Enhancing Nursing Students’ Cultural Awareness using Cross-Cultural Video-Based Simulation: A Pilot Study

Enhancing Nursing Students’ Cultural Awareness using Cross-Cultural Video-Based Simulation: A Pilot Study | 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 Enhancing Nursing Students’ Cultural Awareness using Cross-Cultural Video-Based Simulation: A Pilot Study Siu Ling Chan, John Tai Chun Fung, Jacqueline Bloomfield, Jane Nicol, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6692661/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 Backgrounds: With increasing cultural diversity in global healthcare settings, nurturing culturally competent nurses to serve the diverse population is crucial. This pilot study evaluated the potential of cross-cultural video-based simulation co-created by nursing academia across 3 countries (Australia, Hong Kong, the United Kingdom) in enhancing nursing students’ cultural awareness. Methods: A quasi-experimental study with one-group pre- and post-test evaluation was designed, with 35 nursing students from a university in Hong Kong participating in three educational workshops comprising theory-driven video-based simulation. Validated questionnaires were adopted to measure changes in cultural awareness scores using paired sample t-test. Results: This pilot study suggested the acceptability and feasibility of the intervention as revealed by the significant improvements in cultural awareness scores (pre-test: 9.63, post-test: 10.69, p < 0.001, Cohen’s d = 0.777). Conclusions: This pilot study highlights the potential of video-based simulation for enhancing nursing students’ cultural awareness. Trial registration: The HKU/HA HKW Institutional Review Board approved the study (UW20-411), which was conducted in accordance with the principles of the Declaration of Helsinki. Cultural awareness Cultural competence Video-based simulation IAPCC-SV Figures Figure 1 Figure 2 Figure 3 Introduction Given the increasing cultural diversity within global healthcare systems, it is crucial to nurture culturally competent nurses [ 1 , 2 ]. Developing this competence begins with cultural awareness, which serves as the foundational step in fostering a deeper understanding and appreciation of diverse cultures [ 3 ]. The Global Alliance for Nursing Education and Sciences (GANES) identified cultural competence as an international standard for optimal healthcare outcomes [ 4 ]. In today’s globalized world, where nursing professionals interact regularly with patients from different cultural groups, effective communication, cultural sensitivity, and the ability to navigate cultural differences have become essential nursing skills [ 5 , 6 ]. Numerous studies have shown that healthcare providers' acquisition of non-technical skills, including cultural competence, directly aligns with the enhancement of a safety culture and the improvement of patient safety outcomes [ 7 ]. Traditional nursing education often prioritizes technical and clinical skills, which may overlook non-technical skills such as communication, cultural sensitivity and teamwork [ 8 ].This gap in non-technical skills can hinder nursing students' ability to adapt to diverse clinical contexts and deliver culturally sensitive care, which is increasingly recognized as a critical aspect of patient safety and satisfaction [ 9 ]. Moreover, it is important to recognize that developing cultural competence is an ongoing process for students, with cultural awareness being the essential first step in this journey [ 10 , 11 ]. With rapid development of educational technology, innovative simulation approaches have been developed in higher education throughout the decades. Video-based simulation learning is a method widely recognized for its effectiveness in developing non-technical skills among nursing students [ 12 ].The efficacy of video-based simulations allows students to acquire non-technical skills by observing, analyzing, and reflecting on peer’s performances of specific skills or actions [ 13 , 14 ].This method provides a visual anchor that connects theoretical learning to real-life situations [ 12 ]. Unlike traditional didactic teaching methods, video-based simulations immerse students in realistic, scenario-based learning environments that closely mirror clinical practice. This approach bolsters critical thinking, enhances communication skills, and boosts students’ confidence in delivering culturally sensitive care [ 15 ]. In the context of cultural competence development, animated videos as part of the video-based simulation are highly engaging, leading to better retention of cultural knowledge [ 16 ]. These videos present scenarios that allow learners to interact through choices or actions influencing the outcome [ 17 ]. Using visual aids, colors, and storytelling makes complex cultural concepts more memorable and easier to understand [ 18 ]. They simplify intricate cultural nuances and practices, helping students develop a deeper understanding of diverse patient needs [ 19 ]. By consistently conveying messages of cultural sensitivity, awareness and safety, these animations reinforce the importance of cultural competence in healthcare [ 18 , 20 ]. This clarity and engagement improve students' comprehension of cross-cultural interactions and patient care. Despite the increasing emphasis on cultural awareness, a limited number of nursing programs incorporate structured, evidence-based learning pedagogies to cultivate non-technical skills [ 21 ]. This pilot study aimed to explore the acceptability and feasibility of video-based simulation interventions on cultural competence development of nursing students, through adopting the theoretical foundations grounded in The Process of Cultural Competence in the Delivery of Healthcare Services Model coupled with the Mayer’s Cognitive Theory of Multimedia Learning [ 10 , 22 ]. Methods Study Design This pilot study employed a quasi-experimental design with one-group pre- and post-test to evaluate the potential effectiveness of three cross-cultural video-based simulation workshops, in enhancing the development of nursing students’ cultural awareness. Participants Undergraduate nursing students at a university in Hong Kong were invited to participate in the study. Year 1 to Year 3 students who were enrolled in the life enrichment learning course, were invited to join the study via their registered university emails. For a pilot study, a sample size of around 30 participants is commonly considered adequate to assess its acceptability and feasibility [ 23 ]. Employing convenience sampling, 35 undergraduate nursing students were recruited. Prior informed consent was sought from participants, and the study was approved by the Institutional Review Board (IRB No. UW20-411). Intervention The Process of Cultural Competence in the Delivery of Healthcare Services Model and Mayer’s Cognitive Theory of Multimedia Learning informed the design of culturally specific case-based learning scenarios, which were delivered through the structured online workshops. The Process of Cultural Competence in the Delivery of Healthcare Services Model emphasizes five constructs: cultural awareness, cultural skill, cultural encounter, cultural knowledge, and cultural desire. Cultural awareness focuses on being aware of one’s own biases and prejudices towards other cultural groups. Cultural skill refers to the skill of conducting a cultural assessment. Cultural encounter means nurses learn directly from client’s culture. Cultural knowledge identifies those related to health beliefs and treatment efficacy. Cultural desire explains nurses’ intrinsic motivation to be culturally competent. [ 10 ] In this study, these constructs formed a dynamic framework for developing cultural competence among nursing students, aligning with the goals of nursing education to address global health disparities. Mayer’s Cognitive Theory of Multimedia Learning (CTML) provides a framework for optimizing how students process and retain information [ 22 ]. CTML is based on three core principles: dual channels, which highlight learners process visual and auditory information separately; limited capacity, which recognizes the finite cognitive load learners can handle at one time; and active processing, which underscores the importance of selecting, organizing, and integrating new information for meaningful learning. By using these principles, this pilot study transformed culturally specific Case-Based Learning (CBL) scenarios into engaging animated videos, designed to maximize students' interest, cognitive engagement, and ability to apply cultural concepts in real-world settings. The video-based simulation in this pilot study feature scenarios collaboratively developed and validated by university nursing academia from Australia, Hong Kong and the United Kingdom. Three scenarios were co-created using video animations with a surgical ward, an emergency department and a nursing home as the background, that engaged students in active observation, analysis, and discussion, enabling them to apply theoretical knowledge in practical contexts. Each scenario contained five to six video clips, and it was tailored to reflect the unique cultural challenges the patients were facing, with integrated themes of cultural learning for participants based on Campinha-Bacote’s Model of Cultural Competence, which ensures a comprehensive learning experience. Three online workshops were held, focusing on the three culturally specific scenarios that represented Australia, Hong Kong, and the United Kingdom, respectively, with facilitated discussions. Self-directed Learning Sessions Before the workshops, participants were provided with online pre-reading materials and Panopto lecture videos about the process of developing cultural competence. These emphasized key concepts from Campinha-Bacote’s Model of Cultural Competence. This preparatory step aimed to establish a foundational understanding of cultural concepts among participants. Video-based Simulation Workshops Workshop Structure Each workshop began with case-specific reading, providing background information on the scenario and outlining the cultural challenges to be addressed. Video-based Simulations Five to six video clips were presented during each workshop, depicting culturally specific situations relevant to the emergency department (Hong Kong) in the first session (Fig. 1 ), the surgical ward (Australia) in the second session (Fig. 2 ), and the nursing home (United Kingdom) in the third session (Fig. 3 ). These were designed to highlight cultural issues aligned with the five constructs of Campinha-Bacote’s Model, exposing students to diverse cultural healthcare contexts. Discussion Points For each video clip, discussion points were provided to encourage students to reflect on the cultural issues presented in the scenario. Questions were designed to elicit critical thinking and application of the constructs of developing cultural competence, such as identifying cultural needs, demonstrating cultural sensitivity, and reflecting on personal biases. Facilitated Discussions Students engaged in discussions facilitated by local and international instructors from the respective regions (Hong Kong, Australia, and the United Kingdom). Instructors guided students in analyzing the discussion points, addressing cultural nuances, and providing feedback on their responses. These discussions emphasized interactive and reflective learning, allowing students to deepen their understanding and apply theoretical concepts to practical situations. Data collection Socio-demographic Questionnaire Data pertaining to participants' sociodemographic variables including age, gender, cultural-related experiences (e.g., lived in culturally diverse environments, participated in overseas exchange programs, prior experience living or studying abroad, attended cultural competence learning) and clinical placement experiences were collected at baseline. The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Student Version (IAPCC-SV) The pilot study utilized the IAPCC-SV questionnaires developed by Campinha-Bacote (1999) [ 24 ]. The 20-item tool measures the five constructs of cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire using a four-point Likert scale reflecting the response categories of strongly agree, agree, disagree, and strongly disagree, as outlined in the theoretical model. The IAPCC-SV has been widely recognized as a valid and reliable tool for assessing cultural competence in nursing students and has been adopted by accrediting bodies for nursing programs at both associate and baccalaureate levels. The Cronbach's alpha for the overall scale was 0.783. Reliability coefficients were calculated for the instrument’s five subscales ranging from 0.67 to 0.74 [ 25 ]. Participants completed the IAPCC-SV before the intervention to establish baseline levels of cultural competence and again after the workshops to measure changes in their cultural competence scores. Data Analysis The participants’ sociodemographic variables were analyzed using descriptive statistics. Q-Q plot was used to test the normal distribution. Changes in IAPCC-SV were analyzed using paired sample t-test. The association between the overall cultural competence and the five constructs was examined using Pearson’s correlation coefficient. Data was analyzed using the Statistical Package for Social Science (SPSS) Version 28, with the significance level set at p < 0.05. Results Sociodemographic Characteristics of Participants Table 1 shows the sociodemographic information of the participants, with 25.7% enrolled in Year 1, 57.1% in Year 2, and 17.1% in Year 3. Most participants were aged 18–21 years (88.6%), with 11.4% aged 22–25 years. The sample included 16 males (45.7%) and 19 females (54.3%). Regarding intercultural experiences, 42.9% of participants lived in culturally diverse environments, while 31.4% participated in overseas exchange programs. Additionally, 25.7% reported prior experience living or studying abroad, and 40% attended cultural competence training within the university. Clinically, 37.1% of participants reported experience in clinical placements. There were no significant differences in sociodemographic characteristics, ensuring a consistent baseline for the intervention evaluation. Overall Cultural Competence The normality of the IPACC-SV scores and the five constructs’ scores were assessed using Q-Q plots, which showed data points closely aligned with the diagonal line and no major deviations in detrended plots. This indicates the data were normally distributed. The interventions demonstrated a statistically significant improvement in the cultural competence of nursing students as measured by the IAPCC-SV. Table 2 summarizes the pre- and post-test results for total IAPCC-SV score and the five constructs’ scores. Table 1 Sociodemographic characteristics of participants (n = 35) Intervention group (n = 35) P-value N (%) Year of study 0.477 1 9 (25.7%) 2 20 (57.1%) 3 6 (17.1%) Gender 0.053 Female 19 (54.3%) Male 16 (45.7%) Age 0.873 18–21 31 (88.6%) 22–25 4 (11.4%) 26 or above 0 (0%) Experience of living in a culturally diverse environment 0.058 Yes 15 (42.9%) No 20 (57.1%) Experience of overseas exchange program during university enrolment 0.126 Yes 11 (31.4%) No 24 (68.6%) Experience of living or study abroad prior to university enrolment 0.224 Yes 9 (25.7%) No 26 (74.3%) Experience of attending training/workshops related to cultural competence development 0.067 Yes 14 (40%) No 21 (60%) Experience of clinical practice/clinical placement in the health system 0.079 Yes 13 (37.1%) No 22 (62.9%) *p ≤ 0.05 for statistically significance Table 2 Comparison of perceived clinical competence before and after the intervention Pre-test mean (SD) Post-test mean (SD) t-test (p) Cohen’s d IAPCC-SV Total 58.971 (5.833) 67.514 (7.830) 5.677 (< 0.001) 1.237 Cultural awareness 9.629 (1.330) 10.686 (1.388) 3.613 (0.001) 0.777 Cultural knowledge 13.457 (2.559) 16.371 (2.451) 5.462 (< 0.001) 1.163 Cultural skill 8.514 (1.222) 10.229 (1.497) 5.767 (< 0.001) 1.255 Cultural encounter 14.886 (1.367) 16.171 (1.948) 3.787 (0.001) 0.764 Cultural desire 12.486 (1.442) 14.057 (1.862) 4.127 (< 0.001) 0.944 *p ≤ 0.05 for statistically significance Abbreviations: SD: standard deviation The mean total IAPCC-SV score increased significantly from 58.971 (SD = 5.833) in the pre-test to 67.514 (SD = 7.830) in the post-test (t = 5.677, p < 0.001) with a large effect size (Cohen’s d = 1.237). The mean score for cultural awareness increased significantly from 9.629 (SD = 1.330) to 10.686 (SD = 1.388) (t = 3.613, p = 0.001) with a moderate effect size (Cohen’s d = 0.777). The mean score for cultural knowledge scores increased significantly from 13.457 (SD = 2.559) to 16.371 (SD = 2.451) (t = 5.462, p < 0.001) with a large effect size (Cohen’s d = 1.163). The mean score for cultural skill improved significantly from 8.514 (SD = 1.222) to 10.229 (SD = 1.497) (t = 5.767, p < 0.001) with a large effect size (Cohen’s d = 1.255). The mean score for cultural encounter increased significantly from 14.886 (SD = 1.367) to 16.171 (SD = 1.948) (t = 3.787, p = 0.001) with a moderate effect size (Cohen’s d = 0.764). The mean score for cultural desire increased significantly from 12.486 (SD = 1.442) to 14.057 (SD = 1.862) (t = 4.127, p < 0.001) with a moderate-to-large effect size (Cohen’s d = 0.944). Correlation between overall cultural competence and the five constructs Table 3 shows the correlation coefficients between the five constructs, namely cultural awareness, cultural knowledge, cultural skill, cultural encounter, cultural desire, and overall cultural competence score, which were 0.729, 0.827, 0.830, 0.661 and 0.874, respectively (p < .001). Table 3 Pearson’s correlation coefficients between the overall cultural competence and the five constructs IAPCC – SV Cultural awareness IAPCC – SV Cultural knowledge IAPCC – SV Cultural skill IAPCC – SV Cultural encounter IAPCC – SV Cultural desire IAPCC – SV Total 0.729** 0.827** 0.830** 0.661** 0.874** IAPCC-SV, The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Student Version ** Correlation is significant at <0.001 (two-tailed) Discussion The findings of this pilot study demonstrate that the integration of online cross-cultural video-based simulations into nursing education significantly enhanced the cultural awareness of participating students. Theory-driven cross-cultural video-based simulation teaching model The significant improvements in the IAPCC-SV overall score and the five constructs’ scores validate the applicability of Campinha-Bacote’s Model in guiding the design of culturally specific educational interventions. The emphasis on the constructs allowed the online workshops to address multiple dimensions of cultural competence, ensuring an overarching learning experience [26]. A comprehensive review by Kleftodimos highlights the efficacy of video animation, as part of video-based simulation, allowing students to acquire non-technical skills by observing, analyzing, and reflecting on others' performances of specific skills or actions [27]. This study further verifies the utility of video-based simulation in healthcare education, demonstrating their capacity to provide immersive and impactful learning experiences without the logistical challenges of traditional methods. The study intervention leveraged Mayer’s generative processing principle, encouraging students to actively organize and integrate new knowledge with existing schemas, which can significantly enhance understanding, particularly when applied to complex, real-world problems [28]. Authenticity through scholarly designed scenarios The design and delivery of the video-based simulation workshops was the collaborative effort by nursing academics in Australia, Hong Kong and the United Kingdom. This approach was instrumental in ensuring the simulation accurately reflected the cultural nuances of each region. An integrative review by Marja and Suvi emphasized that the adaptation of real situations is a key factor in the success of sustainable curricula and learning [29]. The review found that authenticity in scenario design enhances learners' engagement and practical application of cultural competence skills. The findings of this study are aligned with this review which suggest the authenticity of scenario design was a critical element in the intervention’s success. By incorporating region-specific cultural challenges and real-world healthcare dynamics, the scenarios provided students with a meaningful and immersive learning experience, further enhancing their preparedness for multicultural clinical environments. Cost-effective approach to enhancing cultural awareness in nursing education While cultural awareness is considered the prerequisite for acquiring cultural competence, research has highlighted significant gaps in nursing students’ awareness of cultural diversity [30,31].The study findings further validate the scalability and efficiency of video-based simulations as a cost-effective, high-impact educational tool for nurse educators to develop cultural awareness as the first step toward overall cultural competence. This may be particularly important for nursing schools in low and middle-income countries where resources may be limited. Animated videos can be reused multiple times, reducing the cost per use over time. It allows educators to allocate resources more effectively while maintaining high-quality education [32,33]. Relationship between cultural awareness and cultural competence The study findings indicate the significant correlation between cultural awareness and cultural competence (r = .729, p < 0.001), suggesting improvements in cultural awareness can significantly contribute to broader cultural competence development. Cultural awareness learning is crucial for nursing students as it plays a vital role in the process of developing cultural competence, enabling the nursing workforce to deliver high-quality care to patients from diverse backgrounds [34,35]. Limitations This pilot study had limitations. Firstly, the sample size was small with only 35 nursing students. Though this pilot study was exploratory, it was not intended to test hypotheses or evaluate efficacy due to the small sample sizes. There was also uncertainty about whether observed changes were due to the theory-driven video-based simulations or other factors. Secondly, this study has not qualitatively explored the perspectives of participating students regarding the intervention. This omission may compromise the validity of the findings that it may not truly reflect the actual experiences of the students involved. Finally, the use of self-reporting questionnaires could introduce biases, such as social desirability bias, which may affect the accuracy of the outcome measures. Conclusion This pilot study demonstrates considerable potential of online cross-cultural video-based simulation as a cost-effective, scalable, and impactful teaching model for enhancing cultural awareness and developing cultural competence in nursing students. By leveraging localized, authentic cultural scenarios, this approach addresses critical gaps in nursing education, preparing students to provide culturally sensitive care in diverse and multicultural healthcare settings. The findings suggest an acceptable and feasible intervention that may provide a compelling foundation for integrating cultural competence development into nursing curricula worldwide, ensuring future healthcare professionals are equipped to meet the challenges of an increasingly interconnected and globalized world. Abbreviations Global Alliance for Nursing Education and Sciences: GANES; Institutional Review Board: IRB; Cognitive Theory of Multimedia Learning: CTML; Case-Based Learning: CBL; The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Student Version: IAPCC-SV; Statistical Package for Social Science; SPSS Declarations Funding This work was supported by Teaching Development Grant (Project no. 782), The University Grants Committee, The Hong Kong Government Clinical trial number not applicable Declarations Ethics approval and consent to participate Ethical approval for the study was granted by the HKU/HA HKW Institutional Review Board (approval no. UW20-411). Participants were assured of their rights, and informed e-consent was obtained from each individual involved. Researchers emphasized that participation was entirely voluntary, and participants were informed that they could withdraw from the study at any time without impacting their educational outcomes or academic grades. The study adhered strictly to the ethical guidelines set forth in the Declaration of Helsinki, and all procedures were conducted in compliance with the standards approved by the HKU/HA HKW Institutional Review Board. Consent for publication Not applicable. Competing interests The Authors declare that there is no conflict of interest. References Červený M, Kratochvilova I, Hellerová V, Tothova V. Methods of increasing cultural competence in nurses working in clinical practice: A scoping review of literature 2011–2021. Front Psychol. 2022;13:936181. 10.3389/fpsyg.2022.936181 . Osmancevic S, Großschädl F, Lohrmann C. Cultural competence among nursing students and nurses working in acute care settings: a cross-sectional study. BMC Health Serv Res. 2023;23(1):105. 10.1186/s12913-023-09103-5 . Kaihlanen AM, Hietapakka L, Heponiemi T. Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training. BMC Nurs. 2019;18:1–9. 10.1186/s12912-019-0363-x . Baker C, Cary AH, da Conceicao Bento M. Global standards for professional nursing education: The time is now. J Prof Nurs. 2021;37(1):86–92. 10.1016/j.profnurs.2020.10.001 . Gradellini C, Gómez-Cantarino S, Dominguez-Isabel P, Molina-Gallego B, Mecugni D, Ugarte-Gurrutxaga MI. Cultural competence and cultural sensitivity education in university nursing courses. A scoping review. Front Psychol. 2021;12:682920. 10.3389/fpsyg.2021.682920 . Vandan N, Wong JY, Lee JJ, Yip PS, Fong DY. Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study. Health Soc Care Commun. 2020;28(2):591–601. 10.1111/hsc.12892 . Abdel-Azeem AM, Abu Hashem WA, Sabek EM, Elsayed FF. Patients’ Safety and Its Relation to Non-technical Skills and Personality Traits among Nurses at Critical Care Units. Menoufia Nurs J. 2024;9(1):217–38. 10.21608/menj.2024.349519 . Lee A, Finstad A, Gawad N, Boet S, Raiche I, Balaa F. Nontechnical skills (NTS) in the undergraduate surgical and anesthesiology curricula: are we adequately preparing medical students? J Surg Educ. 2021;78(2):502–11. 10.1016/j.jsurg.2020.08.001 . Wevling A, Olsen BF, Nygaard AM, Heiberg T. Knowledge and awareness of non-technical skills over the course of an educational program in nursing-a repeated cross-sectional study. Advances in medical education and practice. 2023 Dec 31:31–41. 10.2147/amep.s379341 Campinha-Bacote J. The Process of Cultural Competence in the Delivery Healthcare Services: The Journey Continues (5th Edition). Transcultural C.A.R.E. Associates .2007. Tage PK, Feoh FT, Goa MY, Gatum AM, Djogo HM, Febriyanti E. Nursing students' experiences with improving cultural competence through education and practices in rural Indonesia: a qualitative study†. Front Nurs. 2025;12(1). 10.2478/fon-2025-0005 . Wong AK, Chan EA, Chan KS, Johnston J, Malik G, Peddle M, Webster KF. The effects of video-based simulation in Collaborative Learning in a Student-led Global Classroom (CLSGC) program on non-technical skills among undergraduate nursing students in three regions: A mixed-methods study. Nurse Educ Today. 2024;143:106381. 10.1016/j.nedt.2024.106381 . Natarajan J, Joseph MA, Al Shibli ZS, Al Hajji SS, Al Hanawi DK, Al Kharusi AN, Al Maqbali IM. Effectiveness of an interactive educational video on knowledge, skill and satisfaction of nursing students. Sultan Qaboos Univ Med J. 2022;22(4):546. 10.18295/squmj.2.2022.013 . Schick K, Reiser S, Janssen L, Schacht L, Pittroff SI, Dörfler E, Klein E, Roenneberg C, Dinkel A, Fleischmann A, Berberat PO. Training in medical communication competence through video-based e-learning: How effective are video modeling and video reflection? Patient Educ Couns. 2024;121:108132. 10.1016/j.pec.2023.108132 . Koçan S, Kulakaç N, Aktuğ C, Demirel S. The Effect of Video-Based Simulation Training on Nursing Students' Motivation and Academic Achievement: A Mixed Study. CIN: Computers, Informatics, Nursing. 2023 Sep 1:10–97. 10.1097/cin.0000000000001117 Alucozai F, Richards EA, Ward A, Loomis A. Examining cultural comfort and knowledge in undergraduate nursing students after the implementation of an online educational animation on providing care for Muslim patients. J Transcult Nurs. 2024;35(3):237–43. 10.1177/10436596231225265 . Alucozai F, Richards EA, Ward A, Loomis A. Examining Cultural Comfort and Knowledge in Undergraduate Nursing Students After the Implementation of an Online Educational Animation on Providing Care for Muslim Patients. J Transcult Nurs. 2024;35(3):237–43. 10.1186/s12909-025-06915-3 . Knapp P, Benhebil N, Evans E, Moe-Byrne T. The effectiveness of video animations in the education of healthcare practitioners and student practitioners: a systematic review of trials. Perspect Med Educ. 2022;11(6):309–15. 10.1007/s40037-022-00736-6 . Praveen CK, Srinivasan K. Psychological impact and influence of animation on viewer’s visual attention and cognition: A systematic literature review, open challenges, and future research directions. Comput Math Methods Med. 2022;2022(1):8802542. 10.1155/2022/8802542 . Chooniedass R, Reekie M, Denison J, Mercuri A, Nawara R, Purcell N, Oelke M, Janke R. Embedding cultural safety in nursing education: A scoping review of strategies and approaches. J Prof Nurs. 2025;56:113–29. 10.1016/j.profnurs.2024.11.005 . Vangone I, Caruso R, Magon A, Giamblanco C, Conte G, Baroni I, Russo S, Belloni S, Arrigoni C. High-Fidelity simulation and its impact on non-technical skills development among healthcare professionals: a systematic review and meta-analysis. ACTA Biomed. 2024;95(2):1–7. 10.23750/abm.v95i2.15601 . Mayer RE. The past, present, and future of the cognitive theory of multimedia learning. Educational Psychol Rev. 2024;36(1):8. 10.1007/s10648-023-09842-1 . Hertzog MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008;31(2):180–91. 10.1002/nur.20247 . Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. J Nurs Educ. 1999;38(5):203–7. 10.3928/0148-4834-19990501-06 . Fitzgerald EM, Cronin SN, Campinha-Bacote J. Psychometric testing of the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals -- Student Version (IAPCC-SV). Journal of Theory Construction & Testing [Internet]. 2009 Oct 1 [cited 2025 May 18];13(2):64–8. Available from: https://research-ebsco-com.eproxy.lib.hku.hk/linkprocessor/plink?id=4700b430-bb66-30f6-b2fa-ac1efeddb99e Rahimi M, Khodabandeh Shahraki S, Fatehi F, Farokhzadian J. A virtual training program for improving cultural competence among academic nurse educators. BMC Med Educ. 2023;23(1):445. 10.1186/s12909-023-04414-x . Kleftodimos A. Computer-Animated Videos in Education: A Comprehensive Review and Teacher Experiences from Animation Creation. Digital. 2024;4(3):613–47. 10.3390/digital4030031 . [Internet]. Fiorella L, Mayer RE. The generative activity principle in multimedia learning. Camb Univ Press eBooks. 2021;339–50. 10.1017/9781108894333.036 . Marja SL, Suvi A. Cultural competence learning of the health care students using simulation pedagogy: An integrative review. Nurse Educ Pract. 2021;52:103044. 10.1016/j.nepr.2021.103044 . Hosseini FA, Torabizadeh C, Bagherian S, Thomson B. Cultural awareness in nursing: Concept analysis using Rodgers’ evolutionary approach. J Res Dev Nurs Midwifery. 2021;18(1):1–7. 10.52547/jgbfnm.18.1.1 . Ličen S, Prosen M. The development of cultural competences in nursing students and their significance in shaping the future work environment: a pilot study. BMC Med Educ. 2023;23(1):819. 10.1186/s12909-023-04800-5 . Cookson A, Kim D, Hartsell T. Enhancing student achievement, engagement, and satisfaction using animated instructional videos. Int J Inform Communication Technol Educ (IJICTE). 2020;16(3):113–25. 10.4018/ijicte.2020070108 . Krumm IR, Miles MC, Clay A, Carlos Ii WG, Adamson R. Making effective educational videos for clinical teaching. Chest. 2022;161(3):764–72. 10.1016/j.chest.2021.09.015 . Lonneman W. Teaching strategies to increase cultural awareness in nursing students. Nurse Educ. 2015;40(6):285–8. 10.1097/nne.0000000000000175 . Chan SL, Fung JT, Takemura N, Chau PH, Lee JJ, Choi HR, Wan WH, Withrow H, Lin CC. Enhancing nursing students' cultural awareness through Community of Inquiry-guided online ‘Internationalization at Home’strategies—An intervention study. Nurs Open. 2024;11(8):e2251. 10.1002/nop2.2251 . Additional Declarations No competing interests reported. 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6692661","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494373795,"identity":"e617da1a-3e19-4d66-813b-afe38ea911bd","order_by":0,"name":"Siu Ling Chan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYFAC5sYDDAwHGPgl2BgYGBsSiNHC2ADWIjmDZC0GN4jVYs7e2HCYp+aOvPHttjQJxh1phLVY9hwEajn2zHDbnWPHJBjP5BDWYnAjseEwb8Nhxm030tskGNsqiNdiv3kGqVoSN0ikAR3WRoTDQH45OOfY4eQZN9KSLRLbiPC+OXvzwQdvag7b9s9IM7zxsS2ZCIcBMRMPjJdAWANEC+MPYlSOglEwCkbByAUAqntE9pHXZ8QAAAAASUVORK5CYII=","orcid":"","institution":"University of Hong Kong","correspondingAuthor":true,"prefix":"","firstName":"Siu","middleName":"Ling","lastName":"Chan","suffix":""},{"id":494373796,"identity":"91e5634d-3552-4e5d-8eeb-941375c24313","order_by":1,"name":"John Tai Chun Fung","email":"","orcid":"","institution":"University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"Tai Chun","lastName":"Fung","suffix":""},{"id":494373797,"identity":"61aa9773-7c47-4548-bff2-a0caa2960cb7","order_by":2,"name":"Jacqueline Bloomfield","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"","lastName":"Bloomfield","suffix":""},{"id":494373798,"identity":"850bf35b-9e73-4b72-ae48-2dc2df959da3","order_by":3,"name":"Jane Nicol","email":"","orcid":"","institution":"St Richard’s Hospice","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Nicol","suffix":""},{"id":494373799,"identity":"8cc19dd1-f97f-48d5-926b-25a27594d72d","order_by":4,"name":"Jung Jae Lee","email":"","orcid":"","institution":"University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Jung","middleName":"Jae","lastName":"Lee","suffix":""},{"id":494373800,"identity":"9d2c9245-561a-4b6a-b02e-d337fc749f58","order_by":5,"name":"Wai Hin Wan","email":"","orcid":"","institution":"University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Wai","middleName":"Hin","lastName":"Wan","suffix":""},{"id":494373806,"identity":"39567bf7-dc4f-4337-bd4f-7607e430596d","order_by":6,"name":"Chia Chin Lin","email":"","orcid":"","institution":"University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Chia","middleName":"Chin","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2025-05-18 15:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6692661/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6692661/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88260824,"identity":"452ba766-5b02-410b-8807-7581191a8e11","added_by":"auto","created_at":"2025-08-04 15:19:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":108135,"visible":true,"origin":"","legend":"\u003cp\u003eTaking care of the patient in the emergency department\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6692661/v1/c4fbdc15683028de534c5db5.png"},{"id":88260356,"identity":"cbab0771-f564-410f-9b59-ad8c25f5f2ae","added_by":"auto","created_at":"2025-08-04 15:11:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":162662,"visible":true,"origin":"","legend":"\u003cp\u003eTaking care of the patient in a surgical ward\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6692661/v1/798b72999528cfdb9d3aefae.png"},{"id":88260352,"identity":"19d31aba-a2bb-41bc-8f29-23df51e57bc5","added_by":"auto","created_at":"2025-08-04 15:11:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":205202,"visible":true,"origin":"","legend":"\u003cp\u003eTaking care of the patient in a nursing home\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6692661/v1/dc083b0954ffc34ef072537d.png"},{"id":106397919,"identity":"13d51454-30bd-4507-a7df-5c23aa1a50f7","added_by":"auto","created_at":"2026-04-08 08:15:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1536647,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6692661/v1/86829ee7-f143-43d8-a559-5a0d6d628e6d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Nursing Students’ Cultural Awareness using Cross-Cultural Video-Based Simulation: A Pilot Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGiven the increasing cultural diversity within global healthcare systems, it is crucial to nurture culturally competent nurses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Developing this competence begins with cultural awareness, which serves as the foundational step in fostering a deeper understanding and appreciation of diverse cultures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Global Alliance for Nursing Education and Sciences (GANES) identified cultural competence as an international standard for optimal healthcare outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In today\u0026rsquo;s globalized world, where nursing professionals interact regularly with patients from different cultural groups, effective communication, cultural sensitivity, and the ability to navigate cultural differences have become essential nursing skills [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNumerous studies have shown that healthcare providers' acquisition of non-technical skills, including cultural competence, directly aligns with the enhancement of a safety culture and the improvement of patient safety outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Traditional nursing education often prioritizes technical and clinical skills, which may overlook non-technical skills such as communication, cultural sensitivity and teamwork [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].This gap in non-technical skills can hinder nursing students' ability to adapt to diverse clinical contexts and deliver culturally sensitive care, which is increasingly recognized as a critical aspect of patient safety and satisfaction [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, it is important to recognize that developing cultural competence is an ongoing process for students, with cultural awareness being the essential first step in this journey [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith rapid development of educational technology, innovative simulation approaches have been developed in higher education throughout the decades. Video-based simulation learning is a method widely recognized for its effectiveness in developing non-technical skills among nursing students [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].The efficacy of video-based simulations allows students to acquire non-technical skills by observing, analyzing, and reflecting on peer\u0026rsquo;s performances of specific skills or actions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].This method provides a visual anchor that connects theoretical learning to real-life situations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Unlike traditional didactic teaching methods, video-based simulations immerse students in realistic, scenario-based learning environments that closely mirror clinical practice. This approach bolsters critical thinking, enhances communication skills, and boosts students\u0026rsquo; confidence in delivering culturally sensitive care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the context of cultural competence development, animated videos as part of the video-based simulation are highly engaging, leading to better retention of cultural knowledge [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These videos present scenarios that allow learners to interact through choices or actions influencing the outcome [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Using visual aids, colors, and storytelling makes complex cultural concepts more memorable and easier to understand [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. They simplify intricate cultural nuances and practices, helping students develop a deeper understanding of diverse patient needs [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. By consistently conveying messages of cultural sensitivity, awareness and safety, these animations reinforce the importance of cultural competence in healthcare [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This clarity and engagement improve students' comprehension of cross-cultural interactions and patient care.\u003c/p\u003e\u003cp\u003eDespite the increasing emphasis on cultural awareness, a limited number of nursing programs incorporate structured, evidence-based learning pedagogies to cultivate non-technical skills [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This pilot study aimed to explore the acceptability and feasibility of video-based simulation interventions on cultural competence development of nursing students, through adopting the theoretical foundations grounded in The Process of Cultural Competence in the Delivery of Healthcare Services Model coupled with the Mayer\u0026rsquo;s Cognitive Theory of Multimedia Learning [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis pilot study employed a quasi-experimental design with one-group pre- and post-test to evaluate the potential effectiveness of three cross-cultural video-based simulation workshops, in enhancing the development of nursing students\u0026rsquo; cultural awareness.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003e Undergraduate nursing students at a university in Hong Kong were invited to participate in the study. Year 1 to Year 3 students who were enrolled in the life enrichment learning course, were invited to join the study via their registered university emails. For a pilot study, a sample size of around 30 participants is commonly considered adequate to assess its acceptability and feasibility [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Employing convenience sampling, 35 undergraduate nursing students were recruited. Prior informed consent was sought from participants, and the study was approved by the Institutional Review Board (IRB No. UW20-411).\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe Process of Cultural Competence in the Delivery of Healthcare Services Model and Mayer\u0026rsquo;s Cognitive Theory of Multimedia Learning informed the design of culturally specific case-based learning scenarios, which were delivered through the structured online workshops. The Process of Cultural Competence in the Delivery of Healthcare Services Model emphasizes five constructs: cultural awareness, cultural skill, cultural encounter, cultural knowledge, and cultural desire. Cultural awareness focuses on being aware of one\u0026rsquo;s own biases and prejudices towards other cultural groups. Cultural skill refers to the skill of conducting a cultural assessment. Cultural encounter means nurses learn directly from client\u0026rsquo;s culture. Cultural knowledge identifies those related to health beliefs and treatment efficacy. Cultural desire explains nurses\u0026rsquo; intrinsic motivation to be culturally competent. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In this study, these constructs formed a dynamic framework for developing cultural competence among nursing students, aligning with the goals of nursing education to address global health disparities. Mayer\u0026rsquo;s Cognitive Theory of Multimedia Learning (CTML) provides a framework for optimizing how students process and retain information [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. CTML is based on three core principles: dual channels, which highlight learners process visual and auditory information separately; limited capacity, which recognizes the finite cognitive load learners can handle at one time; and active processing, which underscores the importance of selecting, organizing, and integrating new information for meaningful learning. By using these principles, this pilot study transformed culturally specific Case-Based Learning (CBL) scenarios into engaging animated videos, designed to maximize students' interest, cognitive engagement, and ability to apply cultural concepts in real-world settings.\u003c/p\u003e\u003cp\u003eThe video-based simulation in this pilot study feature scenarios collaboratively developed and validated by university nursing academia from Australia, Hong Kong and the United Kingdom. Three scenarios were co-created using video animations with a surgical ward, an emergency department and a nursing home as the background, that engaged students in active observation, analysis, and discussion, enabling them to apply theoretical knowledge in practical contexts. Each scenario contained five to six video clips, and it was tailored to reflect the unique cultural challenges the patients were facing, with integrated themes of cultural learning for participants based on Campinha-Bacote\u0026rsquo;s Model of Cultural Competence, which ensures a comprehensive learning experience. Three online workshops were held, focusing on the three culturally specific scenarios that represented Australia, Hong Kong, and the United Kingdom, respectively, with facilitated discussions.\u003c/p\u003e\n\u003ch3\u003eSelf-directed Learning Sessions\u003c/h3\u003e\n\u003cp\u003eBefore the workshops, participants were provided with online pre-reading materials and Panopto lecture videos about the process of developing cultural competence. These emphasized key concepts from Campinha-Bacote\u0026rsquo;s Model of Cultural Competence. This preparatory step aimed to establish a foundational understanding of cultural concepts among participants.\u003c/p\u003e\n\u003ch3\u003eVideo-based Simulation Workshops\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eWorkshop Structure\u003c/h2\u003e\u003cp\u003eEach workshop began with case-specific reading, providing background information on the scenario and outlining the cultural challenges to be addressed.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eVideo-based Simulations\u003c/h3\u003e\n\u003cp\u003eFive to six video clips were presented during each workshop, depicting culturally specific situations relevant to the emergency department (Hong Kong) in the first session (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), the surgical ward (Australia) in the second session (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and the nursing home (United Kingdom) in the third session (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These were designed to highlight cultural issues aligned with the five constructs of Campinha-Bacote\u0026rsquo;s Model, exposing students to diverse cultural healthcare contexts.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eDiscussion Points\u003c/h3\u003e\n\u003cp\u003eFor each video clip, discussion points were provided to encourage students to reflect on the cultural issues presented in the scenario. Questions were designed to elicit critical thinking and application of the constructs of developing cultural competence, such as identifying cultural needs, demonstrating cultural sensitivity, and reflecting on personal biases.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eFacilitated Discussions\u003c/h2\u003e\u003cp\u003eStudents engaged in discussions facilitated by local and international instructors from the respective regions (Hong Kong, Australia, and the United Kingdom). Instructors guided students in analyzing the discussion points, addressing cultural nuances, and providing feedback on their responses. These discussions emphasized interactive and reflective learning, allowing students to deepen their understanding and apply theoretical concepts to practical situations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003eSocio-demographic Questionnaire\u003c/h2\u003e\u003cp\u003eData pertaining to participants' sociodemographic variables including age, gender, cultural-related experiences (e.g., lived in culturally diverse environments, participated in overseas exchange programs, prior experience living or studying abroad, attended cultural competence learning) and clinical placement experiences were collected at baseline.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eThe Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Student Version (IAPCC-SV)\u003c/h2\u003e\u003cp\u003eThe pilot study utilized the IAPCC-SV questionnaires developed by Campinha-Bacote (1999) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The 20-item tool measures the five constructs of cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire using a four-point Likert scale reflecting the response categories of strongly agree, agree, disagree, and strongly disagree, as outlined in the theoretical model. The IAPCC-SV has been widely recognized as a valid and reliable tool for assessing cultural competence in nursing students and has been adopted by accrediting bodies for nursing programs at both associate and baccalaureate levels. The Cronbach's alpha for the overall scale was 0.783. Reliability coefficients were calculated for the instrument\u0026rsquo;s five subscales ranging from 0.67 to 0.74 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Participants completed the IAPCC-SV before the intervention to establish baseline levels of cultural competence and again after the workshops to measure changes in their cultural competence scores.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe participants\u0026rsquo; sociodemographic variables were analyzed using descriptive statistics. Q-Q plot was used to test the normal distribution. Changes in IAPCC-SV were analyzed using paired sample t-test. The association between the overall cultural competence and the five constructs was examined using Pearson\u0026rsquo;s correlation coefficient. Data was analyzed using the Statistical Package for Social Science (SPSS) Version 28, with the significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eSociodemographic Characteristics of Participants\u003c/h2\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the sociodemographic information of the participants, with 25.7% enrolled in Year 1, 57.1% in Year 2, and 17.1% in Year 3. Most participants were aged 18\u0026ndash;21 years (88.6%), with 11.4% aged 22\u0026ndash;25 years. The sample included 16 males (45.7%) and 19 females (54.3%).\u003c/p\u003e\n \u003cp\u003eRegarding intercultural experiences, 42.9% of participants lived in culturally diverse environments, while 31.4% participated in overseas exchange programs. Additionally, 25.7% reported prior experience living or studying abroad, and 40% attended cultural competence training within the university.\u003c/p\u003e\n \u003cp\u003eClinically, 37.1% of participants reported experience in clinical placements. There were no significant differences in sociodemographic characteristics, ensuring a consistent baseline for the intervention evaluation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eOverall Cultural Competence\u003c/h2\u003e\n \u003cp\u003eThe normality of the IPACC-SV scores and the five constructs\u0026rsquo; scores were assessed using Q-Q plots, which showed data points closely aligned with the diagonal line and no major deviations in detrended plots. This indicates the data were normally distributed.\u003c/p\u003e\n \u003cp\u003eThe interventions demonstrated a statistically significant improvement in the cultural competence of nursing students as measured by the IAPCC-SV. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the pre- and post-test results for total IAPCC-SV score and the five constructs\u0026rsquo; scores.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics of participants (n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.477\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (54.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (45.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (88.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of living in a culturally diverse environment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of overseas exchange program during university enrolment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (68.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of living or study abroad prior to university enrolment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.224\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (74.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of attending training/workshops related to cultural competence development\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of clinical practice/clinical placement in the health system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (62.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e*p\u0026thinsp;\u0026le;\u0026thinsp;0.05 for statistically significance\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of perceived clinical competence before and after the intervention\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-test mean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-test mean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et-test (p)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohen\u0026rsquo;s d\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC-SV Total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.971 (5.833)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.514 (7.830)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.677 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.237\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural awareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.629 (1.330)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.686 (1.388)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.613 (0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural knowledge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.457 (2.559)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.371 (2.451)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.462 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural skill\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.514 (1.222)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.229 (1.497)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.767 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural encounter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.886 (1.367)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.171 (1.948)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.787 (0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.764\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural desire\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.486 (1.442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.057 (1.862)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.127 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.944\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*p\u0026thinsp;\u0026le;\u0026thinsp;0.05 for statistically significance\u003cbr\u003eAbbreviations: SD: standard deviation\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe mean total IAPCC-SV score increased significantly from 58.971 (SD = 5.833) in the pre-test to 67.514 (SD = 7.830) in the post-test (t = 5.677, p \u0026lt; 0.001) with a large effect size (Cohen\u0026rsquo;s d = 1.237). The mean score for cultural awareness increased significantly from 9.629 (SD = 1.330) to 10.686 (SD = 1.388) (t = 3.613, p = 0.001) with a moderate effect size (Cohen\u0026rsquo;s d = 0.777). The mean score for cultural knowledge scores increased significantly from 13.457 (SD = 2.559) to 16.371 (SD = 2.451) (t = 5.462, p \u0026lt; 0.001) with a large effect size (Cohen\u0026rsquo;s d = 1.163). The mean score for cultural skill improved significantly from 8.514 (SD = 1.222) to 10.229 (SD = 1.497) (t = 5.767, p \u0026lt; 0.001) with a large effect size (Cohen\u0026rsquo;s d = 1.255). The mean score for cultural encounter increased significantly from 14.886 (SD = 1.367) to 16.171 (SD = 1.948) (t = 3.787, p = 0.001) with a moderate effect size (Cohen\u0026rsquo;s d = 0.764). The mean score for cultural desire increased significantly from 12.486 (SD = 1.442) to 14.057 (SD = 1.862) (t = 4.127, p \u0026lt; 0.001) with a moderate-to-large effect size (Cohen\u0026rsquo;s d = 0.944).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eCorrelation between overall cultural competence and the five constructs\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eTable 3 shows the correlation coefficients between the five constructs, namely cultural awareness, cultural knowledge, cultural skill, cultural encounter, cultural desire, and overall cultural competence score, which were 0.729, 0.827, 0.830, 0.661 and 0.874, respectively (p \u0026lt; .001).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3 Pearson\u0026rsquo;s correlation coefficients between the overall cultural competence and the five constructs\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC \u0026ndash; SV Cultural awareness\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC \u0026ndash; SV Cultural knowledge\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC \u0026ndash; SV Cultural skill\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC \u0026ndash; SV Cultural encounter\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC \u0026ndash; SV Cultural desire\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIAPCC \u0026ndash; SV Total\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.729**\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.827**\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.830**\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.661**\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.874**\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eIAPCC-SV, The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Student Version\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e** Correlation is significant at \u0026lt;0.001 (two-tailed)\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this pilot study demonstrate that the integration of online cross-cultural video-based simulations into nursing education significantly enhanced the cultural awareness of participating students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTheory-driven cross-cultural video-based simulation teaching model\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe significant improvements in the IAPCC-SV overall score and the five constructs’ scores validate the applicability of Campinha-Bacote’s Model in guiding the design of culturally specific educational interventions. The emphasis on the constructs allowed the online workshops to address multiple dimensions of cultural competence, ensuring an overarching learning experience [26].\u003c/p\u003e\n\u003cp\u003eA comprehensive review by Kleftodimos highlights the efficacy of video animation, as part of video-based simulation, allowing students to acquire non-technical skills by observing, analyzing, and reflecting on others' performances of specific skills or actions [27]. This study further verifies the utility of video-based simulation in healthcare education, demonstrating their capacity to provide immersive and impactful learning experiences without the logistical challenges of traditional methods. The study intervention leveraged Mayer’s generative processing principle, encouraging students to actively organize and integrate new knowledge with existing schemas, which can significantly enhance understanding, particularly when applied to complex, real-world problems [28].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthenticity through scholarly designed scenarios\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe design and delivery of the video-based simulation workshops was the collaborative effort by nursing academics in Australia, Hong Kong and the United Kingdom. This approach was instrumental in ensuring the simulation accurately reflected the cultural nuances of each region. An integrative review by Marja and Suvi emphasized that the adaptation of real situations is a key factor in the success of sustainable curricula and learning [29]. The review found that authenticity in scenario design enhances learners' engagement and practical application of cultural competence skills. The findings of this study are aligned with this review which suggest the authenticity of scenario design was a critical element in the intervention’s success. By incorporating region-specific cultural challenges and real-world healthcare dynamics, the scenarios provided students with a meaningful and immersive learning experience, further enhancing their preparedness for multicultural clinical environments.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCost-effective approach to enhancing cultural awareness in nursing education\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile cultural awareness is considered the prerequisite for acquiring cultural competence, research has highlighted significant gaps in nursing students’ awareness of cultural diversity [30,31].The study findings further validate the scalability and efficiency of video-based simulations as a cost-effective, high-impact educational tool for nurse educators to develop cultural awareness as the first step toward overall cultural competence. This may be particularly important for nursing schools in low and middle-income countries where resources may be limited. Animated videos can be reused multiple times, reducing the cost per use over time. It allows educators to allocate resources more effectively while maintaining high-quality education [32,33].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRelationship between cultural awareness and cultural competence\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study findings indicate the significant correlation between cultural awareness and cultural competence (r = .729, p \u0026lt; 0.001), suggesting improvements in cultural awareness can significantly contribute to broader cultural competence development. Cultural awareness learning is crucial for nursing students as it plays a vital role in the process of developing cultural competence, enabling the nursing workforce to deliver high-quality care to patients from diverse backgrounds [34,35].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis pilot study had limitations. Firstly, the sample size was small with only 35 nursing students. \u0026nbsp; Though this pilot study was exploratory, it was not intended to test hypotheses or evaluate efficacy due to the small sample sizes. There was also uncertainty about whether observed changes were due to the theory-driven video-based simulations or other factors. Secondly, this study has not qualitatively explored the perspectives of participating students regarding the intervention. This omission may compromise the validity of the findings that it may not truly reflect the actual experiences of the students involved. Finally, the use of self-reporting questionnaires could introduce biases, such as social desirability bias, which may affect the accuracy of the outcome measures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis pilot study demonstrates considerable potential of online cross-cultural video-based simulation as a cost-effective, scalable, and impactful teaching model for enhancing cultural awareness and developing cultural competence in nursing students. By leveraging localized, authentic cultural scenarios, this approach addresses critical gaps in nursing education, preparing students to provide culturally sensitive care in diverse and multicultural healthcare settings. The findings suggest an acceptable and feasible intervention that may provide a compelling foundation for integrating cultural competence development into nursing curricula worldwide, ensuring future healthcare professionals are equipped to meet the challenges of an increasingly interconnected and globalized world.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGlobal Alliance for Nursing Education and Sciences: GANES; Institutional Review Board: IRB; Cognitive Theory of Multimedia Learning: CTML; Case-Based Learning: CBL; The Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals- Student Version: IAPCC-SV; Statistical Package for Social Science; SPSS\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Teaching Development Grant (Project no. 782), The University Grants Committee, The Hong Kong Government\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was granted by the HKU/HA HKW Institutional Review Board (approval no. UW20-411). Participants were assured of their rights, and informed e-consent was obtained from each individual involved. Researchers emphasized that participation was entirely voluntary, and participants were informed that they could withdraw from the study at any time without impacting their educational outcomes or academic grades. The study adhered strictly to the ethical guidelines set forth in the Declaration of Helsinki, and all procedures were conducted in compliance with the standards approved by the HKU/HA HKW Institutional Review Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors declare that there is no conflict of interest. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eČerven\u0026yacute; M, Kratochvilova I, Hellerov\u0026aacute; V, Tothova V. Methods of increasing cultural competence in nurses working in clinical practice: A scoping review of literature 2011\u0026ndash;2021. Front Psychol. 2022;13:936181. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2022.936181\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2022.936181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsmancevic S, Gro\u0026szlig;sch\u0026auml;dl F, Lohrmann C. Cultural competence among nursing students and nurses working in acute care settings: a cross-sectional study. BMC Health Serv Res. 2023;23(1):105. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-023-09103-5\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-09103-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaihlanen AM, Hietapakka L, Heponiemi T. Increasing cultural awareness: qualitative study of nurses\u0026rsquo; perceptions about cultural competence training. BMC Nurs. 2019;18:1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-019-0363-x\u003c/span\u003e\u003cspan address=\"10.1186/s12912-019-0363-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaker C, Cary AH, da Conceicao Bento M. Global standards for professional nursing education: The time is now. J Prof Nurs. 2021;37(1):86\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.profnurs.2020.10.001\u003c/span\u003e\u003cspan address=\"10.1016/j.profnurs.2020.10.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGradellini C, G\u0026oacute;mez-Cantarino S, Dominguez-Isabel P, Molina-Gallego B, Mecugni D, Ugarte-Gurrutxaga MI. Cultural competence and cultural sensitivity education in university nursing courses. A scoping review. Front Psychol. 2021;12:682920. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2021.682920\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2021.682920\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVandan N, Wong JY, Lee JJ, Yip PS, Fong DY. Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study. Health Soc Care Commun. 2020;28(2):591\u0026ndash;601. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hsc.12892\u003c/span\u003e\u003cspan address=\"10.1111/hsc.12892\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdel-Azeem AM, Abu Hashem WA, Sabek EM, Elsayed FF. Patients\u0026rsquo; Safety and Its Relation to Non-technical Skills and Personality Traits among Nurses at Critical Care Units. Menoufia Nurs J. 2024;9(1):217\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21608/menj.2024.349519\u003c/span\u003e\u003cspan address=\"10.21608/menj.2024.349519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee A, Finstad A, Gawad N, Boet S, Raiche I, Balaa F. Nontechnical skills (NTS) in the undergraduate surgical and anesthesiology curricula: are we adequately preparing medical students? J Surg Educ. 2021;78(2):502\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jsurg.2020.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jsurg.2020.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWevling A, Olsen BF, Nygaard AM, Heiberg T. Knowledge and awareness of non-technical skills over the course of an educational program in nursing-a repeated cross-sectional study. Advances in medical education and practice. 2023 Dec 31:31\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/amep.s379341\u003c/span\u003e\u003cspan address=\"10.2147/amep.s379341\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCampinha-Bacote J. The Process of Cultural Competence in the Delivery Healthcare Services: The Journey Continues (5th Edition). \u003cem\u003eTranscultural C.A.R.E. Associates\u003c/em\u003e.2007.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTage PK, Feoh FT, Goa MY, Gatum AM, Djogo HM, Febriyanti E. Nursing students' experiences with improving cultural competence through education and practices in rural Indonesia: a qualitative study\u0026dagger;. Front Nurs. 2025;12(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2478/fon-2025-0005\u003c/span\u003e\u003cspan address=\"10.2478/fon-2025-0005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong AK, Chan EA, Chan KS, Johnston J, Malik G, Peddle M, Webster KF. The effects of video-based simulation in Collaborative Learning in a Student-led Global Classroom (CLSGC) program on non-technical skills among undergraduate nursing students in three regions: A mixed-methods study. Nurse Educ Today. 2024;143:106381. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nedt.2024.106381\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2024.106381\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNatarajan J, Joseph MA, Al Shibli ZS, Al Hajji SS, Al Hanawi DK, Al Kharusi AN, Al Maqbali IM. Effectiveness of an interactive educational video on knowledge, skill and satisfaction of nursing students. Sultan Qaboos Univ Med J. 2022;22(4):546. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18295/squmj.2.2022.013\u003c/span\u003e\u003cspan address=\"10.18295/squmj.2.2022.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchick K, Reiser S, Janssen L, Schacht L, Pittroff SI, D\u0026ouml;rfler E, Klein E, Roenneberg C, Dinkel A, Fleischmann A, Berberat PO. Training in medical communication competence through video-based e-learning: How effective are video modeling and video reflection? Patient Educ Couns. 2024;121:108132. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pec.2023.108132\u003c/span\u003e\u003cspan address=\"10.1016/j.pec.2023.108132\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKo\u0026ccedil;an S, Kulaka\u0026ccedil; N, Aktuğ C, Demirel S. The Effect of Video-Based Simulation Training on Nursing Students' Motivation and Academic Achievement: A Mixed Study. CIN: Computers, Informatics, Nursing. 2023 Sep 1:10\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/cin.0000000000001117\u003c/span\u003e\u003cspan address=\"10.1097/cin.0000000000001117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlucozai F, Richards EA, Ward A, Loomis A. Examining cultural comfort and knowledge in undergraduate nursing students after the implementation of an online educational animation on providing care for Muslim patients. J Transcult Nurs. 2024;35(3):237\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/10436596231225265\u003c/span\u003e\u003cspan address=\"10.1177/10436596231225265\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlucozai F, Richards EA, Ward A, Loomis A. Examining Cultural Comfort and Knowledge in Undergraduate Nursing Students After the Implementation of an Online Educational Animation on Providing Care for Muslim Patients. J Transcult Nurs. 2024;35(3):237\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-025-06915-3\u003c/span\u003e\u003cspan address=\"10.1186/s12909-025-06915-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKnapp P, Benhebil N, Evans E, Moe-Byrne T. The effectiveness of video animations in the education of healthcare practitioners and student practitioners: a systematic review of trials. Perspect Med Educ. 2022;11(6):309\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40037-022-00736-6\u003c/span\u003e\u003cspan address=\"10.1007/s40037-022-00736-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePraveen CK, Srinivasan K. Psychological impact and influence of animation on viewer\u0026rsquo;s visual attention and cognition: A systematic literature review, open challenges, and future research directions. Comput Math Methods Med. 2022;2022(1):8802542. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2022/8802542\u003c/span\u003e\u003cspan address=\"10.1155/2022/8802542\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChooniedass R, Reekie M, Denison J, Mercuri A, Nawara R, Purcell N, Oelke M, Janke R. Embedding cultural safety in nursing education: A scoping review of strategies and approaches. J Prof Nurs. 2025;56:113\u0026ndash;29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.profnurs.2024.11.005\u003c/span\u003e\u003cspan address=\"10.1016/j.profnurs.2024.11.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVangone I, Caruso R, Magon A, Giamblanco C, Conte G, Baroni I, Russo S, Belloni S, Arrigoni C. High-Fidelity simulation and its impact on non-technical skills development among healthcare professionals: a systematic review and meta-analysis. ACTA Biomed. 2024;95(2):1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.23750/abm.v95i2.15601\u003c/span\u003e\u003cspan address=\"10.23750/abm.v95i2.15601\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMayer RE. The past, present, and future of the cognitive theory of multimedia learning. Educational Psychol Rev. 2024;36(1):8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10648-023-09842-1\u003c/span\u003e\u003cspan address=\"10.1007/s10648-023-09842-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHertzog MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008;31(2):180\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/nur.20247\u003c/span\u003e\u003cspan address=\"10.1002/nur.20247\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCampinha-Bacote J. A model and instrument for addressing cultural competence in health care. J Nurs Educ. 1999;38(5):203\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3928/0148-4834-19990501-06\u003c/span\u003e\u003cspan address=\"10.3928/0148-4834-19990501-06\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFitzgerald EM, Cronin SN, Campinha-Bacote J. Psychometric testing of the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals -- Student Version (IAPCC-SV). Journal of Theory Construction \u0026amp; Testing [Internet]. 2009 Oct 1 [cited 2025 May 18];13(2):64\u0026ndash;8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://research-ebsco-com.eproxy.lib.hku.hk/linkprocessor/plink?id=4700b430-bb66-30f6-b2fa-ac1efeddb99e\u003c/span\u003e\u003cspan address=\"https://research-ebsco-com.eproxy.lib.hku.hk/linkprocessor/plink?id=4700b430-bb66-30f6-b2fa-ac1efeddb99e\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahimi M, Khodabandeh Shahraki S, Fatehi F, Farokhzadian J. A virtual training program for improving cultural competence among academic nurse educators. BMC Med Educ. 2023;23(1):445. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-023-04414-x\u003c/span\u003e\u003cspan address=\"10.1186/s12909-023-04414-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKleftodimos A. Computer-Animated Videos in Education: A Comprehensive Review and Teacher Experiences from Animation Creation. Digital. 2024;4(3):613\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/digital4030031\u003c/span\u003e\u003cspan address=\"10.3390/digital4030031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Internet].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFiorella L, Mayer RE. The generative activity principle in multimedia learning. Camb Univ Press eBooks. 2021;339\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/9781108894333.036\u003c/span\u003e\u003cspan address=\"10.1017/9781108894333.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarja SL, Suvi A. Cultural competence learning of the health care students using simulation pedagogy: An integrative review. Nurse Educ Pract. 2021;52:103044. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nepr.2021.103044\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2021.103044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHosseini FA, Torabizadeh C, Bagherian S, Thomson B. Cultural awareness in nursing: Concept analysis using Rodgers\u0026rsquo; evolutionary approach. J Res Dev Nurs Midwifery. 2021;18(1):1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.52547/jgbfnm.18.1.1\u003c/span\u003e\u003cspan address=\"10.52547/jgbfnm.18.1.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLičen S, Prosen M. The development of cultural competences in nursing students and their significance in shaping the future work environment: a pilot study. BMC Med Educ. 2023;23(1):819. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-023-04800-5\u003c/span\u003e\u003cspan address=\"10.1186/s12909-023-04800-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCookson A, Kim D, Hartsell T. Enhancing student achievement, engagement, and satisfaction using animated instructional videos. Int J Inform Communication Technol Educ (IJICTE). 2020;16(3):113\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4018/ijicte.2020070108\u003c/span\u003e\u003cspan address=\"10.4018/ijicte.2020070108\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrumm IR, Miles MC, Clay A, Carlos Ii WG, Adamson R. Making effective educational videos for clinical teaching. Chest. 2022;161(3):764\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.chest.2021.09.015\u003c/span\u003e\u003cspan address=\"10.1016/j.chest.2021.09.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLonneman W. Teaching strategies to increase cultural awareness in nursing students. Nurse Educ. 2015;40(6):285\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/nne.0000000000000175\u003c/span\u003e\u003cspan address=\"10.1097/nne.0000000000000175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChan SL, Fung JT, Takemura N, Chau PH, Lee JJ, Choi HR, Wan WH, Withrow H, Lin CC. Enhancing nursing students' cultural awareness through Community of Inquiry-guided online \u0026lsquo;Internationalization at Home\u0026rsquo;strategies\u0026mdash;An intervention study. Nurs Open. 2024;11(8):e2251. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/nop2.2251\u003c/span\u003e\u003cspan address=\"10.1002/nop2.2251\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\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":"Cultural awareness, Cultural competence, Video-based simulation, IAPCC-SV","lastPublishedDoi":"10.21203/rs.3.rs-6692661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6692661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackgrounds:\u003c/h2\u003e\u003cp\u003eWith increasing cultural diversity in global healthcare settings, nurturing culturally competent nurses to serve the diverse population is crucial. This pilot study evaluated the potential of cross-cultural video-based simulation co-created by nursing academia across 3 countries (Australia, Hong Kong, the United Kingdom) in enhancing nursing students\u0026rsquo; cultural awareness.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003e A quasi-experimental study with one-group pre- and post-test evaluation was designed, with 35 nursing students from a university in Hong Kong participating in three educational workshops comprising theory-driven video-based simulation. Validated questionnaires were adopted to measure changes in cultural awareness scores using paired sample t-test.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThis pilot study suggested the acceptability and feasibility of the intervention as revealed by the significant improvements in cultural awareness scores (pre-test: 9.63, post-test: 10.69, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.777).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eThis pilot study highlights the potential of video-based simulation for enhancing nursing students\u0026rsquo; cultural awareness.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003e The HKU/HA HKW Institutional Review Board approved the study (UW20-411), which was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e","manuscriptTitle":"Enhancing Nursing Students’ Cultural Awareness using Cross-Cultural Video-Based Simulation: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 15:03:39","doi":"10.21203/rs.3.rs-6692661/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":"86003e77-8a16-4feb-b915-858f791361d9","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-08T08:14:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 15:03:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6692661","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6692661","identity":"rs-6692661","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}