Cultural competence in nursing was measured using the Cultural Competence Scale for Registered Nurses (CCS-RN), developed by Kim et al. [13]. The scale consists of 35 questions and seven subfactors. The participants were asked to answer each question using a 5-point Likert scale. The total scores range from 35 to 175 points, with higher scores indicating higher levels of cultural competence in nursing. The reliability of the original instrument showed the Cronbach’s α score of α=0.94, whereas the Cronbach’s α score for this study was α=0.97.

Multicultural acceptance was measured using the 2018 Korean Multicultural Acceptability Scale, developed by Ahn et al. [14] and modified by Kim et al. [15]. The scale consists of 35 questions and eight subfactors, described across three dimensions. The reverse-coded questions were calculated backward, and the score for multicultural acceptability was calculated as the original score divided by the number of questions. The total score ranges from 1 to 5, with higher scores indicating higher levels of multicultural acceptance. Questions about the area of residence, which were not relevant to the study, and questions that were identical to the general characteristics questions of the study were excluded. The original tool had a Cronbach’s α reliability of α=0.92, whereas this study had a Cronbach’s α reliability of α=0.95.

To investigate the educational needs of MBU nurses, two processes were followed: (1) we conducted interviews, using open-ended questions; and (2) we collected and analyzed data published by previous studies. A total of eight nurses were interviewed; the general characteristics of the nurses were as follows: average age, 29.5 years; education—one community college graduate, six university graduates, and one graduate school graduate; and marital status—all single. Three of the nurses worked in neonatal units, two in neonatal intensive care units, one in a pediatric intensive care unit, and two in obstetrics units, with an average of 4 years and 9 months in the MBU. The interviews were conducted one-on-one, for an average duration of 15 minutes, using the following open-ended questions: “On average, how many foreign mothers do you care for/experience in your hospital per year?”; “What is the country of origin of the majority of migrant mothers whom you care for/experience in your hospital?”; “What are the challenges of caring for/experiencing foreign mothers?”; “How did you overcome the difficulties that arose while caring for/experiencing migrant mothers?”; “What questions do you usually have while caring for/experiencing foreign mothers?”; “How did you resolve your questions about migrant mothers?”; and “If you were to participate in multicultural education for MBU nurses, what would be your preferred method of learning?”

Interviews were conducted with eight nurses from a MBU to analyze the characteristics of multicultural mothers they encountered and to assess their educational needs regarding multicultural nursing. The findings revealed that each nurse engaged with at least one multicultural mother per month. These mothers primarily resided in Korea for various reasons, including marriage migration, undocumented status, U.S. military affiliations, or medical tourism, representing nationalities such as Vietnamese, Chinese, Thai, Cambodian, Filipino, American, Japanese, and Russian, with Vietnamese marriage migrants constituting the largest group.

The nurses reported experiencing frustration and regret due to language and cultural differences. Multicultural mothers often exhibited passive and reserved behaviors, stemming from language barriers. To address communication challenges, nurses frequently sought assistance from the hospital’s international medical team or utilized translation devices, in addition to employing nonverbal communication strategies such as gestures to better understand the mothers’ needs. Confusion occasionally arose from unexpected situations linked to cultural discrepancies, leading to instances where multicultural mothers misinterpreted nurses’ explanations, thereby posing potential health risks.

The analysis of educational needs indicated that the available resources for culturally competent nursing were often unverified and inadequate for independent learning. The nurses expressed a need to acquire cultural knowledge and context in a structured educational environment prior to their interactions with multicultural mothers. Suggested topics for educational content included country-specific practices related to pregnancy, childbirth, and childcare, culturally specific precautions, health beliefs, South Korea’s multicultural policies, and tailored nursing interventions for multicultural mothers.

Regarding preferences for multicultural education, nurses noted that conventional lecture-based formats, which they had encountered during their university studies, tended to be less memorable over time. They expressed an interest in special sessions where multicultural mothers could share their experiences and challenges within hospital settings. Flexibility in scheduling and location for educational offerings was deemed essential, along with access to PowerPoint materials for on-demand reference and opportunities to engage with case-based scenarios for indirect cultural nursing experience. Furthermore, the nurses emphasized the importance of education to enhance their cultural competence. They found audiovisual materials beneficial for long-term retention of knowledge, while simulation-based learning was highlighted as an effective approach for understanding clinical applications in real-world contexts.

Moreover, we analyzed domestic and international literature, published in the last decade, on educational content, strategies and methods, period and time, and effects. The search was conducted using the Research Information Service of the Korean Ministry of Education, PubMed, and Google Scholar platforms, with the following keywords: “concept mapping and nursing,” “multicultural education and nursing,” “multicultural mother,” “marriage migrant women,” “cultural competence in nursing and nursing,” “cultural competence and nursing,” “multicultural acceptability and nursing,” “concept map and nursing,” “immigrant woman,” “nursing cultural competency,” and “multicultural acceptability.” Out of the results, the studies that did not target nursing students or nurses were excluded.

At the “Design” stage, learning goals were set based on the data collected during the analysis. Educational contents, strategies, and methods were extracted from previous studies, and deemed appropriate for the learning goals. An evaluation tool was selected to check the effectiveness of the concept mapping multicultural education program for MBU nurses and the program draft was created.

At the “Development” stage, the details were selected based on the draft of the educational program. Furthermore, the educational contents were specified and lecture materials were designed to develop training program materials. Examples of concept mapping and simulations were developed. Then the content, methods, educational materials, concept mapping handouts, and simulation scenarios were evaluated by experts, using the content validity index (CVI). The group of experts comprised three nurses with a master’s degree or higher who had been working in the MBUs for more than 5 years, three nursing professors, and one nurse teacher. The content validity for each item was calculated using the item-level content validity index (I-CVI), and for all the items using the scale-level content validity index (S-CVI). Consequently, an I-CVI of 0.78 or higher and an S-CVI of 0.9 or higher were considered to be valid [17]. Through revision and refinement, based on the CVI, the final concept mapping multicultural education program for MBU nurses was developed (Table 1).

The recruited participants were asked to complete the CCS-RN and the National Multicultural Acceptability Measurement Instrument, as well as a preliminary questionnaire for general characteristics. The experimental group participated in the concept mapping multicultural education program for MBU nurses for 5 weeks.

In the orientation before the start of the multicultural education program, the method for creating concept maps was explained. Since concept mapping requires focused thinking, nurses were allowed to choose a comfortable time and place to create the maps. Apart from the fifth session, which was conducted as a discussion, the multicultural education program was carried out using concept maps in each session. Cases that aligned with the learning objectives were presented, and after the education, participants were given ample time to think and create concept maps of necessary nursing interventions and assessments based on priorities.

For the “Evaluation” stage, the experimental group was assessed at the end of the program using the Cultural Competence in Nursing Scale and the National Multicultural Acceptability Scale. Meanwhile, the control group, which did not participate in the program, was assessed using the same methods 5 weeks after the pre-program survey.

The was conducted with the approval of the IRB and the institutional authority, utilizing recruitment advertisements posted on the hospital’s online bulletin board. Potential participants were provided with an explanation of the study’s purpose and were asked to sign a consent form after carefully considering their willingness to participate. It was clearly communicated that participation was voluntary and that they could withdraw their consent at any time.

Given that the participants work in shifts, the researcher shared the training schedule and Zoom access address with the experimental group, so that they could participate once a week, according to their work and personal schedules. Available dates were researched ahead of time to ensure that no more than five participants per day were arranged at sessions. The experimental group consisted of three groups, with two to five participants per group. To prevent the diffusion of the treatment, the experimental group was asked to keep the contents of the training confidential until the end of the second survey. In the orientation, we explained how to complete the concept mapping, which required concentration. We allowed the participants to choose a comfortable time and place to complete it. Apart from the fifth session, the whole multicultural education program was conducted using concept mapping. Cases that met the learning objectives were presented, and the participants were given enough time to think about and create a concept map of the necessary nursing interventions and circumstances, according to priorities. The five sessions took 40–50 minutes each. In the fourth session, a foreign mother was selected from the ward where participants in the experimental group worked. A case study and concept map were made according to the nursing information of the selected foreign mother. If there were no migrant mothers admitted to the ward during the training, the nurses were asked to complete case studies and concept mapping with information from previously admitted foreign mothers. The experimental group was surveyed at the end of the education program, and the control group was surveyed 5 weeks after completing the pre-program survey.