’ values would invade patients’ rights to participate in their care. They discovered that an equal footing was the key to appreciating different opinions and beliefs. They noticed that patients complained more about the inequality between doctors and patients than they thought: The unilateral decisions and judging patients’ views notably frustrated patients, because they did not acknowledge patients as principal agents of care. They discovered that hierarchical Confucian cultures and their prejudice against deviant cultures prevented them from respecting patients’ values. They recognised that their science-centredness and medical knowledge, perspectives from their religion of Protestantism, and conservative and closed Korean cultures considering harmony as virtue acted as standards influencing their prejudices. Thus, they were inspired to let the patients participate in the clinical process and, therefore, decided to explore their values with prejudice and the influences of their cultural backgrounds. I must not apply my culture and values to patients as a doctor. I should understand cultural differences. Each patient has different values. I will become a doctor who respects patients’ opinions so that they can be involved in the diagnosis and treatment process. (BB29) The participants identified that sufficient discussion between doctors and patients is requisite to individualised care, which needs satisfactory explanation and conversation in horizontal relations. They understood doctors’ difficulties in busy clinical settings relating to spending time dealing with the various needs of patients with uncommon diseases and language barriers. They had been proud of advanced Korean medical services but noticed that patients complained more seriously about Korean medical cultures of short clinical encounters than they thought. They identified the contradictory Korean NHIS policy as a serious obstacle to more extended discussions. They recognised the reality that the Korean medical services could not handle the diverse values of the patients. Thus, they were motivated to explore contradictions in the Korean medical systems and traditions that might interfere with sufficient discussions. They decided to develop clinical competence to perform longer consultations. People of different cultures might feel uncomfortable with our medical system, which is specialised for the Korean mentality of speed. I realised patients had difficulties expressing their stories because of short clinical encounters. I had thought our [fast] medical system was right and other countries’ systems were inefficient. I will form habits to explain kindly to patients and to discuss with them. (BB62) The participants noticed that flexible medical services with alertness were necessary for individually tailored care, while uniform services with Korean-targeted medical knowledge might make patients feel insignificant. Providing the same service to all neglects patients’ individuality. They recognised that being alert and sensitive to each individual was crucial. They found that the Korean culture of a single ethnicity, preconceptions that ‘foreigners speak English’ or ‘patients would be like them,’ and nationality stereotypes might keep them from regarding individuality. They were motivated not to rush to assume or judge patients’ cultures, including languages, and ask the patients and learn from them. They decided to explore uniform services based on the single-ethnic Korean culture and nationality stereotypes through reflective practices and direct experiences with people because they realised that indirect resources, such as media, might deliver stereotypical information. The most important thing is to approach without stereotyping. Not everyone has the same thoughts, even in the same cultural regions. People may have similar thinking, although their cultural regions differ. We cannot identify individuals with the cultures to which they belong. As one from an Islamic country could believe in Christianity, I learned stereotyping puts a person in a cultural box. (AA39) Treating them indiscriminately as ordinary Koreans The participants stated that CSC would serve international patients as ordinary Koreans by providing adequate consideration. Meanwhile, doctors’ avoidance and regional discrimination made patients refuse to visit clinics. They noticed similar patterns of inadequate thinking, avoidance, and discrimination in themselves. Thus, they decided to explore their behaviours, prejudices, stereotypes, and preconceptions through reflective practice from direct experiences. The participants realised that providing adequate consideration was decisive for indiscriminate service. Conversely, they discovered that doctors’ considerate behaviours, in their perspectives based on stereotypes and preconceptions, resulted in discrimination. They noticed that international patients felt discriminated against when doctors showed behaviours that they never did to Koreans. For example, Korean doctors did not interact with international patients using honorific and kind language, while they spoke politely to Korean patients speaking in the same manner. They understood the good intention of Korean doctors to respect the patients’ liberal and individualistic cultures based on their perspectives that ‘foreigners dislike respect and rapport because they are different from Koreans’. However, they found that the patients felt disregarded because the patients knew and expected Korean manners. They recognised that everyone is the same in their sufferings regardless of nationality and culture. Thus, they were inspired to treat international patients the same as Koreans. They decided to reflect on their biases about ways of respecting foreigners. Before the classes, I thought that CS was understanding and accepting of their cultures, but now I think the same treatment as Korean patients without discrimination is also CS. I had thought foreign residents didn’t know Korean culture, but this was inaccurate. (CC59) I thought that foreign patients were special. The biggest worry of international patients may be doctors’ feeling of burden because they consider the patients special. They are humans, after all. They are similar in thinking and feeling. I will practice, considering them as usual patients, the same as me. (AA37) The participants identified doctors’ avoidant behaviours with effortless attitudes to communicate as a pivotal obstacle to indiscriminate service. Conversely, doctors’ solid will and efforts to approach patients directly were indispensable. They understood that doctors’ lack of confidence in unfamiliar care with different languages and religions might cause panic about mistakes and misunderstandings. They discovered similar feelings in themselves due to preconceptions about complex international and Muslim patient care. They also realised their prejudice against foreigners and Islam stereotypes. However, they empathised with the patients’ feelings of alienation when doctors preferred interpreters or Korean companions. They found that the third person might intervene in patient-doctor interactions, alienating doctors. They noticed that their preconceptions, considering the language barrier too much, and their silent self-effacement culture might weaken their motivation to direct contact. Insights that they are doctors inspired them to try their best to communicate directly. They decided to prepare themselves to prevent panicking by becoming familiar with other cultures while hoping to feel confident by upgrading their language proficiency. The biggest obstacle would be the feeling of separation of doctors from international patients. Doctors’ internal issues, difficulty initiating a conversation, and feelings of fear might be the biggest challenges. The most important thing is not to have preconceptions and prejudices. As a doctor, I make efforts to treat them. (AA34) Despite language barriers, doctors’ attempts to see patients may help and comfort them. Doctors tend to ask fewer questions and offer fewer explanations when patients are foreigners. I will try my best so that patients do not feel neglected, although languages differ. However, the best thing is good communication. Thus, I need to study languages. (AA78) The participants realised that discrimination against people from less developed regions might aggravate inequity. They recognised that even ordinary people, including them, could commonly discriminate against others. They discovered they had unconsciously looked down on people from developing countries, rural areas, North Korean defectors, or Korean Chinese, although they had determined to treat them equally. They found that they evaluated, judged, and belittled the patients based on geographical stereotypes and prejudices (e.g. asking superfluous questions regarding patients’ regional origins, such as ‘Where are you from?’, or providing cheap treatment assuming that patients from less-developed regions are poor). Thus, they decided to mind their unconscious biases. Patients might have experienced difficulties because they were judged and treated differently according to their cultures. They were asked whether they had money or refused. We should not discriminate against people according to nationality. (C46) I expected people’s intellectual levels and compliance to be high. I felt tense when I encountered middle-aged male patients from province regions with rough accents of dialects and nonstandard language. (AA86) Major debates related to CS among the participants Target of interest The participants changed their positions from being wary of the ‘outside’ to embracing all ‘inside’ (Fig. 4 ). Before the CS classes, they blamed doctors or foreign patients because they believed that they had no biases, but others did. They focused on doctors and foreigners and regarded them as others. Their job was to study knowledge and skills because they considered themselves students. Thus, they valued indirect experiences such as media and books to acquire information about cultures and ethico-legal knowledge. [Figure 4 ] However, after the CS classes, the participants reflected on their biases and explored Korean medical settings from patients’ perspectives. They found that they were biased and influenced by surrounding cultures. They also discovered that contradictory Korean medical systems would deepen patients’ suffering. They realised that international patients were the same persons as themselves and Koreans: They are us. Therefore, their job changed to personal and professional development for CSC because they are doctors, and CS is a process for better care. They preferred direct experiences such as meeting people because studying from media and books might not help in real-life care contexts. They noticed that patients wanted doctors’ attention, not knowledge. Appropriate scope of CSC The participants’ views on the scope of CSC can be divided into four categories based on how they perceive patients’ cultures (Fig. 5 ). Before the classes, many participants believed that doctors should accept all patients’ cultures, sacrificing their culture, whereas some insisted that foreign patients must follow Korean culture. Others suggested that doctors should allow patients to express their cultures within the boundaries of ethics and safety. Finally, some students argued that patients and doctors should compromise. [Figure 5 ] After the classes, however, many participants recognised that doctors should not force their cultures, and mutual respect between patients and doctors is important because they felt the strong influences of doctors’ cultures. However, they were still uncertain about how much care could ensure mutual respect without sacrificing doctors’ culture. Discussion and conclusion Through the classes, students focused on their biases, the power of doctors’ culture, and influential systems related to CS and recognised what CSC exactly is according to patients’ perspectives, which were key goals in CS education. We could find Korean contextualised situations, actors , and discourses related to CS. The findings revealed that the translation of the ANT in the CS classes was successful. ANT strategies in CS education In this study, the ANT-based CS education strategy helped students internalise ANT’s perspective of relational ontology (Latour, 1993 ; MacLeod et al., 2019 ). The participants realised that the actors exist as individuals, in contrast to the grouped human actors as others, such as foreigners/Koreans before the classes. They noticed that predetermined stereotypes were not helpful because patients do not have fixed identities in ever-changing societies. They also recognised non-human actors , such as biases, cultural customs, medical discourses, facilities, healthcare systems, and hospital services, as equally significant to human actors . Similar to the ANT, CS education aims for learners to regard patients as diverse individuals beyond the dichotomous classification of othering and reflect on biases, discourses, and structures (Curtis et al., 2019 ; Jowsey, 2019 ; Papps & Ramsden, 1996 ; Ramsden, 2002 ). This study also revealed that students could learn CS effectively through translations by separating the actors and reassembling them with other silent actors (Callon, 1984 ; Kitto et al., 2012 ). Before CS education, to participants, international patients were black boxes of diseases and foreign geographical, biological, and cultural actors with stereotypes of non-compliance. Meanwhile, after the dialogues, participants translated the same patients into new actor-networks of human individuals with sufferings and various characteristics. They also discovered qualitatively different concepts of culture and CS in their new actor-networks . The results implied that active agency experiences with direct contacts and reflective practice may promote successful translation. The participants understood the concept of CS and changed their discourse positions despite no specific lectures. Literature has reported successful student-led activities against racism in curriculum and medicine (Afolabi et al., 2021 ; Forrest & Geraghty, 2022 ; Williams & Armstrong, 2019 ). Such findings imply that students could learn and practice CS when educators provide students with advocate roles in proper translation settings. In this study, participants advocated for both patients and doctors after the course. They became aware of the silent but authentic difficulties of patients and doctors, which were struggles they had never expected before. In this study, the participants noticed they did not listen to the voices of individuals, patients from minoritised groups, Koreans with diverse cultures, people from less developed regions, and even Korean doctors in today’s Korea, which was influenced by dominant discourses. CS aims to hear the voices of the culturally marginalised and encourage learners to consider them equal and become active agents for social justice (Curtis et al., 2019 ; Jowsey, 2019 ; Papps & Ramsden, 1996 ; Ramsden, 2002 ). The findings show that the ANT translation strategy effectively empowered learners to reach the goals of CS education. CS education for Korean medical students The results support why CS education, beyond cultural competence, is also needed for Korean medical students. The findings before CS education showed that the participants were unaware of their biases, blamed others, and had doctor-centredness. They felt that they needed to acquire knowledge and skills, which is cultural competence emphasised, but caused stereotyping and othering (Curtis et al., 2019 ; Kirmayer, 2012 ; Kumagai & Lypson, 2009 ; MacNaughton et al., 2016). The results showed that without CS education, students would worry about patients’ complaints and suits and attempt to overcome language and cultural barriers with knowledge and clinical competence. Meanwhile, after the classes, they learned about new roles and positions of doctors, patients, and students and what patient-centredness signifies, out of the black boxes of doctor-centred discourses. They recognised the shortcomings of doctor-centred care and that doctors’ implicit perspectives might be problematic, as CS emphasises that care recipients determine CSC (Jowsey, 2019 ; Papps & Ramsden, 1996 ). Their positions changed to focus on themselves and the service provider-centred healthcare system's limitations, which were CS education's intended outcomes (Jowsey, 2019 ). Meanwhile, the results implied that the terminology of ‘cultural humility’ might be inappropriate for Korean students. Cultural humility has emphasised humble attitudes with ‘non-paternalistic partnerships’ of doctors in power imbalanced dynamics between doctors and patients (Tervalon & Murray-García, 1998 ). The results suggest that Korean students and doctors might regard them as humble enough because they believed they sacrificed Korean culture to respect international cultures. This might prevent them from seeing that they are still paternalistic in power-imbalanced cultures. Respect, ‘Jonjung’ in Korean, means treating others highly by lowering oneself in Korean contexts. Korean etiquette based on Confucianism highlights propriety, treating another person as valuable by giving up one’s interest for them. Propriety needs to reflect on what one wants and then yield it to others, termed ‘Geuk-gi-bok-rye’ in Korean (Lee, 2014 ). Through the CS dialogues, the participants recognised that their unconscious humility and self-effacement might hurt patients. However, the results showed that the participants were confused about how much they should embrace patients’ culture rather than insisting on theirs because assertion was an unfamiliar concept in Korea. Humility, self-sacrifice, and self-effacement in Korean traditional virtues might clash with the virtue of assertiveness in the modern era. Furthermore, as many students have experienced foreigners’ or patients’ biases (Ahmad et al., 2022 ; Paul-Emile et al., 2020 ; Rizk et al., 2020 ), one-sided recommendations to doctors about humility towards patients might be inappropriate because doctors also have the right to be respected. Today, former students from diverse backgrounds have become doctors, which means that they would be continuously minoritised by humility discourses in the Korean context. CS is for all, including patients and doctors, and educators must not stereotype all students from dominant groups as biased (Hassouneh, 2006 ; Novak et al., 2022 ). Therefore, CS education strategies to enhance mutual respect with positive self-assertion would be helpful in the Korean context. Translating CS in the foundation of learners’ cultural wisdom We found that the participants understood CS by applying Korean cultural wisdom to the modern world. For example, heartfelt sincerity, togetherness with true heart, consolation and solicitude with compassion, and putting themselves in others’ positions are all from Confucian wisdom that emphasises benevolence or human heartedness, ‘In’ in Korean, in Korean community culture. Furthermore, they recognised that CS is not a particular treatment different from ordinary care: As a human and a doctor, CS is an everyday practice for all. Thus, they realised that they did not need more knowledge and skills but rather needed to get rid of inner conflicts and burdens, such as being free from false beliefs and becoming enlightened through continuous spiritual training, represented by emptiness or voidness in Buddhism, ‘Gong’ in Korean, and dao in Daoism or Confucianism, ‘do’ in Korean. The results imply that students could acquire appropriate CS attitudes with the help of their cultural wisdom. The participants also recognised the shortcomings of their beliefs, such as Confucianism, the myth of single ethnicity, science-centredness, and Protestantism discourses in Korean contexts. Such discourses were somewhat different from Western studies’ discourses, such as specific racial/ethnic supremacy, Western medicine’s supremacy over traditional medical care, and capitalism (Arieli et al., 2012 ; Hassouneh, 2006 ; Lavoie et al., 2022 ; Mehus et al., 2019 ; Micheal et al., 2021 ; Pimentel et al., 2021 ; Pitama et al., 2018 ). However, this study’s results support Western research reporting on biomedical discourses and patriarchy (Bullon, 2013 ; Hassouneh, 2006 ; Kirmayer, 2012 ; Wong et al., 2021 ). Among them, hierarchical and conservative Confucianism and single ethnicity are the traditional discourses, in which science-centredness from Western medicine and Protestantism aggravated close discourses, holding a dim view of the unusual as deviant. The results imply that students could identify outdated cultural discourses in changing local and global contexts. The results showed that the participants connected Korean wisdom to modern terms, such as individuality and indiscrimination, implying that students might create new CS concepts when we empower them to translate them into their cultural perspectives. Through translation, Protestant students could understand CS from the perspective of God’s love, identify paradoxically close Protestant attitudes against LGBTQIA + in Korea, and realise true love for all. Scientific students could understand CS from the scientist's perspective, discover race-based medicine's irrationality, and recognise proper evidence-based practice for all (Afolabi et al., 2021 ; Curtis et al., 2019 ). CS educators’ roles in Korean contexts This study suggested that Korean CS educators use Korean cultural wisdom to administer CS education culturally safely. The results imply that the primary contribution of CS education to the medical curriculum is to dismantle black-boxed and biased discourse about culture and CS education. Therefore, CS educators should focus more on establishing culturally safe systems and cultures rather than just teaching students in CS classes. Development programs for policymakers, school and hospital leaders, doctors, and faculties might be necessary for CS because they could drive institutional changes, allocate institutional resources, and influence curriculum (Pitama et al., 2018 ; Vass & Adams, 2021 ). In Korean contexts, we might have actions regarding Confucianism, the myth of single ethnicity, science-centredness, and Protestantism discourses for CS. However, there are calls for action regarding ‘white curriculum and logic’ in Western medicine (Plaisime et al., 2023 ) in historical racism contexts in Western society. Literature has presented racially biased content in Western medicine references (Amutah et al., 2021 ; Krishnan et al., 2019 ). Therefore, Korean educators should also consider the influences of biased Western medical practices. Applying the ANT to medical education and research We found that the ANT is applicable in CS education and medical education research. (Baker et al., 2021 ; Bleakley, 2012 ; Lingard, 2007 ). The ANT started in science and technology studies but has extended its impact to social and other studies in understanding spaces, migration, powers, organisations, health care, and education (Bilodeau & Potvin, 2016 ; Holifield, 2009 ; Lau, 2001 ; Law, 1992 ; Lee, 2016 ; Tummons et al., 2018 ). Medical education research has also reported the applicability of ANT, such as for communication, surgical training, interprofessional education, and objective structured clinical examinations (Bearman & Ajjawi, 2018 ; Ibrahim et al., 2015 ; Lingard, 2007 ; McDougall et al., 2016 ; Nestel et al., 2017 ). The ANT might be useful in exploring non-human actors and discourses in work-based learning environments, such as clinical placements or interprofessional teams (McMurtry et al., 2016 ; Sheehan et al., 2017 ). The ANT could also promote effective translation in programs with severe discourse conflicts or learners’ resistance (Baker et al., 2021 ; Kuper et al., 2017 ). Additionally, we discovered that research involves a translation process. Researchers problematise an issue and demonstrate to the readers how significant the issue is, which Lingard ( 2015 ) calls the problem/gap/hook considered in a study. Researchers uncover black-boxed concepts to reassemble new knowledge and provide the readers with further research issues for enrolment and mobilisation. The ANT’s translation process framework might help researchers design research to attract readers. Limitations and further research This study has some limitations. First, we did not analyse specific biases in-depth. Further research is required to explore silent biases and their associations with Korean culture. Second, we did not examine the perspectives of instructors, international guests, and researchers, although they also deeply reflected on the subject and were impressed by the course. Third, common discourses were Korean-specific, and thus, may not be applicable in other countries' cultural contexts. These aspects could be addressed in future studies. Fourth, we recognised, through analysis, that ‘empathy’ or ‘professionalism’ might be black boxes that need to unfold (Lingard, 2007 ). Last, in future research, we recommend using SA to investigate non-human actors , including materiality and discourses in medical education (Ahmady & Khani, 2022 ; Martin et al., 2016 ; Ott et al., 2021 ). Declarations Competing interests: The authors declare that they have no competing interests Acknowledgements: The authors thank Professor Ji Kyoung Park, Professor Jiyoung Yun, and the students for participating in the CS class, Lauren Nirta for co-developing the class, and Hee Jung Na for assisting with the research. Author contributions: All authors contributed to the study’s conception and design. Material preparation and data collection were performed by HyeRin Roh. Data analysis was performed by all authors. The first draft of the manuscript was written by HyeRin Roh and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Compliance with ethical standards: The Inje University Busan Paik Hospital Institutional Review Board reviewed and approved the research (IRB 2023-01015). 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Medical Education , 55 (2), 213–221. https://doi.org/10.1111/medu.14344 Williams, E., & Armstrong, M. (2019). Increasing trust and communication in medical education through a student-led social justice initiative. Academic Medicine, 94 (6), 752-753. https://doi.org/10.1097/acm.0000000000002635 Wong, S. H. M., Gishen, F., & Lokugamage, A. U. (2021). ‘Decolonising the medical curriculum’: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. London Review of Education , 19 (1), e19116. https://doi.org/10.14324/lre.19.1.16 Additional Declarations No competing interests reported. Supplementary Files Appendix231004.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3423047","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":238804609,"identity":"739e7326-9136-4d6b-846d-64f028720f3c","order_by":0,"name":"HyeRin Roh","email":"","orcid":"","institution":"Inje University College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"HyeRin","middleName":"","lastName":"Roh","suffix":""},{"id":238804610,"identity":"ab1f3df7-f7af-43e6-a75e-e92cb72b40ef","order_by":1,"name":"Kyung Hye Park","email":"","orcid":"","institution":"Yonsei University Wonju College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kyung","middleName":"Hye","lastName":"Park","suffix":""},{"id":238804611,"identity":"aff8d574-c618-472f-8b6d-703e7c553c7f","order_by":2,"name":"Jina Oh","email":"","orcid":"","institution":"Inje University College of Nursing","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jina","middleName":"","lastName":"Oh","suffix":""},{"id":238804612,"identity":"926f0016-5bfe-4302-8526-e0e47a3bd454","order_by":3,"name":"Hyoseon Choi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIie3RsQrCMBCA4StdI11ThPYVEgLBQVx9jYauxbE4CoV0dPVxWgJ2iZ07ONjF2VE3DwQHh1g3h/zjhY8jCYDP96fRCwCLgLwH4XeSIYl3PxPWTCXpumoHpVdCdKd2fOgzRHUTiq2DcHvMF0rnUtpNLmb6CtRmobIucigkVbpZyoHIeaANwABhu5tCxIHI+IEk/UZS+iKSUSLpDAlDolyEEbxL1ueC2kII0hvCraq4c0uNL3YrV3xfWz7eS5MknTGxc0vzMcDfCVwAt7iPfT6fz4c9AQU6Se9m+OSdAAAAAElFTkSuQmCC","orcid":"","institution":"Chosun University College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hyoseon","middleName":"","lastName":"Choi","suffix":""}],"badges":[],"createdAt":"2023-10-09 06:59:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3423047/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3423047/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44526205,"identity":"35b4e101-2e60-469c-8415-2b26d1cf577c","added_by":"auto","created_at":"2023-10-12 17:06:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1078093,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTransformation of the meanings of human and non-human actors in the classroom\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) and b) show that the platform, project, slides, microphone, and lights in the classroom served the instructor and invited speakers. The instructor and speakers deliver the information, and the students listen to them.\u003c/p\u003e\n\u003cp\u003ec) and d) show that the\u003cstrong\u003e \u003c/strong\u003eplatform, microphone, and lights served the international patient guests and students. The students actively ask questions, and the guests answer. The instructor supports dialogues between students and the guests.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/b42438bca3198e0ab8d2210f.png"},{"id":44526204,"identity":"dc96686f-7557-476f-9e58-eefda330f634","added_by":"auto","created_at":"2023-10-12 17:06:20","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":194792,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelational map: the black box of culturally safe care before the CS class\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/d529b6e4d90f96072685a9d4.jpg"},{"id":44527746,"identity":"2d525ff1-37c2-48d5-aa10-17d69caea547","added_by":"auto","created_at":"2023-10-12 17:14:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":236631,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelational map: Newly formed actor-networks of culturally safe care after the CS class\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/2f36d5d9c232eb4a12023b3f.jpg"},{"id":44526206,"identity":"e707bd9c-8c0a-4b06-b0ec-2aebacb31a7e","added_by":"auto","created_at":"2023-10-12 17:06:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":412545,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePositional map: The participants’ target of interest in cultural safety\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/a3c540ccd3fe35bd1436dff3.png"},{"id":44526208,"identity":"673e4fda-b77a-4089-8e87-35184308b376","added_by":"auto","created_at":"2023-10-12 17:06:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":343258,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePositional map: How much should doctors accept patients’ cultures?\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/b1a8b669de1daa918a7d442b.png"},{"id":56690376,"identity":"cb9adade-a991-40cf-afc0-f19416124aad","added_by":"auto","created_at":"2024-05-18 01:53:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2949553,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/12946301-292e-49e9-a61d-7d90c3f090ad.pdf"},{"id":44526226,"identity":"2808e89e-dcfd-4a36-b3a6-49d7a8a6b411","added_by":"auto","created_at":"2023-10-12 17:06:22","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":41085,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix231004.docx","url":"https://assets-eu.researchsquare.com/files/rs-3423047/v1/39afb8aaf48b31d23f31a280.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reassembling cultural safety education for Korean medical students based on the actor-network theory: Situational analysis of discourses","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHow would Korean medical students respond to cultural safety (CS), and what would change after CS education? Which factors and discourses related to culturally safe care (CSC) would emerge in Korean contexts, where doctors are primarily native Koreans, and patients may be from other countries? How could CS be translated into Korean contexts for equity, diversity, and inclusion? While most CS programs have targeted Indigenous Peoples in countries with colonial histories (Lavoie et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mehus et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Pimentel et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Pitama et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), literature has rarely reported on programs in countries that had been occupied, such as Korea. Some studies have documented a small number of Asian students\u0026rsquo; reflections (Plaisime et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), but their main focus was white/Black-based racism, which does not apply to Korean contexts. Descriptions of Asian students in literature do not adequately represent individual Korean medical students to consider factors and discourses for successful CS programs in Korea. Compared to considerable research about CS courses (Kurtz et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), studies examining qualitative changes in students\u0026rsquo; discourses in CS programs have also been scarce (Jowsey, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Furthermore, some literature has reported students\u0026rsquo; resistance towards CS education, highlighting the need for further research on the subject (Arieli et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Bullon, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Gonzalez et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Micheal et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ona et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe believe CS education is also necessary in Korea for promoting learners to reflect critically on their biases, the power relations between doctors and patients, and the underlying social structures influencing health inequities, which are the primary aims of CS education (Curtis et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Jowsey, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Papps \u0026amp; Ramsden, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Ramsden, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Korean doctors\u0026rsquo; and patients\u0026rsquo; responses towards CSC might be more complex, and CSC might be defined differently in Korea, due to the significant variance between Korean and Western culture and history. Exploring Korean students\u0026rsquo; discourses would help CS educators understand individual Asian students\u0026rsquo; attitudes towards CS in their classes and improve pedagogical strategies for students from non-Western backgrounds. It would also help educators design and implement contextualised CS education in their respective countries. As CS aims to decolonise Western medicine (Wong et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), CS education should also decolonise Western CS education, thus embracing the world.\u003c/p\u003e\n\u003ch3\u003eActor-network theory\u003c/h3\u003e\n\u003cp\u003eThe actor-network theory (ANT) (Callon, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1984\u003c/span\u003e; Latour, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Law, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1992\u003c/span\u003e) can be an inspiring conceptual and theoretical framework for investigating Korean medical students' responses, factors, and discourses and their changes through CS programs. ANT criticises modernism\u0026rsquo;s dichotomy, which divides the constructs of spirit/material, human/nature, and western/non-western (Latour, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). Regarding the ontological question of what the world is like, ANT answers that the world is not divided in reality but constitutes the collective of humans and non-humans (Latour, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). With the ANT approach, everything (\u003cem\u003eactors\u003c/em\u003e in ANT), including humans and non-humans in the social and natural worlds, interacts in constantly changing networks (Latour, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Law, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1992\u003c/span\u003e): Reality is not fixed and pre-formed but exists as specific, diversified, and relational individuals (Latour, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). ANT recognises human and non-human \u003cem\u003eactors\u003c/em\u003e as equals and considers non-human \u003cem\u003eactors\u003c/em\u003e a dynamic agency shaping the world (Callon, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1984\u003c/span\u003e; Latour, 2017). For example, material things in a classroom, such as platforms, projects, and slides, are significant \u003cem\u003eactors\u003c/em\u003e, asymmetrically enhancing communications between professors and students (Law, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1992\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eANT aims to show how the world, including knowledge and power, emerges, maintains, evolves, or disappears through \u003cem\u003eactor-networks\u003c/em\u003e (Latour, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Law, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1992\u003c/span\u003e). To the epistemological question of how we can know the outside world, ANT answers that the networks of human and non-human \u003cem\u003eactors\u003c/em\u003e\u0026rsquo; interactions create knowledge. It explores \u003cem\u003eblack boxes\u003c/em\u003e, which are \u003cem\u003eactor-networks\u003c/em\u003e that are simplified and stable but fold heterogenous complexities (Law, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1992\u003c/span\u003e). \u003cem\u003eBlack boxes\u003c/em\u003e are unfolded and reassembled with other \u003cem\u003eactors\u003c/em\u003e to create a new \u003cem\u003eactor-network\u003c/em\u003e through the following four phases of \u003cem\u003etranslation\u003c/em\u003e: \u003cem\u003eProblematisation\u003c/em\u003e is when an \u003cem\u003eactor\u003c/em\u003e defines the problem\u0026rsquo;s nature in a specific situation and suggests an alternative; \u003cem\u003einteressement\u003c/em\u003e refers to locking other \u003cem\u003eactors\u003c/em\u003e into the roles in the \u003cem\u003eactor\u0026rsquo;s\u003c/em\u003e approach; \u003cem\u003eenrolment\u003c/em\u003e defines and interrelates other \u003cem\u003eactors\u0026rsquo;\u003c/em\u003e roles; and \u003cem\u003emobilisation\u003c/em\u003e means \u003cem\u003eactors\u003c/em\u003e connect across the network (Callon, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1984\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding learning, ANT has different perspectives from objectivism and constructivism (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Objectivism aims to transmit knowledge to achieve educational objectives through effective lectures, and constructivism aims to organise learning environments to support learners\u0026rsquo; knowledge construction (Jonassen, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). Meanwhile, according to the ANT, learning occurs in \u003cem\u003etranslation\u003c/em\u003e through networks among human and non-human \u003cem\u003eactors\u003c/em\u003e (Fenwick \u0026amp; Edwards, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). As networked communities encourage \u003cem\u003etranslation\u003c/em\u003e (Fox, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), the ANT suggests that educators should plan interactions and activities as part of the \u003cem\u003etranslation\u003c/em\u003e process (Fenwick \u0026amp; Edwards, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Fountain, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1999\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe characteristic views of objectivism, constructivism, and actor-network theory\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObjectivism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConstructivism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eActor-network theory\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransmitted by instructors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConstructed by individual learners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNetworked by human and non-human actors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcquisition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTranslation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-human actors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelivery tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning resources to support human actors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDynamic agency symmetrically as human actors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe focus of instructional design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstructors\u0026rsquo; activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning environments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBuilding communities and discourses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDetailed characteristics for this table are based on a synthesis of relevant literature (Jonassen, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Fenwick \u0026amp; Edwards, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Fox, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Fountain, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1999\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCS educators can apply the ANT in their classes for successful \u003cem\u003etranslation\u003c/em\u003e. The ANT can be helpful, because CS classes involve non-human \u003cem\u003eactors\u003c/em\u003e, including biases, discourses, pedagogy, and classroom facilities, which are a significant part of these classes. Specific biases, preconceptions, and social structures are \u003cem\u003eblack boxes\u003c/em\u003e, and changing discourses and positionality would be new \u003cem\u003eactor-networks\u003c/em\u003e. Exploring students\u0026rsquo; \u003cem\u003eblack boxes\u003c/em\u003e and newly assembled \u003cem\u003eactor-networks\u003c/em\u003e could enable educators to understand students\u0026rsquo; attitudes towards CS and their transformation through CS education. The \u003cem\u003etranslation\u003c/em\u003e process may reduce the risks of emotional distress for all culturally dominant and minoritised groups and teachers. However, only a few medical education studies have used the ANT to explore CS-related issues (Bleakley, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; MacLeod et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, applying the ANT, this study aimed to analyse changes in students\u0026rsquo; discourses on CSC through CS education. The specific research questions are listed below.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhich situations and related \u003cem\u003eactors\u003c/em\u003e do the students consider for CSC before and after CS education?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat \u003cem\u003eblack boxes\u003c/em\u003e related to CSC changed to new \u003cem\u003eactor-networks\u003c/em\u003e after CS education?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhich debates related to CS were predominant among medical students in a CS class?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eKorean context\u003c/h2\u003e \u003cp\u003eKorea has been a single-ethnic country with a solid national identity for a long time. Korea had a history of successfully resisting several invasions by foreign troops, but never colonised other countries. However, Korea experienced forced cultural destruction under Japanese occupation for 35 years, from 1910 to 1945. Koreans had rarely encountered people of different appearances until the late 19th century when the French, US, and British powers attacked Joseon. Since the mid-2000s, Korea has experienced a significant influx of people from East Asia, Southeast Asia, and the United States. Additionally, there has been a notable increase in the number of North Korean defectors and Korean Chinese residing in the country. Currently, foreign residents constitute more than four per cent of the Korean population. Korea has its own language, Korean, and English is the main language taught as a foreign language.\u003c/p\u003e \u003cp\u003eTraditionally, Neo-Confucianism, Buddhism, and Taoism were integrated into Korean culture, which enhanced self-cultivation and community cultures. Self-cultivation aims to recover one\u0026rsquo;s true nature through enlightenment free from unhealthy desires: \u0026lsquo;Do\u0026rsquo; in Korean. Community cultures encourage humility, mutual respect, harmony, and embracement. A common cultural characteristic in Korean relationships is \u0026lsquo;jeong\u0026rsquo;, which refers to \u0026lsquo;uncalculated self-sacrifice and unconditional compassionate feelings or affects related to persons, objects, or things with which people may have relationships\u0026rsquo; (Heo et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2016\u003c/span\u003e, p. 327). Protestantism and Catholicism are also major religions in modern Korea, while more than half of the population does not believe in any religion. American missionaries mostly propagated Protestantism since the late 19th century.\u003c/p\u003e \u003cp\u003eKorea adopted Western medicine in the early 20th century, but many traditional Korean medical clinics still exist. Korea has a National Health Insurance Service (NHIS), which allows people to access healthcare easily, quickly, and affordably. However, short clinical encounters and governments\u0026rsquo; limited financial support are among the shortcomings of the NHIS (Moon, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eResearch design and positioning\u003c/h2\u003e \u003cp\u003eTo answer the research questions, we designed a qualitative pre/post study using students\u0026rsquo; essays. We chose the ANT as our theoretical framework because its ontological and epistemological foundations support this research.\u003c/p\u003e \u003cp\u003eFor the research methodology, we employed the grounded theory based on the assumption that it would help provide a new understanding of the psychosocial phenomena and experiences of Korean medical students in CS classes. Among grounded theory methodologies, we chose Clarke\u0026rsquo;s situational analysis (SA), because SA adopts non-human \u003cem\u003eactors\u003c/em\u003e in science and technology studies and attempts to overcome the limitations of previous grounded theories (Clarke et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). SA is a situation-centred approach, systematically aligning research participants\u0026rsquo; interactions to complex social contexts and conditions (Clarke et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). It provides visual maps to understand significant elements in situations, relationships, social worlds, and discursive positions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (Clarke et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Clarke et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Thus, SA would help us investigate human and non-human \u003cem\u003eactors\u003c/em\u003e, \u003cem\u003eactor-networks\u003c/em\u003e, and discourses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaps of situational analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of maps\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAims at\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHelps\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSituational map\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShows all meaningful human and non-human actors in a specific situation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrame the situation, identify invisible but significant elements, and categorise them\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelational map\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecify complex relations among the principal elements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsider how the elements had complex networks with other particular elements and discourses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial worlds/arenas\u003c/p\u003e \u003cp\u003emap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent powerful collective actors influencing discourses in arenas of commitment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExplore social dimensions, including organisations and institutions, of the situation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositional map\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRepresent the major discursive positions on particular issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepict engaged discourses and debates\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eDetails for this table are based on a synthesis of relevant literature (Martin et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Clarke et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Clarke et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe research team comprised CS education, ANT, and grounded theory methodology experts. Authors HR and KHP have expertise in CS education and are involved in the CS classes; thus, they provided CS expertise in designing the classes and interpreting the findings. HR and HC have ANT expertise, and their primary contribution was to ensure that the paper was written based on the ANT approach. JO and HC are grounded theory experts and were not involved in the CS classes. Instead, they ensured rigorousness in the grounded theory methodology employed and provided objective views to explore the data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe implemented mandatory CS classes for fifth-year students at Inje University College of Medicine from 2017 to 2019 (Roh \u0026amp; Nirta, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). We decided to exclude classes that occurred in and after 2020 because online settings due to the pandemic significantly altered non-human \u003cem\u003eactors\u003c/em\u003e. A total of 302 students (99, 95, and 108 in the years 2017, 2018, and 2019, respectively) enrolled in the CS classes. Among them, eight did not submit essays; thus, the total number of research participants was 294. They were ethnically and nationally Korean. Before the classes, we explained their aims, processes, and activities in detail and obtained all participants\u0026rsquo; oaths of confidentiality.\u003c/p\u003e \u003cp\u003eThe school\u0026rsquo;s curriculum comprises six years of study: one and a half years of premedical, two and a half years of preclinical, and two years of clinical clerkships. As part of the integrated curriculum, students learn subjects relating to medical humanities and social sciences, including communication, ethics, professionalism, patient safety, and health systems. The participants had previously known about \u0026lsquo;diversity with tolerance\u0026rsquo;, but never encountered the concept of CS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCS classes based on the ANT translation process\u003c/h2\u003e \u003cp\u003eWe established CS programs using the ANT \u003cem\u003etranslation\u003c/em\u003e process for a culturally safe class climate, considering human and non-human \u003cem\u003eactors.\u003c/em\u003e The program was a 6-h course, which consisted of an initial 2-h session on \u003cem\u003eproblematisation\u003c/em\u003e and \u003cem\u003einteressement\u003c/em\u003e, followed by a 4-h session on \u003cem\u003eenrolment\u003c/em\u003e and \u003cem\u003emobilisation.\u003c/em\u003e We held the second session three days after the first, allowing the participants to prepare themselves for the second session. HR coordinated the classes, and KHP participated as an invited speaker in the program. As CS emphasises a partnership approach that empowers patients (Jowsey, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Papps \u0026amp; Ramsden, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e1996\u003c/span\u003e), we empowered participants as active agents in the class for culturally safe education.\u003c/p\u003e \u003cp\u003eThe CS class intended to separate traditional classroom \u003cem\u003eactor-networks\u003c/em\u003e to reassemble new \u003cem\u003eactor-networks\u003c/em\u003e about the roles of students, teachers, and material things. The participants experienced the role changes of professors, students, and patients. For example, HR, the professor, and invited speakers changed their roles from delivering knowledge to encouraging students\u0026rsquo; translation about CS. They did not give formal lectures on the concepts of CS. Instead, they empowered the participants to change their roles from passive to active learners. International guests, usually listeners as patients in a clinic, changed their positions to speakers. The platform, microphones, loudspeakers, and lights, usually for teachers in the classroom, served patient guests and students who were traditionally underrepresented in ordinary hospitals and classrooms. In contrast, the lecture desk and screen in the centre of the usual lecture theatre remained behind the scenes (Figure. 1).\u003c/p\u003e \u003cp\u003e[Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eProblematisation\u003c/h2\u003e \u003cp\u003eHR posed current CS issues related to international patient care in Korean healthcare. First, she asked the participants to anticipate the challenges experienced by international patients and Korean doctors in Korean clinics, which was to empower the participants to reflect on CS issues. Next, she shared international residents\u0026rsquo; increasing population status and healthcare usage in Korea to make the participants consider significant CS issues as they relate to Korean medical settings. She then showed a video clip presenting cases of culturally unsafe care to help the participants gain awareness of its seriousness. She also delivered the reality of international patients\u0026rsquo; experiences in Korean clinics through academic evidence. Finally, she highlighted that she prepared the CS classes for patients and future doctors experiencing difficulties in CSC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eInteressement\u003c/h2\u003e \u003cp\u003eHR invited two Korean physicians and one Australian nurse to ensure that the participants considered the CS issue in their practice. The invited speakers sincerely and empathetically shared their experiences of culturally unsafe care and demonstrated their learning journey with reflective practice. The Australian nurse also shared her international friends\u0026rsquo; experiences as foreign patients in Korean clinics. Then, HR helped the participants reflect on the changes in their thoughts towards CS to encourage them to extend their role to care for international (not only Korean) patients. She also announced the parts that the participants should take in the second session.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEnrolment\u003c/h2\u003e \u003cp\u003e To enrol the participants, HR empowered them to meet with the guests in person, in a culturally safe manner. HR assigned them the following three roles: host, question developer, and questioner. First, the host\u0026rsquo;s role was to welcome international patient guests warmly. Before the dialogue, she provided short orientations about common nonverbal rude manners to help the participants behave in a culturally safe way. Second, the role of the question developer was to formulate the questions using the question formulation technique (QFT) (Rothstein \u0026amp; Santana, 2011). Through small group discussions, the participants brainstormed questions on what they wanted to know regarding guests\u0026rsquo; medical experiences, cultures, and expectations towards Korean doctors. Next, they modified their questions to express them in a more culturally safe way, both verbally and nonverbally and then prioritised them. Third, the questioner\u0026rsquo;s role was to ask the guests questions group by group. The participants collaboratively practised their questioning in a culturally safe way before the dialogue. The participants and guests used English, native languages, or Korean during dialogues, as they preferred (Roh \u0026amp; Nirta, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The participants actively engaged in the roles assigned.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMobilisation\u003c/h2\u003e \u003cp\u003eTo mobilise the participants into new \u003cem\u003eactor-networks\u003c/em\u003e of CS, HR asked the guests to share the class experiences with take-home messages after finishing the dialogue: The guests thanked them for their hospitality. Then, HR encouraged them to reflect on their class experiences through small group discussions and writing essays. Additionally, they created action plans for personal and professional development for CSC, allowing them to advocate for the patients and doctors in a culturally safe way.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData collection and analysis\u003c/h2\u003e \u003cp\u003eWe collected the participants\u0026rsquo; essays before and after the classes. The following questions were posed to guide the students\u0026rsquo; writing: 1) \u0026lsquo;What does CSC mean?\u0026rsquo;; 2) \u0026lsquo;What obstacles do you think international patients experience?\u0026rsquo;; 3) \u0026lsquo;What difficulties do doctors face when encountering international patients?\u0026rsquo;; and 4) \u0026lsquo;What and how will you prepare for CS?\u0026rsquo;. The participants wrote one- to two-page reflective essays in 30 min and submitted them to the research assistant, who transcribed them for analysis digitally. We focused on situations, \u003cem\u003eactors\u003c/em\u003e, and discourses related to CS while excluding specific biases on particular demographics.\u003c/p\u003e \u003cp\u003eBefore SA, we performed the initial, focused, and theoretical coding based on the constructivist grounded approach (Charmaz, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) to \u0026lsquo;digest\u0026rsquo; the data and grasp the students\u0026rsquo; psychosocial processes during the classes. Subsequently, we constructed three maps using situation analysis. We chose an organised situational map for the situations with significant \u003cem\u003eactors\u003c/em\u003e, a relational map for the \u003cem\u003eactor-networks\u003c/em\u003e related to CSC, and a positional map for students\u0026rsquo; major debates. We did not limit predefined situations or categories of \u003cem\u003eactors\u003c/em\u003e and \u003cem\u003eactor-networks\u003c/em\u003e and explored them freely from the data.\u003c/p\u003e \u003cp\u003eWe conducted a constant comparative analysis using memos during the coding and mapping processes. First, authors HR and KHP analysed the data independently and cross-checked the codes, categories, themes, quotes, and mapping. Then, authors JO and HS reviewed the initial results. Finally, all authors checked and discussed the results using maps to visualise the situation and discourses. We numbered the students of the pre-class in 2017 A, post-class in 2017 AA, pre-class in 2018 B, post-class in 2018 BB, pre-class in 2019 C, and post-class in 2019 CC. We used inclusive terminology while writing the paper, but have used the participants\u0026rsquo; expressions in the \u003cspan refid=\"Sec14\" class=\"InternalRef\"\u003eResults\u003c/span\u003e section for authenticity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRigour with reflexivity\u003c/h2\u003e \u003cp\u003eWe checked the quality of this study according to conceptual depth criteria for grounded theory studies: range, complexity, subtlety, resonance, and credibility (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (Clark et al., 2022; Nelson, 2016). We presented quotations and visual maps to ensure the range and complexity criteria. Then, as suggested by Nelson, we carefully examined the language used by the participants and researchers with the help of memos during analysis, to take the subtlety criteria into consideration. We also utilised the ANT for the resonance criteria to ensure sufficient conceptual depth of the study and reflect on researchers\u0026rsquo; positions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConceptual depth criteria for situational analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNelson\u0026rsquo;s definition*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecific examples\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lsquo;A wide range of evidence from the data to illustrate the concepts\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeaningful codes, quotations, examples, or maps\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplexity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lsquo;The concepts must be demonstrably part of a rich network of other concepts and themes in the data within which there are complex connections\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiagrams such as positional, social worlds, and situational maps in situational analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtlety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lsquo;Subtlety in the concepts is understood by the researcher and used constructively to articulate the richness in its meaning\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMemo writing to pay attention to the participants\u0026rsquo; language and the language generated by researchers during the analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResonance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lsquo;The concepts have resonance with existing literature in the area being investigated\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTheories in previous literature\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCredibility**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lsquo;The concepts, as part of a wider analytic story, stand up to testing for external validity\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic analysis, reflexivity***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eDetails for this table are based on a synthesis of relevant literature (Charmaz \u0026amp; Thornburg, 2021; Clarke et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Nelson, 2016; Taylor \u0026amp; Francis, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Nelson (2016) has claimed that \u0026lsquo;saturation\u0026rsquo; is a problematic concept and suggested alternative criteria for grounded theory approaches: Conceptual depth criteria.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e**Nelson (2016) suggests validity as one of the conceptual depth criteria, and Clarke et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) have changed it to credibility and trustworthiness.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e***Charmaz \u0026amp; Thornburg (2021) suggest having sufficient data, systematic analysis, and reflexivity for credibility. Among them, we adopted systematic analysis and reflexivity for credibility criteria in this study because the range criteria include sufficient data concepts.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFor credibility, we tried to ensure systematic analysis and reflexivity (Charmaz \u0026amp; Thornberg, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Taylor \u0026amp; Francis, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). We systematically constructed the initial, focused, and theoretical coding for a thorough investigation. We continuously reflected on our unconscious biases and discourses related to CS, CS education, and research methodologies to prevent our perspectives from blinding the actual findings. We found our \u003cem\u003eblack-boxed\u003c/em\u003e dichotomous ideas about educators/students, doctors/patients, and dominant/socially minoritised groups: \u0026lsquo;Doctors and students have culturally unsafe attitudes\u0026rsquo;, \u0026lsquo;Patients have culturally safe behaviours\u0026rsquo;, and \u0026lsquo;The first target of CS education is individual students, not systems or social structures in medicine and medical education\u0026rsquo;. We also reflected on our biases against Confucian Korean cultures due to our experiences of being discriminated against. We realised that our negative attitudes against Confucianism might hinder our analysis of the actual findings. We also discovered our biases against postmodern approaches. We found our preference for constructionist pedagogies and conventional grounded theory methodologies rather than the ANT and SA. However, we reviewed theories and methodologies to select the most appropriate ones, repeating reflections on our research aims and questions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eChanges in situations and significant\u003c/strong\u003e \u003cstrong\u003eactors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the classes, the situation the participants imagined was when doctors met foreign patients with interpreters in large hospitals (Appendix 1). Specifically, Korean doctors diagnosed and treated foreign patients with/without interpreters or carers in large Korean hospitals, culturally inappropriate settings full of Korean patients, carers, and healthcare professionals. Language barriers, religious customs, surrounding people\u0026rsquo;s discrimination, socioeconomic and biological factors of patients, and knowledge were significant \u003cem\u003eactors\u003c/em\u003e. They assumed that the patients were foreigners with different languages, religions, and biological backgrounds. To them, patients\u0026rsquo; culture might disrupt treatment: Their focus was the diseases.\u003c/p\u003e\n\u003cp\u003eAfter the classes, the situation changed to when the participants, as doctors, meet patients regardless of their nationality in their clinics (Appendix 2). Specifically, as doctors, they met international and Korean patients, together with the patients\u0026rsquo; different companions and healthcare workers in hectic Korean clinical settings. Influential \u003cem\u003eactors\u003c/em\u003e were their biases with preconceptions, Korean clinical settings with cultural factors, doctors\u0026rsquo; discriminative care with avoidance, and reflections with direct experiences. They assumed that the patients were from various cultural backgrounds, not focusing on whether they were foreigners or not; simply approaching them as individuals experiencing pain. They recognised that silent discourses, including biases, cultures of all, and surrounding structures, might hamper patients\u0026rsquo; access to clinics.\u003c/p\u003e\n\u003cp\u003eFurthermore, they expressed terms of situations and \u003cem\u003eactors\u003c/em\u003e more clearly, richly, and authentically after the CS classes. For example, before the course, the participants merely commented on \u0026lsquo;carers\u0026rsquo;, but they used more specific terminology such as \u0026lsquo;husbands\u0026rsquo; or \u0026lsquo;employers\u0026rsquo; after the classes. Additionally, before the classes, they used terms such as \u0026lsquo;empathy\u0026rsquo;, which in Korea, is a concept students learn through academic lectures and texts. However, after the course, they used colloquial words widely used by Koreans in daily life, such as \u0026lsquo;soeong-sim- seong-eui\u0026rsquo; (heartfelt sincerity).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBlack boxes\u003c/strong\u003e \u003cstrong\u003erelated to CSC before the CS program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the classes, the participants assumed that \u0026lsquo;culture\u0026rsquo; was about nationality, language, and religion, and the service was for foreign patients. They believed \u0026lsquo;CSC\u0026rsquo; to be a culturally customised treatment with humanistic approaches and the best medical practice that might enhance patients\u0026rsquo; compliance for good clinical outcomes and prevent harm (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). They weighed the importance of doctors\u0026rsquo; curer role in treating diseases as scientists. They felt that they should study languages, acquire knowledge about cultures, and develop clinical competence in international patient care.\u003c/p\u003e\n\u003cp\u003e[Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eCulturally customised treatment\u003c/h2\u003e\n \u003cp\u003eThe participants believed that doctors should customise medical treatments for foreign patients with tolerance and language proficiency for CSC. Meanwhile, they believed that ignoring patients\u0026apos; cultural customs and taboos in culturally inappropriate facilities would influence patients\u0026rsquo; compliance.\u003c/p\u003e\n \u003cp\u003eThe participants regarded tolerance of cultural customs as significant, expecting tolerance to influence rapport building, enhance patients\u0026rsquo; compliance, and produce good clinical outcomes. They thought that doctors should accept foreign patients as they are: the cultural customs of foreign patients\u0026rsquo; nations and religions. They considered open-mindedness without prejudice as principal because \u0026lsquo;difference\u0026rsquo; does not mean \u0026lsquo;wrong\u0026rsquo;. They believed that medical care should be holistic to understand patients based on their cultures. Thus, they felt that experiencing cultures through media, books, and travelling abroad would help reduce their prejudice.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eCSC is to accept that there are different cultures from mine and admit differences as different, not incorrect. Ways of thinking and cultures evolve differently because geographical and cultural environments differ. We should respect other cultures because I always become a stranger if I visit other cultural regions. If time permits, I could acquire knowledge about many cultural regions through travelling, books, and TV. When my understanding of other cultural regions increases, I think my understanding of multicultural patients will increase, and the doctor-patient relationship will improve.\u003c/em\u003e (A65)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTo get [good treatment outcomes] beyond rapport building and increase patients\u0026rsquo; compliance, we should know how patients\u0026rsquo; culture influences their health. For example, the treatment for Koreans taking Korean herbal medicine and Canadians not taking it would be different.\u003c/em\u003e (C16)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants assumed that language proficiency was primary for culturally customised treatment. They considered English, interpreters, and nonverbal communication as alternative communication tools. This was because they thought that foreigners could not speak Korean and could only speak English. Furthermore, even though they could speak Korean, they would experience difficulty, because Korean medical terminology would be different and unfamiliar to language used in daily life. They considered the language barrier the most challenging obstacle for patients and doctors. They were concerned about doctors\u0026rsquo; difficulties in diagnosis and treatment because they could not wholly understand the patients and build rapport due to language differences. Consequently, they felt that they should develop linguistic abilities, especially in English, and learn to utilise interpreters.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eLanguage issues are the most challenging. It would be tough for patients to correctly talk about their symptoms and conditions in incommunicable situations. Doctors may not take necessary histories well and have limited patient education. Even with an interpreter, communicating accurately would be hard because of the big risk of interpreters\u0026rsquo; arbitrary distortion. I need to study foreign languages a lot.\u003c/em\u003e (B9)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants focused on the cultural etiquettes and taboos related to the medical practice of the patients\u0026rsquo; countries or religions to customise their treatment accordingly. They believed that patients had the right to be respected about their medical beliefs and precautions even though doctors could not understand them. They expressed that the inappropriate service systems and facilities in Korean hospitals, such as the lack of worship areas, might deepen patients\u0026rsquo; discomfort, misunderstanding, and loneliness. Concerned that they might make cultural mistakes due to their lack of knowledge and inexperience of unfamiliar patients\u0026rsquo; cultures, they were also worried about the increase of burden on doctors in terms of the additional time and effort needed to care for international patients than Korean patients. They believed that they should acquire knowledge on other cultures\u0026rsquo; medical customs and related dos and don\u0026rsquo;ts and on the profiles of multicultural populations.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eCSC is to respect things I cannot accept by medical common sense, such as Jehovah\u0026rsquo;s Witnesses\u0026rsquo; transfusion refusal or female Muslim patients\u0026rsquo; unacceptance of body exposure to male doctors. Although such cultural customs may appear different and inconsequential to me, those customs might have a mountain of meanings, more valuable than their life, to them.\u003c/em\u003e (C91)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThe biggest problem is that doctors cannot rapidly solve patients\u0026rsquo; difficulties and obstacles. It would be hard for doctors because they need time and effort to communicate with them, find new medicines, and understand their ways of thinking. Doctors also have difficulties relating to having to study more to receive such patients.\u003c/em\u003e (A55)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eA humanistic approach\u003c/h2\u003e\n \u003cp\u003eThe participants considered that surrounding people\u0026rsquo;s and healthcare professionals\u0026rsquo; discriminatory attitudes would influence patients\u0026rsquo; compliance. They believed that doctors should empathise with foreign patients\u0026rsquo; vulnerable circumstances, treating them as human beings.\u003c/p\u003e\n \u003cp\u003eThe participants assumed that the discriminatory gaze of surrounding people and healthcare professionals against the patients, seeing them as strangers in multi-person rooms and the wards, might be influential factors: Expulsion would enhance patients\u0026rsquo; non-compliance, resulting in harmful practices. They thought that the patients might feel daunted, alienated, and unsatisfied due to close-minded people and healthcare professionals. Thus, they commented on the importance of a non-discriminatory gaze and not using discriminatory words.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eI anticipate that the patients would receive unwelcome glances from people who think conversations would be difficult. They might be inappropriately treated, have to wait longer to receive treatment, or be rejected. Additionally, it would be hard to ask questions or receive answers.\u003c/em\u003e (C46)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants regarded empathising with vulnerable foreign patients\u0026rsquo; circumstances and maladaptation to afford clinical care in unfamiliar clinical settings as meaningful to the humanistic approach. They assumed that foreign patients would struggle with issues such as poor financial status, no health insurance, and undocumented status. They also supposed that non-supportive systems and facilities (e.g. different clinical care payment processes, complex hospital facilities with confusing signs, transportation difficulties without adequate carer support) might worsen foreign patients\u0026rsquo; experiences in Korean care systems, which might deepen their fear, tension, confusion, and discomfort. Thus, they thought that doctors should provide considerate care with a supportive approach and improve facilities for foreign patients by exploring their difficulties and finding solutions. They felt that they should acquire knowledge of different healthcare systems in patients\u0026rsquo; countries and the supportive systems for multicultural patients in Korea.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eNot all, but many multicultural families in Korea have low incomes. Thus, they could not afford the treatment they wanted or could not receive health insurance benefits because of visa problems.\u003c/em\u003e (C6)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIf they are inpatients in hospitals, they need time to adapt to staying with Koreans and our diets, besides [Korean style of] clinical encounters, because of unfamiliar environments. Considering my language and behaviours, I will prepare to make them comfortable in an unfamiliar place. Also, I will get acquainted with social work/hospital systems aligned to their treatment.\u003c/em\u003e (B17)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eThe best medical practice\u003c/h2\u003e\n \u003cp\u003eThe participants believed that doctors should pursue the best medical practice in foreign patient care because the patients have the right to receive the best treatment. As they regarded correct diagnosis and treatment as vital, they focused on effectively dealing with unscientific patients with defensible strategies.\u003c/p\u003e\n \u003cp\u003eThe participants considered epidemiology and biological factors by detailed history taking as central to correct diagnosis and treatment. They were concerned about other diseases more prevalent among those with certain geographic and racial/ethnic characteristics, but rare in Koreans. They were also worried that different clinical features and physical structures might impact doctors\u0026rsquo; accurate diagnosis. Additionally, genetic factors influencing enzyme activation, disease progress, and physiologic reactions to therapies might affect doctors\u0026rsquo; decisions in choosing appropriate treatments and estimating prognosis. Therefore, they felt that they should learn about common diseases in patients\u0026rsquo; countries and the various biological factors of patients to prevent misdiagnosis and treatment failure.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eThey would have different DNA from Koreans. Consequently, their clinical features might differ slightly, prevalent diseases may differ, and appropriate medicines may differ. In the case of other races/ethnicities or nationalities, we should pay more attention to diagnosis/treatment. Increasing interest in racial studies focused on other countries would be desirable.\u003c/em\u003e (A40)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants believed that doctors should allow patients\u0026rsquo; opinions within medical principles to guide the best medical practices because doctors must adopt scientific approaches. They felt that doctors should judge correct treatment by ethical and legal standards for patient safety. They had strong repulsion against alternative remedies or treatment refusal but took them for granted because of the ethical code to respect patients\u0026rsquo; self-determination. While regarding patients as active participants in clinical care, they were concerned about non-compliant patients who assert only their culture, ignore Korean cultures, and disrespect Korean doctors. Their experiences of being discriminated against in foreign countries encouraged them to worry about them. They valued informed consent with sufficient and understandable explanations. Although it might be impossible to persuade unscientific patients, they still felt they should convince them as best as possible to uphold medical principles. They considered building a trusting rapport and eloquence to prevail over patients as helpful strategies. They commented that they should acquire knowledge of ethico-legal evidence and communication skills.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eCSC is to understand patients but persuade them for their treatment within the boundaries that they do not disregard patients\u0026rsquo; cultures, although the patients make decisions based on incomprehensible thoughts from doctors\u0026rsquo; perspectives. CS is important because treatment, after all, is for patients.\u003c/em\u003e (C73)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eCSC is making patients follow doctors\u0026rsquo; therapeutic decisions without reluctance and building rapport by respecting patients. It would be difficult to build a strong rapport with patients. I will prepare myself to admit and respect other cultures and develop eloquence to make patients understand and participate in [doctors\u0026rsquo;] treatments without discomfort.\u003c/em\u003e (C8)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eNew\u003c/strong\u003e \u003cstrong\u003eactor-networks\u003c/strong\u003e \u003cstrong\u003eof CSC after the CS program\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAfter the classes, the participants recognised that \u0026lsquo;culture\u0026rsquo; was beyond language, nationality, and specific religions, and CSC was for all, including Korean patients. They defined \u0026lsquo;CSC\u0026rsquo; as making patients feel at home, tailoring care individually, and serving patients indiscriminately as ordinary Koreans for medical care accessibility (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). They realised that doctors are healers who treat humans, not diseases; thus, respecting culture is meaningful in patient care. They concluded that medical care comprises more than just providing treatment. They felt that they needed reflections and practice for CS through direct experiences, including global ones.\u003c/p\u003e\n \u003cp\u003e[Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eMaking patients comfortable\u003c/h2\u003e\n \u003cp\u003eThe participants explained that CSC would make international patients feel comfortable, as they would feel back home. They realised that deep understanding with an openhearted and warm approach could make the patients feel that they are in a familiar environment. Conversely, they recognised that some unconscious non-verbal habits could unintentionally make patients feel unpleasant, which might prevent the patients from visiting clinics, although they could access clinics easily. They noticed similar unconscious patterns in themselves, which were influenced by their cultural backgrounds and preconceptions. Thus, for international patients\u0026rsquo; comfort, they decided to sincerely understand patients\u0026rsquo; perspectives, provide consolation and solicitude from their hearts, and reflect on their preconceptions and unconscious cultural habits influenced by their cultural backgrounds.\u003c/p\u003e\n \u003cp\u003eThe participants realised that deeply understanding international patients as they are and welcoming them as humans are fundamental to making them feel at home. They noticed that CS started by sincerely sensing the hearts of patients in their hearts. They discovered that deep awareness of patients\u0026rsquo; perspectives could make them understand their illnesses, including emotions. They admitted that their perspectives could prevent them from understanding patients wholly. They recognised that patients\u0026rsquo; culture signifies their life experiences and personal characteristics such as lifestyles. They decided to pay complete attention to patients to understand all about them as humans.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eCSC is thinking and understanding what patients set a high value on, how they have lived, and their ways of thinking and behaviours. It is seeing and respecting the inside, more than what meets the eye. Thus, it is of greater importance because \u0026lsquo;culture\u0026rsquo; eventually represents patients. We meet \u0026lsquo;human beings\u0026rsquo;, not \u0026lsquo;diseases\u0026rsquo;. I will pay attention to patients with all my heart, seeing them as persons as they are.\u003c/em\u003e (BB66)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants recognised that warm consolation with solicitude could make international patients feel more at home. They identified that togetherness with true hearts, not with communication guidelines or manuals, was essential. They found that they could share and ease the patients\u0026rsquo; pain and sorrow with warm words of compassion because they empathised with ill patients\u0026rsquo; feelings of fear and being lost in other lands. They discovered that providing comfort by putting themselves in patients\u0026rsquo; positions and attentively listening to their voices could alleviate patients\u0026rsquo; illness and sadness. While regretting that they had neglected the importance of rapport, they noticed that their cultural custom of no friendly expressions might prevent them from providing warm consolation and solicitude. Consequently, they decided to warmly express their compassion and share patients\u0026rsquo; sufferings \u0026lsquo;from the bottom of their hearts and souls\u0026rsquo; through practice and observing senior clinical teachers during clinical placements.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eWhat international patients need the most is doctors\u0026rsquo; compassion and sincere care, not only verbal communication. It will enable humanistic communication, transcending cultural barriers. I may not know beforehand about all cultures, but I will try to provide humane solicitude and consolation.\u003c/em\u003e (CC11)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants recognised that proper non-verbal habits from international patients\u0026rsquo; perspectives were basic, while some cultural behaviours of doctors might evoke unpleasant feelings in patients. They discovered that nonverbal etiquette or manners of Korean traditions, regions, or personal habits (e.g. \u0026lsquo;awkward smile when feeling embarrassed\u0026rsquo;) might cause unintentional misunderstanding. They found that they had similar patterns during the dialogues with international guests. They realised that not only explicitly rude manners but also ordinary culturally different non-verbal behaviours with good intentions might hurt and upset international patients. Therefore, they were concerned about making unintentional mistakes because of their unconscious cultural non-verbal habits. They were motivated to explore widespread nonverbal patterns that could hurt the patients and learn culturally safe non-verbal etiquette to provide patients with a pleasant experience.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eI deeply felt that our unconscious behaviours and thoughtless smiles marked international patients for life. I should mind that my sayings and doings, which we take for granted, unintentionally hurt them. I usually murmured \u0026lsquo;foreigner\u0026rsquo; when I saw them. I will mind my p\u0026rsquo;s and q\u0026rsquo;s and attitudes from now on.\u003c/em\u003e (CC52)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eTailoring care individually\u003c/h2\u003e\n \u003cp\u003eThe participants defined CSC as individually tailored services in culturally safe cultures and systems. They realised that considering patients as diverse individuals and respecting patients\u0026rsquo; values with sufficient discussion could be fundamental to individualised care. Conversely, they recognised that uniform services with generalised stereotypes disrespected patients, a critical obstacle to accessing medical care in Korea. They noticed similar disrespectful attitudes with stereotyping in themselves. They also found influences of their cultures and prejudice, science-centred medical cultures, hierarchical Confucian cultures, contradictory Korean NHIS, and the myth of a single ethnicity in Korea. Thus, they were motivated to consider diversity and respect patients\u0026rsquo; values by ensuring longer clinical encounters and flexible medical services. They decided to explore their stereotypes with preconceptions and Korean medical cultures through direct experiences and reflective exercises.\u003c/p\u003e\n \u003cp\u003eThe participants realised that considering persons as diverse individuals was foundational to individually tailored care, which implied respecting differences. They recognised that Korean patients were also unique individuals, meaning CS was for every patient, including Koreans. They discovered that each patient had different needs despite having the same diseases and nationalities, and they should consider all aspects of patients\u0026rsquo; characteristics. They identified their prejudice against differences and preconceptions (e.g. \u0026lsquo;CS was for international patients\u0026rsquo;, \u0026lsquo;Koreans were the same\u0026rsquo;, and \u0026lsquo;culture was about nationality and religion\u0026rsquo;), which prevented them from considering patients\u0026rsquo; individuality. Thus, they were inspired to go beyond acquiring knowledge about national or religious cultures. They decided to learn more about diverse cultures and directly interact with various people to gain experiences.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eI thought that CS covered international patients, but I noticed today that it also includes Koreans and those from other religions and sexual orientations. I should consider not only the national dimension of cultures but also everything about patients, always.\u003c/em\u003e (AA35)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eBefore the classes, I considered nationality and race as different cultural customs. I learned today that people are different, not racially but individually. I should approach them differently according to individuality. I felt that directly meeting and experiencing is important to understand individual patients.\u003c/em\u003e (AA103)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants also realised that respecting patients\u0026rsquo; values could enhance individualised care. They found that forcing doctors\u0026rsquo; values would invade patients\u0026rsquo; rights to participate in their care. They discovered that an equal footing was the key to appreciating different opinions and beliefs. They noticed that patients complained more about the inequality between doctors and patients than they thought: The unilateral decisions and judging patients\u0026rsquo; views notably frustrated patients, because they did not acknowledge patients as principal agents of care. They discovered that hierarchical Confucian cultures and their prejudice against deviant cultures prevented them from respecting patients\u0026rsquo; values. They recognised that their science-centredness and medical knowledge, perspectives from their religion of Protestantism, and conservative and closed Korean cultures considering harmony as virtue acted as standards influencing their prejudices. Thus, they were inspired to let the patients participate in the clinical process and, therefore, decided to explore their values with prejudice and the influences of their cultural backgrounds.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eI must not apply my culture and values to patients as a doctor. I should understand cultural differences. Each patient has different values. I will become a doctor who respects patients\u0026rsquo; opinions so that they can be involved in the diagnosis and treatment process.\u003c/em\u003e (BB29)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants identified that sufficient discussion between doctors and patients is requisite to individualised care, which needs satisfactory explanation and conversation in horizontal relations. They understood doctors\u0026rsquo; difficulties in busy clinical settings relating to spending time dealing with the various needs of patients with uncommon diseases and language barriers. They had been proud of advanced Korean medical services but noticed that patients complained more seriously about Korean medical cultures of short clinical encounters than they thought. They identified the contradictory Korean NHIS policy as a serious obstacle to more extended discussions. They recognised the reality that the Korean medical services could not handle the diverse values of the patients. Thus, they were motivated to explore contradictions in the Korean medical systems and traditions that might interfere with sufficient discussions. They decided to develop clinical competence to perform longer consultations.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003ePeople of different cultures might feel uncomfortable with our medical system, which is specialised for the Korean mentality of speed. I realised patients had difficulties expressing their stories because of short clinical encounters. I had thought our [fast] medical system was right and other countries\u0026rsquo; systems were inefficient. I will form habits to explain kindly to patients and to discuss with them.\u003c/em\u003e (BB62)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants noticed that flexible medical services with alertness were necessary for individually tailored care, while uniform services with Korean-targeted medical knowledge might make patients feel insignificant. Providing the same service to all neglects patients\u0026rsquo; individuality. They recognised that being alert and sensitive to each individual was crucial. They found that the Korean culture of a single ethnicity, preconceptions that \u0026lsquo;foreigners speak English\u0026rsquo; or \u0026lsquo;patients would be like them,\u0026rsquo; and nationality stereotypes might keep them from regarding individuality. They were motivated not to rush to assume or judge patients\u0026rsquo; cultures, including languages, and ask the patients and learn from them. They decided to explore uniform services based on the single-ethnic Korean culture and nationality stereotypes through reflective practices and direct experiences with people because they realised that indirect resources, such as media, might deliver stereotypical information.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eThe most important thing is to approach without stereotyping. Not everyone has the same thoughts, even in the same cultural regions. People may have similar thinking, although their cultural regions differ. We cannot identify individuals with the cultures to which they belong. As one from an Islamic country could believe in Christianity, I learned stereotyping puts a person in a cultural box.\u003c/em\u003e (AA39)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eTreating them indiscriminately as ordinary Koreans\u003c/h2\u003e\n \u003cp\u003eThe participants stated that CSC would serve international patients as ordinary Koreans by providing adequate consideration. Meanwhile, doctors\u0026rsquo; avoidance and regional discrimination made patients refuse to visit clinics. They noticed similar patterns of inadequate thinking, avoidance, and discrimination in themselves. Thus, they decided to explore their behaviours, prejudices, stereotypes, and preconceptions through reflective practice from direct experiences.\u003c/p\u003e\n \u003cp\u003eThe participants realised that providing adequate consideration was decisive for indiscriminate service. Conversely, they discovered that doctors\u0026rsquo; considerate behaviours, in their perspectives based on stereotypes and preconceptions, resulted in discrimination. They noticed that international patients felt discriminated against when doctors showed behaviours that they never did to Koreans. For example, Korean doctors did not interact with international patients using honorific and kind language, while they spoke politely to Korean patients speaking in the same manner. They understood the good intention of Korean doctors to respect the patients\u0026rsquo; liberal and individualistic cultures based on their perspectives that \u0026lsquo;foreigners dislike respect and rapport because they are different from Koreans\u0026rsquo;. However, they found that the patients felt disregarded because the patients knew and expected Korean manners. They recognised that everyone is the same in their sufferings regardless of nationality and culture. Thus, they were inspired to treat international patients the same as Koreans. They decided to reflect on their biases about ways of respecting foreigners.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eBefore the classes, I thought that CS was understanding and accepting of their cultures, but now I think the same treatment as Korean patients without discrimination is also CS. I had thought foreign residents didn\u0026rsquo;t know Korean culture, but this was inaccurate.\u003c/em\u003e (CC59)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI thought that foreign patients were special. The biggest worry of international patients may be doctors\u0026rsquo; feeling of burden because they consider the patients special. They are humans, after all. They are similar in thinking and feeling. I will practice, considering them as usual patients, the same as me.\u003c/em\u003e (AA37)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants identified doctors\u0026rsquo; avoidant behaviours with effortless attitudes to communicate as a pivotal obstacle to indiscriminate service. Conversely, doctors\u0026rsquo; solid will and efforts to approach patients directly were indispensable. They understood that doctors\u0026rsquo; lack of confidence in unfamiliar care with different languages and religions might cause panic about mistakes and misunderstandings. They discovered similar feelings in themselves due to preconceptions about complex international and Muslim patient care. They also realised their prejudice against foreigners and Islam stereotypes. However, they empathised with the patients\u0026rsquo; feelings of alienation when doctors preferred interpreters or Korean companions. They found that the third person might intervene in patient-doctor interactions, alienating doctors. They noticed that their preconceptions, considering the language barrier too much, and their silent self-effacement culture might weaken their motivation to direct contact. Insights that they are doctors inspired them to try their best to communicate directly. They decided to prepare themselves to prevent panicking by becoming familiar with other cultures while hoping to feel confident by upgrading their language proficiency.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eThe biggest obstacle would be the feeling of separation of doctors from international patients. Doctors\u0026rsquo; internal issues, difficulty initiating a conversation, and feelings of fear might be the biggest challenges. The most important thing is not to have preconceptions and prejudices. As a doctor, I make efforts to treat them.\u003c/em\u003e (AA34)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eDespite language barriers, doctors\u0026rsquo; attempts to see patients may help and comfort them. Doctors tend to ask fewer questions and offer fewer explanations when patients are foreigners. I will try my best so that patients do not feel neglected, although languages differ. However, the best thing is good communication. Thus, I need to study languages.\u003c/em\u003e (AA78)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe participants realised that discrimination against people from less developed regions might aggravate inequity. They recognised that even ordinary people, including them, could commonly discriminate against others. They discovered they had unconsciously looked down on people from developing countries, rural areas, North Korean defectors, or Korean Chinese, although they had determined to treat them equally. They found that they evaluated, judged, and belittled the patients based on geographical stereotypes and prejudices (e.g. asking superfluous questions regarding patients\u0026rsquo; regional origins, such as \u0026lsquo;Where are you from?\u0026rsquo;, or providing cheap treatment assuming that patients from less-developed regions are poor). Thus, they decided to mind their unconscious biases.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003ePatients might have experienced difficulties because they were judged and treated differently according to their cultures. They were asked whether they had money or refused. We should not discriminate against people according to nationality.\u003c/em\u003e (C46)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI expected people\u0026rsquo;s intellectual levels and compliance to be high. I felt tense when I encountered middle-aged male patients from province regions with rough accents of dialects and nonstandard language.\u003c/em\u003e (AA86)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eMajor debates related to CS among the participants\u003c/h2\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eTarget of interest\u003c/h2\u003e\n \u003cp\u003eThe participants changed their positions from being wary of the \u0026lsquo;outside\u0026rsquo; to embracing all \u0026lsquo;inside\u0026rsquo; (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Before the CS classes, they blamed doctors or foreign patients because they believed that they had no biases, but others did. They focused on doctors and foreigners and regarded them as others. Their job was to study knowledge and skills because they considered themselves students. Thus, they valued indirect experiences such as media and books to acquire information about cultures and ethico-legal knowledge.\u003c/p\u003e\n \u003cp\u003e[Figure \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eHowever, after the CS classes, the participants reflected on their biases and explored Korean medical settings from patients\u0026rsquo; perspectives. They found that they were biased and influenced by surrounding cultures. They also discovered that contradictory Korean medical systems would deepen patients\u0026rsquo; suffering. They realised that international patients were the same persons as themselves and Koreans: They are us. Therefore, their job changed to personal and professional development for CSC because they are doctors, and CS is a process for better care. They preferred direct experiences such as meeting people because studying from media and books might not help in real-life care contexts. They noticed that patients wanted doctors\u0026rsquo; attention, not knowledge.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eAppropriate scope of CSC\u003c/h2\u003e\n \u003cp\u003eThe participants\u0026rsquo; views on the scope of CSC can be divided into four categories based on how they perceive patients\u0026rsquo; cultures (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). Before the classes, many participants believed that doctors should accept all patients\u0026rsquo; cultures, sacrificing their culture, whereas some insisted that foreign patients must follow Korean culture. Others suggested that doctors should allow patients to express their cultures within the boundaries of ethics and safety. Finally, some students argued that patients and doctors should compromise.\u003c/p\u003e\n \u003cp\u003e[Figure \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eAfter the classes, however, many participants recognised that doctors should not force their cultures, and mutual respect between patients and doctors is important because they felt the strong influences of doctors\u0026rsquo; cultures. However, they were still uncertain about how much care could ensure mutual respect without sacrificing doctors\u0026rsquo; culture.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion and conclusion","content":"\u003cp\u003eThrough the classes, students focused on their biases, the power of doctors\u0026rsquo; culture, and influential systems related to CS and recognised what CSC exactly is according to patients\u0026rsquo; perspectives, which were key goals in CS education. We could find Korean contextualised situations, \u003cem\u003eactors\u003c/em\u003e, and discourses related to CS. The findings revealed that the \u003cem\u003etranslation\u003c/em\u003e of the ANT in the CS classes was successful.\u003c/p\u003e\n\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n\u003ch2\u003eANT strategies in CS education\u003c/h2\u003e\n\u003cp\u003eIn this study, the ANT-based CS education strategy helped students internalise ANT\u0026rsquo;s perspective of relational ontology (Latour, \u003cspan class=\"CitationRef\"\u003e1993\u003c/span\u003e; MacLeod et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). The participants realised that the \u003cem\u003eactors\u003c/em\u003e exist as individuals, in contrast to the grouped human \u003cem\u003eactors\u003c/em\u003e as others, such as foreigners/Koreans before the classes. They noticed that predetermined stereotypes were not helpful because patients do not have fixed identities in ever-changing societies. They also recognised non-human \u003cem\u003eactors\u003c/em\u003e, such as biases, cultural customs, medical discourses, facilities, healthcare systems, and hospital services, as equally significant to human \u003cem\u003eactors\u003c/em\u003e. Similar to the ANT, CS education aims for learners to regard patients as diverse individuals beyond the dichotomous classification of othering and reflect on biases, discourses, and structures (Curtis et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Jowsey, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Papps \u0026amp; Ramsden, \u003cspan class=\"CitationRef\"\u003e1996\u003c/span\u003e; Ramsden, \u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThis study also revealed that students could learn CS effectively through \u003cem\u003etranslations\u003c/em\u003e by separating the \u003cem\u003eactors\u003c/em\u003e and reassembling them with other silent \u003cem\u003eactors\u003c/em\u003e (Callon, \u003cspan class=\"CitationRef\"\u003e1984\u003c/span\u003e; Kitto et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Before CS education, to participants, international patients were \u003cem\u003eblack boxes\u003c/em\u003e of diseases and foreign geographical, biological, and cultural \u003cem\u003eactors\u003c/em\u003e with stereotypes of non-compliance. Meanwhile, after the dialogues, participants translated the same patients into new \u003cem\u003eactor-networks\u003c/em\u003e of human individuals with sufferings and various characteristics. They also discovered qualitatively different concepts of culture and CS in their new \u003cem\u003eactor-networks\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThe results implied that active agency experiences with direct contacts and reflective practice may promote successful \u003cem\u003etranslation.\u003c/em\u003e The participants understood the concept of CS and changed their discourse positions despite no specific lectures. Literature has reported successful student-led activities against racism in curriculum and medicine (Afolabi et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Forrest \u0026amp; Geraghty, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Williams \u0026amp; Armstrong, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such findings imply that students could learn and practice CS when educators provide students with advocate roles in proper \u003cem\u003etranslation\u003c/em\u003e settings. In this study, participants advocated for both patients and doctors after the course. They became aware of the silent but authentic difficulties of patients and doctors, which were struggles they had never expected before.\u003c/p\u003e\n\u003cp\u003eIn this study, the participants noticed they did not listen to the voices of individuals, patients from minoritised groups, Koreans with diverse cultures, people from less developed regions, and even Korean doctors in today\u0026rsquo;s Korea, which was influenced by dominant discourses. CS aims to hear the voices of the culturally marginalised and encourage learners to consider them equal and become active agents for social justice (Curtis et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Jowsey, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Papps \u0026amp; Ramsden, \u003cspan class=\"CitationRef\"\u003e1996\u003c/span\u003e; Ramsden, \u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e). The findings show that the ANT \u003cem\u003etranslation\u003c/em\u003e strategy effectively empowered learners to reach the goals of CS education.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n\u003ch2\u003eCS education for Korean medical students\u003c/h2\u003e\n\u003cp\u003eThe results support why CS education, beyond cultural competence, is also needed for Korean medical students. The findings before CS education showed that the participants were unaware of their biases, blamed others, and had doctor-centredness. They felt that they needed to acquire knowledge and skills, which is cultural competence emphasised, but caused stereotyping and othering (Curtis et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Kirmayer, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Kumagai \u0026amp; Lypson, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; MacNaughton et al., 2016). The results showed that without CS education, students would worry about patients\u0026rsquo; complaints and suits and attempt to overcome language and cultural barriers with knowledge and clinical competence. Meanwhile, after the classes, they learned about new roles and positions of doctors, patients, and students and what patient-centredness signifies, out of the \u003cem\u003eblack boxes\u003c/em\u003e of doctor-centred discourses. They recognised the shortcomings of doctor-centred care and that doctors\u0026rsquo; implicit perspectives might be problematic, as CS emphasises that care recipients determine CSC (Jowsey, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Papps \u0026amp; Ramsden, \u003cspan class=\"CitationRef\"\u003e1996\u003c/span\u003e). Their positions changed to focus on themselves and the service provider-centred healthcare system's limitations, which were CS education's intended outcomes (Jowsey, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eMeanwhile, the results implied that the terminology of \u0026lsquo;cultural humility\u0026rsquo; might be inappropriate for Korean students. Cultural humility has emphasised humble attitudes with \u0026lsquo;non-paternalistic partnerships\u0026rsquo; of doctors in power imbalanced dynamics between doctors and patients (Tervalon \u0026amp; Murray-Garc\u0026iacute;a, \u003cspan class=\"CitationRef\"\u003e1998\u003c/span\u003e). The results suggest that Korean students and doctors might regard them as humble enough because they believed they sacrificed Korean culture to respect international cultures. This might prevent them from seeing that they are still paternalistic in power-imbalanced cultures. Respect, \u0026lsquo;Jonjung\u0026rsquo; in Korean, means treating others highly by lowering oneself in Korean contexts. Korean etiquette based on Confucianism highlights propriety, treating another person as valuable by giving up one\u0026rsquo;s interest for them. Propriety needs to reflect on what one wants and then yield it to others, termed \u0026lsquo;Geuk-gi-bok-rye\u0026rsquo; in Korean (Lee, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThrough the CS dialogues, the participants recognised that their unconscious humility and self-effacement might hurt patients. However, the results showed that the participants were confused about how much they should embrace patients\u0026rsquo; culture rather than insisting on theirs because assertion was an unfamiliar concept in Korea. Humility, self-sacrifice, and self-effacement in Korean traditional virtues might clash with the virtue of assertiveness in the modern era. Furthermore, as many students have experienced foreigners\u0026rsquo; or patients\u0026rsquo; biases (Ahmad et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Paul-Emile et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; Rizk et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e), one-sided recommendations to doctors about humility towards patients might be inappropriate because doctors also have the right to be respected. Today, former students from diverse backgrounds have become doctors, which means that they would be continuously minoritised by humility discourses in the Korean context. CS is for all, including patients and doctors, and educators must not stereotype all students from dominant groups as biased (Hassouneh, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e; Novak et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Therefore, CS education strategies to enhance mutual respect with positive self-assertion would be helpful in the Korean context.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n\u003ch2\u003eTranslating CS in the foundation of learners\u0026rsquo; cultural wisdom\u003c/h2\u003e\n\u003cp\u003eWe found that the participants understood CS by applying Korean cultural wisdom to the modern world. For example, heartfelt sincerity, togetherness with true heart, consolation and solicitude with compassion, and putting themselves in others\u0026rsquo; positions are all from Confucian wisdom that emphasises benevolence or human heartedness, \u0026lsquo;In\u0026rsquo; in Korean, in Korean community culture. Furthermore, they recognised that CS is not a particular treatment different from ordinary care: As a human and a doctor, CS is an everyday practice for all. Thus, they realised that they did not need more knowledge and skills but rather needed to get rid of inner conflicts and burdens, such as being free from false beliefs and becoming enlightened through continuous spiritual training, represented by emptiness or voidness in Buddhism, \u0026lsquo;Gong\u0026rsquo; in Korean, and dao in Daoism or Confucianism, \u0026lsquo;do\u0026rsquo; in Korean. The results imply that students could acquire appropriate CS attitudes with the help of their cultural wisdom.\u003c/p\u003e\n\u003cp\u003eThe participants also recognised the shortcomings of their beliefs, such as Confucianism, the myth of single ethnicity, science-centredness, and Protestantism discourses in Korean contexts. Such discourses were somewhat different from Western studies\u0026rsquo; discourses, such as specific racial/ethnic supremacy, Western medicine\u0026rsquo;s supremacy over traditional medical care, and capitalism (Arieli et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Hassouneh, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e; Lavoie et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mehus et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Micheal et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Pimentel et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Pitama et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, this study\u0026rsquo;s results support Western research reporting on biomedical discourses and patriarchy (Bullon, \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Hassouneh, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e; Kirmayer, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Wong et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Among them, hierarchical and conservative Confucianism and single ethnicity are the traditional discourses, in which science-centredness from Western medicine and Protestantism aggravated close discourses, holding a dim view of the unusual as deviant. The results imply that students could identify outdated cultural discourses in changing local and global contexts.\u003c/p\u003e\n\u003cp\u003eThe results showed that the participants connected Korean wisdom to modern terms, such as individuality and indiscrimination, implying that students might create new CS concepts when we empower them to translate them into their cultural perspectives. Through translation, Protestant students could understand CS from the perspective of God\u0026rsquo;s love, identify paradoxically close Protestant attitudes against LGBTQIA\u0026thinsp;+\u0026thinsp;in Korea, and realise true love for all. Scientific students could understand CS from the scientist's perspective, discover race-based medicine's irrationality, and recognise proper evidence-based practice for all (Afolabi et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Curtis et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n\u003ch2\u003eCS educators\u0026rsquo; roles in Korean contexts\u003c/h2\u003e\n\u003cp\u003eThis study suggested that Korean CS educators use Korean cultural wisdom to administer CS education culturally safely. The results imply that the primary contribution of CS education to the medical curriculum is to dismantle \u003cem\u003eblack-boxed\u003c/em\u003e and biased discourse about culture and CS education. Therefore, CS educators should focus more on establishing culturally safe systems and cultures rather than just teaching students in CS classes. Development programs for policymakers, school and hospital leaders, doctors, and faculties might be necessary for CS because they could drive institutional changes, allocate institutional resources, and influence curriculum (Pitama et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Vass \u0026amp; Adams, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn Korean contexts, we might have actions regarding Confucianism, the myth of single ethnicity, science-centredness, and Protestantism discourses for CS. However, there are calls for action regarding \u0026lsquo;white curriculum and logic\u0026rsquo; in Western medicine (Plaisime et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e) in historical racism contexts in Western society. Literature has presented racially biased content in Western medicine references (Amutah et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Krishnan et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Therefore, Korean educators should also consider the influences of biased Western medical practices.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n\u003ch2\u003eApplying the ANT to medical education and research\u003c/h2\u003e\n\u003cp\u003eWe found that the ANT is applicable in CS education and medical education research. (Baker et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Bleakley, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Lingard, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e). The ANT started in science and technology studies but has extended its impact to social and other studies in understanding spaces, migration, powers, organisations, health care, and education (Bilodeau \u0026amp; Potvin, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Holifield, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Lau, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e; Law, \u003cspan class=\"CitationRef\"\u003e1992\u003c/span\u003e; Lee, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Tummons et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Medical education research has also reported the applicability of ANT, such as for communication, surgical training, interprofessional education, and objective structured clinical examinations (Bearman \u0026amp; Ajjawi, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Ibrahim et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Lingard, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; McDougall et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Nestel et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). The ANT might be useful in exploring non-human \u003cem\u003eactors\u003c/em\u003e and discourses in work-based learning environments, such as clinical placements or interprofessional teams (McMurtry et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Sheehan et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). The ANT could also promote effective \u003cem\u003etranslation\u003c/em\u003e in programs with severe discourse conflicts or learners\u0026rsquo; resistance (Baker et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kuper et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAdditionally, we discovered that research involves a \u003cem\u003etranslation\u003c/em\u003e process. Researchers problematise an issue and demonstrate to the readers how significant the issue is, which Lingard (\u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e) calls the problem/gap/hook considered in a study. Researchers uncover \u003cem\u003eblack-boxed\u003c/em\u003e concepts to reassemble new knowledge and provide the readers with further research issues for enrolment and mobilisation. The ANT\u0026rsquo;s translation process framework might help researchers design research to attract readers.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Limitations and further research","content":"\u003cp\u003eThis study has some limitations. First, we did not analyse specific biases in-depth. Further research is required to explore silent biases and their associations with Korean culture. Second, we did not examine the perspectives of instructors, international guests, and researchers, although they also deeply reflected on the subject and were impressed by the course. Third, common discourses were Korean-specific, and thus, may not be applicable in other countries' cultural contexts. These aspects could be addressed in future studies. Fourth, we recognised, through analysis, that \u0026lsquo;empathy\u0026rsquo; or \u0026lsquo;professionalism\u0026rsquo; might be \u003cem\u003eblack boxes\u003c/em\u003e that need to unfold (Lingard, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Last, in future research, we recommend using SA to investigate non-human \u003cem\u003eactors\u003c/em\u003e, including materiality and discourses in medical education (Ahmady \u0026amp; Khani, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Martin et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ott et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors thank Professor Ji Kyoung Park, Professor Jiyoung Yun, and the students for participating in the CS class, Lauren Nirta for co-developing the class, and Hee Jung Na for assisting with the research.\u003c/p\u003e\n\u003cp\u003eAuthor contributions: All authors contributed to the study\u0026rsquo;s conception and design. Material preparation and data collection were performed by HyeRin Roh. Data analysis was performed by all authors. The first draft of the manuscript was written by HyeRin Roh and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCompliance with ethical standards: The Inje University Busan Paik Hospital Institutional Review Board reviewed and approved the research (IRB 2023-01015). The Board waived the informed consent requirement because this study was retrospective, conducted after class completion, and presented a minimal risk of harm to the students.\u003c/p\u003e\n\u003cp\u003eFunding: None\u003c/p\u003e\n\u003cp\u003eConsent to participate: The Board waived informed consent for the research, because this study was retrospective, after class completion, and presented no more than minimal risk of harm to the students.\u003c/p\u003e\n\u003cp\u003eData availability statement: The data cannot be shared openly but are available on request from authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAfolabi, T., Borowsky, H. M., Cordero, D. M., Paul, D. W., Said, J. T., Sandoval, R. S., Davis, D., \u0026Ouml;lveczky, D., \u0026amp; Chatterjee, A. (2021). 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(2021). \u0026lsquo;Decolonising the medical curriculum\u0026rsquo;: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. \u003cem\u003eLondon Review of Education\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1), e19116. https://doi.org/10.14324/lre.19.1.16\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Grounded theory, Situational analysis, Social justice, Equity, diversity, and inclusion (EDI)","lastPublishedDoi":"10.21203/rs.3.rs-3423047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3423047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eConducting an education program on cultural safety (CS) based on the actor-network theory\u0026rsquo;s (ANT) translation strategy, this study aimed to investigate changes relating to situations, significant actors, and discourse positions among Korean medical students. This qualitative pre/post study used situational analysis. Participants included 294 fifth-year medical students who attended CS classes between 2017\u0026minus;2019. For successful translation, the CS classes empowered the students as active agents to have direct dialogues with international guests, designing all human and non-human actors in the classroom to support them. The authors collected and coded data from students\u0026rsquo; reflective essays, and then conducted organised situational, relational, and positional mapping. Following the classes, the participants reflected more on CS-related situations and actors. They defined culturally safe care as making patients feel at home, tailoring care individually, and providing treatment indiscriminately. Instead of focusing on others, they recognised their own biases, influences of their cultures on patient care, and contradictions in the Korean healthcare system, realising the healer role of doctors and the importance of patient-centeredness. Further, we explored how the students\u0026rsquo; confusion about appropriate levels of accepting patients\u0026rsquo; cultures might be associated with notions regarding humility rooted in Korean culture. We found that the ANT and situational analysis are applicable in CS education and research, and could be considered in future studies.\u003c/p\u003e","manuscriptTitle":"Reassembling cultural safety education for Korean medical students based on the actor-network theory: Situational analysis of discourses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-12 17:06:15","doi":"10.21203/rs.3.rs-3423047/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"83966237-dd5e-4ede-9cd6-f15708c0e4e1","owner":[],"postedDate":"October 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-18T01:53:19+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-12 17:06:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3423047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3423047","identity":"rs-3423047","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}