In recent years, Korea has experienced an increase in its foreign resident population, driven by higher rates of international marriages, an influx of foreign labor, and the popularity of the Korean Wave (Hallyu); these individuals now make up 4.3% of the total population [1]. This percentage is nearing the OECD (Organization for Economic Co-operation and Development) countries’ 5% threshold for defining a multicultural society, indicating that Korea is rapidly evolving into a more multicultural nation. The 2022 Yearbook of Korea immigration statistics, published by the Ministry of Justice, reports that approximately 166,000 marriage immigrants were living in Korea in 2022 [1]. Furthermore, in that same year, marriages between Korean men and foreign women accounted for 72% of all international marriages. Within 2 years of marriage, 60.8% of these women gave birth to their first child in a hospital or clinic [1]. Given Korea’s low birth rate, which is a significant social concern, the increase in women migrating to Korea for marriage and the births within these multicultural families underscore the urgent need for culturally competent nursing care during pregnancy and childbirth.

Marriage immigrant women (MIW) often encounter cultural and language barriers when they relocate to Korea. These challenges, combined with the physical discomfort and emotional instability associated with pregnancy and childbirth, can increase their psychological vulnerability, particularly as they are also at risk of social isolation [2]. Therefore, it is crucial for nurses who care for pregnant MIW to have cultural competency. This competency is essential because the health of pregnant women is directly linked to fetal health. Research has indicated that pregnant MIW are less likely to attend prenatal check-ups compared to their Korean counterparts [3] and have higher incidences of meconium-stained amniotic fluid and low birth weight infants [4].

Cultural competency involves recognizing one’s own cultural background and respecting differences in culture [5]. In the field of nursing, it specifically refers to the ability to respect and understand the diverse cultural backgrounds of patients, while effectively responding to their unique needs [6]. Enhancing cultural competency among nurses is vital in a multicultural society, offering benefits to both nurses and patients. This is especially critical for MIW, who are often more susceptible to crises due to cultural differences experienced during pregnancy and childbirth, potentially leading to significant health disparities; therefore, it is imperative to develop nurses’ cultural competency to better advocate for these women [7]. A study conducted by Cross [8] indicated that cultural competency is shaped by both the individual characteristics of the nurse and the organizational factors within the healthcare setting. Consequently, it is essential to identify the individual and organizational factors that influence the cultural competency of nurses in women’s hospitals and utilize these insights to enhance cultural competency.

Among individual factors, multicultural attitudes contribute to an accurate understanding of and empathy towards diverse cultures, facilitating consistent strategies in addressing multicultural issues [9]. Nursing that embraces multiculturalism not only improves the satisfaction of multicultural patients but also helps reduce health disparities linked to cultural differences [6]. Therefore, a multicultural attitude is vital for nurses who care for multicultural patients.

Multicultural efficacy refers to the confidence to proactively engage with multicultural environments [10]. It represents another individual factor that may influence cultural competency. Individuals with high multicultural efficacy recognize and respect cultural differences, displaying both confidence and practical competency in multicultural interactions [11]. Conversely, those with low multicultural efficacy might face cultural conflicts or form stereotypes about foreign patients [11]. Consequently, it is essential to evaluate the multicultural efficacy of nurses in women’s hospitals and examine its effect on their cultural competency when providing care to patients from diverse backgrounds.

Intercultural communicative competency is a key individual factor that impacts cultural competency, directly influencing both nurses and patients in multicultural care settings. A prior study has found that many MIW face language barriers when seeking healthcare services in Korea, hindering their ability to receive proper care [12]. Healthcare providers also face challenges in gathering health-related information, such as family and medical histories, and frequently deal with misunderstandings and confusion, which disrupt the continuity of care [13].

Among organizational factors, hospital support for cultural competency is anticipated to impact nurses’ cultural competency. This support encompasses cultural competency training for staff, culturally relevant printed materials and forms, and hospital policies that embrace cultural diversity. Without sufficient hospital support for multicultural patients, nurses may struggle to provide appropriate care due to the added responsibilities of their roles [14]. In turn, this lack of support can heighten the psychological burden on nurses. Thus, hospital support for cultural competency is essential in delivering care to multicultural patients. Although it is expected that such support would positively affect nurses’ cultural competency, research exploring this relationship remains insufficient.

Previous research on cultural competency in Korean nursing has predominantly focused on nurses working in general hospitals [15-18]. Many MIW tend to initially settle in smaller cities and seek care at women’s hospitals during pregnancy and childbirth. However, there has been limited research on the cultural competency of nurses in women’s hospitals located in these provincial cities, where cultural support services are less readily available than in major urban centers. Moreover, there is a scarcity of systematic studies in Korea that differentiate cultural competency into individual and organizational factors. Consequently, this study aimed to examine women’s hospital nurses’ multicultural attitudes, multicultural efficacy, and intercultural communicative competency as individual factors and the hospital’s support for cultural competency as an organizational factor to determine the influence of these variables on cultural competency. The findings of this study are intended to provide foundational data for the development of educational programs aimed at enhancing the cultural competency of nurses in women’s hospitals.

This correlational cross-sectional study investigated the effects of multicultural attitudes, multicultural efficacy, intercultural communicative competency, and hospital support for cultural competency on the cultural competency of nurses in women’s hospitals. The study adhered to the STROBE guidelines (https://www.strobe-statement.org/).

This study investigated the levels of cultural competency among nurses in women’s hospitals, examining both individual and organizational factors that influence this competency. The results showed that nurses with more positive multicultural attitudes and higher intercultural communicative competency exhibited greater cultural competency.

In this study, the mean total score for participants’ cultural competency was 150.54 out of 231, with an average score of 4.56 out of 7. This was somewhat lower than the scores reported in previous studies [16, 20], which recorded average scores of 4.89 and 5.04, respectively, using the same instrument. This difference may stem from differences in workplace environments, as in the previous study, all [16] and 61% [20] of the participants were nurses from university hospitals and tertiary hospitals, which likely offer greater support for enhancing cultural competency. The subdomains were ranked from highest to lowest as follows: awareness, sensitivity, knowledge, and skills. This ranking aligns with the findings of Ko et al. [16], where awareness was scored highest, while sensitivity, knowledge, and skills were comparatively lower. Previous research has also shown that multicultural awareness is challenging to improve through short-term or one-time educational interventions [31]. The lower scores in knowledge and skills in this study could be due to the fewer participants who had received multicultural education. Most educational programs designed to enhance cultural competency among Korean nurses tend to concentrate on awareness and sensitivity, often neglecting knowledge and skills [32]. These findings underscore the necessity for comprehensive educational programs that encompass all dimensions of cultural competency.

Regarding the individual factors influencing cultural competency, both multicultural attitudes and intercultural communicative competency were identified as significant predictors. These factors retained their significance even in the final model, which incorporated the organizational factor. Multicultural attitudes emerged as the most influential individual factor (β=.46, p<.001), suggesting that higher levels of multicultural attitudes are associated with greater cultural competency. In this study, the average score for multicultural attitudes was 72.69 out of 96, with an average item score of 4.54 out of 6. This aligns with the score of 4.38 obtained using the same instrument in a previous study involving clinical nurses [21]. Although research exploring the correlation between multicultural attitudes and cultural competency among nurses is limited, studies involving nursing students have demonstrated that positive multicultural attitudes enhance cultural competency [10]. This supports the findings of the current study. Individuals with higher multicultural attitudes are more likely to view and embrace a multicultural society positively [33]. In contrast, negative attitudes towards multiculturalism can lead to discrimination, bias, and stereotypes, which pose barriers to nurses in delivering value-neutral care to individuals from diverse cultural backgrounds [34]. Therefore, it is essential for nurses to respect, accept, and empathize with cultural differences in their care delivery.

Another individual factor that influenced cultural competency was intercultural communicative competency (β=.19, p=.025); this finding is consistent with previous studies on healthcare professionals [22]. In this study, the average total score for intercultural communicative competency was 34.23 out of 50, with a mean rating of 3.42 out of 5. This is slightly lower than the score of 3.8 reported in earlier studies involving university students using the same instrument [35]. Additionally, 31.3% of the participants in this study had received multicultural education, compared to 58.5% in the university student study [35]. This suggests that exposure to multicultural education may enhance intercultural communicative competency. In nursing settings, where clear communication is crucial, improving intercultural communicative competency is vital for enhancing cultural competency [18]. Patient-centered communication when caring for multicultural patients can motivate patients to engage more actively in their treatment [36] and improve nurses’ clinical performance [17]. Conversely, nurses with lower communication competency may find it challenging and burdensome to connect with multicultural patients [14]. These nurses may also experience uncertainty and anxiety, which can negatively impact their cultural competency [37]. Given that nursing tasks—such as assessing patient needs, providing education, and explaining care—rely heavily on language, communication competency is crucial for patient care. However, there remains a shortage of training programs to enhance nurses’ intercultural communicative competency and a lack of resources or personnel support to address communication barriers in clinical settings [14]. Furthermore, with an increasingly diverse patient population in Korea, it is impractical for nurses to learn every patient’s native language. Therefore, medical institutions and government bodies should support the provision of interpreter services and multilingual guidelines. In addition to strengthening verbal communication skills, it is necessary to strengthen intercultural communicative competency through the development of nonverbal communication skills, such as understanding patients’ cultural backgrounds, communication attitudes based on consideration, and coping with cultural conflicts that arise during communication. To support this, communication-related nursing curricula should incorporate training aimed at enhancing intercultural communicative competency.

This study found that the mean total score for multicultural efficacy among individual factors was 67.51 out of 100, with a point average score of 2.70 out of 4. This is similar to the score of 2.65 reported in a previous study [20] that used the same tool to assess nurses’ multicultural efficacy. The subdomains were ranked as affective, practical, and cognitive, aligning with Byun and Park’s [20] findings, where the affective and practical domains scored higher than the cognitive domains. Although multicultural efficacy showed a positive correlation with cultural competency in this study, it did not emerge as a significant predictor in the final analysis. This finding contrasts with Byun and Park’s [20] study, which identified multicultural efficacy as a primary factor influencing nurses’ cultural competency. Beach et al. [38] suggested that multicultural attitude is an antecedent to multicultural efficacy, meaning that improvements in multicultural attitudes can enhance multicultural efficacy, which, in turn, positively impacts cultural competency. Since this study examined both multicultural attitudes and efficacy as individual factors, it limits the ability to assess the independent influence of each variable on cultural competency. When multiple variables with significant correlations are entered into a regression analysis, their relative impacts may obscure certain effects; in this case, the influence of multicultural attitudes on cultural competency was greater than that of multicultural efficacy, possibly rendering multicultural efficacy nonsignificant in the final model. Thus, future studies should examine each variable’s effect independently. Research on multicultural efficacy and cultural competency within Korean nursing remains limited, with only two studies, including this one. Moreover, because this study produced results that contrast with previous research [20], which identified multicultural efficacy as a major influencing factor on cultural competency, further investigation into the impact of multicultural efficacy on cultural competency—particularly among nurses in women’s hospitals frequented by multicultural patients—is necessary.

After examining the effect of organizational factor on cultural competency, the final model revealed that hospital support for cultural competency had no significant impact. The average total score for hospital support for cultural competency was 18.53 out of 32, with a mean rating of 2.32 out of 4. This is comparable to the 2.51 score reported in a previous study that used the same instrument to examine nurses at a general hospital [31]. However, over 80% of participants in this study reported that their hospital lacked guidelines for caring for foreign patients, which complicates comparisons with general hospitals where organizational support for multicultural patients is more readily available. Although there was a positive correlation between hospital support for cultural competency and cultural competency itself, it was not statistically significant in the final analysis. Conversely, a prior study found that programs and guidelines for foreign patient care within hospitals positively influenced nurses’ cultural competency [15]. Many MIW reside in smaller rural cities in Korea, where they primarily access local clinics or hospitals for maternity care [39]. Women’s hospitals, which provide care throughout women’s lives, especially need strong institutional support to improve the cultural competency of nurses serving multicultural patients. However, in regional small and mid-sized women’s hospitals, such as where this study was conducted, resources such as foreign language forms, training, and support for nurses working with multicultural patients were minimal or absent, likely contributing to the limited impact of hospital support on cultural competency in this context. The United States, with its long history as a multicultural society, has implemented extensive government-supported policies to reduce cultural conflicts between patients and healthcare providers. In contrast, Korea, with limited national support, primarily relies on a few large general hospitals with foreign patient centers and on-site interpreters to support multicultural patients [40]. Therefore, in addition to enhancing hospital support for cultural competency, government-led programs are essential to build cultural capacity, including training resources, particularly for nurses in small and medium-sized hospitals.

Finally, in the first model that examined the impact of general characteristics such as education level, religion, and overseas travel experience on cultural competency, it was determined that overseas travel experience plays a significant role (β=.19, p=.016). This indicates that individuals with more extensive overseas travel experience tend to have higher cultural competency, aligning with the findings of Yang et al. [6]. Overseas travel promotes multicultural acceptance [41], which in turn fosters greater openness and understanding of diverse cultures, thereby enhancing cultural competency [6]. However, as this study did not evaluate the frequency of overseas travel, further research is necessary to determine how different levels of travel experience may affect cultural competency.

This study utilized convenience sampling of nurses working in women’s hospitals in specific regions, which may restrict the applicability of the results to all nurses in women’s hospitals. Future studies should incorporate a broader and more varied group of nurses from different areas. Additionally, although this study included participants who had experience caring for foreign patients, it did not explore the frequency of these interactions, which limits the analysis of sensitivity to this factor. Furthermore, the study did not evaluate the participants’ personal multicultural backgrounds, such as whether they were from multicultural families or were MIW themselves. This omission restricts our understanding of cultural competency. Future research should consider these aspects to better assess cultural competency among nurses in women’s hospitals. The final model in this study accounted for 49.8% of the variance in cultural competency by including individual factors like multicultural attitudes and intercultural communicative competency. Therefore, further research should explore additional individual and organizational factors that could help explain the levels of cultural competency among nurses in women’s hospitals.