Transcultural Adaptation of Tibetan Nursing Trainees: A Case Study of “9+3” Vocational Technical Students in Sichuan Province, China

Background

China is a multi-ethnic and multicultural country [1]. Tibetans are an ethnic minority peculiar to China [1]. The Tibetan areas have a special political and strategic position in China because of historical reasons [2]. Speeding up the economic and educational development of Tibetan areas, maintaining stability, and improving people’s livelihood in Tibetan areas are of far-reaching significance to safeguarding China’s national unity [2].

As the second largest Tibetan area in China, Sichuan has 32 Tibetan counties, covering an area of 0.25 million square kilometers, accounting for 52% of the province’s total area, with a population of 1.962 million, including 1.243 million Tibetans, accounting for 63.4% of the total population of the Tibetan area [3].

To improve the economic and educational development of Tibetan areas, Sichuan Province officially launched the “9+3” Tibetan free vocational education program in March 2009 [4]. It is one of the “major livelihood projects” implemented by the Sichuan Provincial government [5]. The “9+3” free vocational education program refers to organizing 10 000 graduates who have completed 9 years of vocational education (including primary and junior high school education) in Tibetan areas to receive 3 years of free vocational education in the developed hinterland cities, so as to train talents who combine high-quality skilled labor with higher scientific and technological quality [5]. The implementation of the “9+3” free education program, relying on the hinterland to rapidly promote the development of the quality of the Tibetan population, was not only related to people’s livelihood, stability, and development, but also highlighted the public welfare value of vocational education [6].

However, the cultural traditions and living habits of Tibetan and Han nationality are different [7]. Adolescence is an important turning point for individuals from childhood to maturity, and it is also the stage in which individuals are most prone to social maladjustment [8]. The social adaptation of teenagers is not only related to the healthy development of their own psychology, but also affects interpersonal harmony and social stability [9,10]. Various cultural contradictions and conflicts will have an unavoidable impact on the personality development and stereotyping of teenagers [11]. When Tibetan students leaved Tibet to study in the hinterland and enter a city with a different culture and life from their own, they may have conflicts with Han students because of their different living habits and hobbies, and may even lead them to commit crime because of their sense of loneliness and inferiority complex [12]. Therefore, it is necessary to study their psychological characteristics in this period, find the problems in time, and solve them in time. This is also a Han’s prerequisite for Tibetan students in Sichuan to adapt to society [13].

Nursing education is an important part of “9+3” free teaching. Nursing is an important, therapeutic, and interpersonal process. The nurse-patient relationship can be thought of as one that helps the person cared for [14]. Nurses need to understand the following factors through nurse-patient communication and experience exchange: the patient’s life experience and disease, the impact of the disease on the patient, and the patient’s health expectations [15]. Satisfactory patient-care outcomes result from the nurse’s understanding of the patient’s life experience and ability to provide care that meets the patient’s health expectations [16]. However, cultural differences may lead to ineffective nurse-patient communication [16]. Nurses may have difficulty understanding the feelings of patients, and have difficulty establishing a relationship of trust with patients, leading to low patient satisfaction and increased medical disputes, which in turn adversely affect nurses’ work and mental state [16]. Therefore, ensuring that nurses have effective interaction skills is critical to improving patient satisfaction and positive care outcomes.

“9+3” Tibetan trainee nurses come from areas where the Tibetan culture and the Tibetan language predominate. Regional and cultural differences give rise to the problem that interns have in transcultural adaptation.

Ward, a New Zealand psychologist, proposed that the problem of transcultural adaptation can be mainly examined from 2 dimensions: the social level and the individual level [17]. The influencing factors at the social level included birth society and guest society; the factors at the individual level included individual characteristics and emotional characteristics [18]. On the other hand, these influencing factors, which existed at the social and individual level, would be reflected in the emotional, behavioral, and cognitive aspects of the participants [18]. At present, Ward’s “acculturation process model” is recognized as a comprehensive and systematic theoretical model for the study of intercultural adaptation [19].

In the past few years, research on nursing students’ transcultural adaptation has mainly consisted of single-center studies and the conclusions were mostly that there was maladjustment [20,21]. In addition, the literature on Tibetan nurses as a specific research group was mainly concentrated 5 years ago, and the studies rarely involved nurses in the internship stage [22,23].

In order to clarify the current situation of transcultural adaptation of Tibetan nursing trainees, this study selected Tibetan nursing trainees in Chengdu, Luzhou, and Nanchong to investigate their cross-cultural adaptation. A questionnaire survey based on Ward’s acculturation process model was used to investigate the intercultural adaptation of Tibetan nursing trainees. After achieving an in-depth understanding of the current situation of intercultural adaptation of Tibetan students, it is hoped that this paper can provide more theoretical support and guidance for the cultivation of intercultural adaptation of Tibetan and other ethnic minority youth in China.

Material and Methods

RESEARCH DESIGN:

Based on Ward’s acculturation process model, transcultural adaptation was divided into 2 dimensions of adaptations (sociocultural and psychological) [24]. The questionnaire on transcultural adaptation of Tibetan nursing trainees in this study included 46 items and the following constructs: 1) Q1 to Q4 referred to basic information of the respondents, such as gender, student home region, whether they were the only child or not, and the administrative level of the city where the trainee internship hospital was located (Table 1, Supplementary Table 1); 2) Q5 to Q26 referred to sociocultural adaptation, according to Wang’s questionnaire on Sociocultural adaptation [25], which was divided into 3 levels: life adaptation (including Q5, Q6, and Q7), interpersonal adaptation (including Q8, Q9, Q10, Q11, Q12, Q13, Q14, and Q15)and work adaptation (including Q16, Q17, Q18, Q19, Q20, Q21, Q22, Q23, Q24, Q25, and Q26), using a 5-point Likert scale (Supplementary Table 1). “Strongly disagree” to “strongly agree” were counted as 1, 2, 3, 4, and 5 points in sequence; 3) Q27 to Q46 referred to psychological adaptation, based on the SDS questionnaire scale, using a 4-point Likert scale, which reflected 4 groups of specific symptoms of depressive state: psychosomatic symptoms (including Q27 and Q29), somatic disorders (including Q28, Q30, Q31, Q32, Q33, Q34, Q35, and Q36), psychomotor disorders (including Q38 and Q39), and depressive psychological disorders (including Q37, Q40, Q41, Q42, Q43, Q44, Q45, and Q46) (Supplementary Table 1). A value of 1, 2, 3, and 4 was assigned to a response depending upon whether the item was worded positively or negatively.

For items Q27, Q29, Q30, Q33, Q34, Q35, Q36, Q39, Q41, and Q45 the scoring was:

Items Q28, Q31, Q32, Q37, Q38, Q40, Q42, Q43, Q44, and Q46 were reverse-scored as follows:

DATA COLLECTION:

The questionnaire was distributed online through “Questionnaire Star”, a small program of “WeChat”, completed by mobile phone input.

Questionnaire Star is a professional online questionnaire survey, evaluation, and voting platform, which has powerful functions and can provide a series of services such as online questionnaire design, data collection, custom reports, academic research, and survey result analysis.

The basic steps for generating electronic questionnaires from questionnaire stars were as follows [26]:

RESEARCH PARTICIPANTS:

The sample size was calculated according to a minimum of 5 times the number of scale items for questionnaire [16]. At least 230 valid questionnaires were required for total 46 items of the study to meet the requirement. Considering an unreturned rate of 20%, a stratified proportional random sampling technique was employed, with departments used as the strata for randomly selecting 290 Tibetan practice nurses (80% for each stratum) from total 363 Tibetan nurses in clinical practice stage of “9+3” free vocational education in Chengdu, Luzhou, and Nanchong of Sichuan Province. In the end, of the 290 questionnaires disseminated, 237 were returned valid (81.72%); thus, the requirements of sample size were met.

ETHICAL CONSIDERATIONS:

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Affiliated Hospital of North Sichuan Medical College Ethics Committee [No.2020ER(A)030]. All participants gave their informed consent before they participated in the study.

DATA ANALYSIS:

After the questionnaire data were collected, the SPSSAU project (2020), an online application software retrieved from https://www.spssau.com, was used to data coding and archiving. Descriptive statistical analyses were performed to analyze the demographic characteristics of the nursing students. There were 3 major steps for performing analysis of intercultural adaptation:

Results

COMPOSITION OF THE OBJECT:

The sample composition of the questionnaire is shown in Table 1. The baseline data of the respondents were classified and counted according to gender, student home region, whether they were the only child, and the city administration level where the internship hospital was located. Among them, there were 15 males, accounting for 6.33%; 222 women, accounting for 93.67%; 27 people from rural or pastoral areas, accounting for 11.39%; 197 people from urban areas, accounting for 83.12%; and 13 people from the urban-rural junction, accounting for 5.49%. There were 51 only children, accounting for 21.52%; 186 non-only children, accounting for 78.48%; 36 people from provincial capitals, accounting for 15.19%; 161 people in prefecture-level cities, accounting for 67.93%; 38 people in county-level cities, accounting for 16.03%; and 2 people in rural towns and cities, accounting for 0.84%.

RELIABILITY ANALYSIS OF THE QUESTIONNAIRE:

In this study, the researchers designed 22 items (Q5 to Q26) to indirectly measure sociocultural adaptation and 20 items (Q27 to Q46) to measure psychological adaptation. These 2 types of items used different points scales; therefore, reliability and validity of sociocultural adaptation and psychological adaptation needed to be tested separately.

The Cronbach Alpha value of sociocultural adaptation was 0.951 >0.7, which shows that the reliability quality of the research data was very high (Table 2A). In view of “coefficient Alpha if Item deleted”, if items of Q5 and Q6 were deleted, the reliability coefficient will increase significantly (Table 2B). To sum up, the questionnaire data on sociocultural adaptation could be used for further analysis.

The Cronbach Alpha value of psychological adaptation was 0.789 >0.7, which shows that the reliability quality of the research data was very high and questionnaire data of sociocultural adaptation could be used for further analysis (Table 2A). Items of Q30, Q32, Q33, Q34, Q35, Q36, Q39, Q41, and Q42 needed be deleted to increase the reliability coefficient in view of “Corrected Item-Total Correlation” (Table 2C).

VALIDITY ANALYSIS OF THE QUESTIONNAIRE:

Exploratory factor analysis (EFA) results of sociocultural adaptation dimension:

KMO and Bartlett’s test were used to verify the validity. Bartlett’s sphericity test revealed χ2=4614.674, df=231, P=0.000, and the KMO value was 0.919 >0.6, indicating that the validity of the research data was very good (Table 3.1.1).

Using the scree test, the EFA identified the 3 dimensions of this questionnaires as demonstrated in the scree plot in Figure 1, explaining 68.831% of the variance.

An overview of the results of the EFA is shown in Table 3.1.2. A total of 3 factors were extracted by factor analysis, and the eigenvalues were all greater than 1. The cumulative variance explanation rate after rotation was 68.831% >50%. Factor 1 accounted for 27.735% of the response variance (eigenvalue 6.102), Factor 2 accounted for 25.910% (eigenvalue 5.700), and Factor 3 accounted for 15.186% (eigenvalue 3.341).

As shown in Table 3.1.3, the corresponding communalities values of sociocultural adaptation items were all higher than 0.4, indicating that the research item information can be extracted effectively and there was a corresponding relationship between items and factors. Factor 1 (10 items), consisted of items Q8, 9, 10, 11, 12, 13, 14, 15, 16, and 17. Factor 2 (9 items), consisted of items Q18, 19, 20, 21, 22, 23, 24, 25, and 26. Factor 3 (3 items), consisted of items Q5, 6, and 7.

Exploratory factor analysis (EFA) results of psychological adaptation dimension:

In the first exploratory factor analysis results of all psychological adaptation items, KMO value was 0.854 >0.6, and Bartlett’s sphericity test revealed χ2=1947.425, df=190, P=0.000, indicating that the validity of the research data was very good (Table 3.2.1), but the corresponding communalities values of Q28, 32 were less than 0.4, indicating that the research item information could not be effectively expressed (Table 3.2.2). Therefore, these 2 items should be deleted and analyzed again after deletion.

After removing the suggested items, the corresponding communalities values were all higher than 0.4, indicating that the research item information could be extracted effectively and there was a corresponding relationship between items and factors (Table 3.2.3).

Using the scree test, the EFA identified the 4 dimensions of this questionnaires as demonstrated in the scree plot in Figure 2, explaining 61.999% of the variance.

The KMO value was 0.850 >0.6, and Bartlett’s sphericity test revealed χ2=1840.170, df=153, P=0.000, indicating that the validity of the research data was very good (Table 3.2.4).

An overview of the results of the EFA is shown in Table 3.2.5. A total of 4 factors were extracted by factor analysis, and the eigenvalues were all greater than 1. Factor 1 accounted for 19.000% of the response variance (eigenvalue 3.420), Factor 2 accounted for 18.606% (eigenvalue 3.349), Factor 3 accounted for 12.731% (eigenvalue 2.292), and Factor 4 accounted for 11.661% (eigenvalue 2.099). The cumulative variance explanation rate after rotation was 61.999% >50%. Factor 1 (5 items), consisted of items Q40, 42, 43, 44, and 46. Factor 2 (6 items), consisted of items Q27, 29, 30, 36, 39, and 41. Factor 3 (4 items), consisted of items Q33, 34, 35, and 45. Factor 4 (3 items), consisted of items Q31, 37, and 38.

OVERALL LEVEL OF TRANSCULTURAL ADAPTATION:

In terms of sociocultural adaptation, the optimal score of the questionnaire was 110, and the higher the score, the better the sociocultural adaptation. The average score of sociocultural adaptability of Tibetan trainee nurses in this study was 85.14±16.60 (Table 4).

In terms of psychological adaptation, the maximum possible score of the questionnaire was 80. The lower the score was, the better the psychological adaptation would be. If the score exceeded 41, there were psychological problems [30]. The average score of Tibetan trainee nurses in this study was 38.70±10.19 (Table 4).

The original scores of all the respondents were converted to Z-scores, which were used as the study variable, with 0 as the average and 1 as the standard deviation.

The sociocultural adaptability of Tibetan trainee nurses was divided into 4 levels from poor to good, which were very poor, poor, good, and very good, corresponding to Z <−1, −1 ≤Z ≤0, and 0 <Z ≤1, Z >1. The number of participants and percentage at each level are shown in the Table 5.

On the contrary, the psychological adaptability of Tibetan trainee nurses was divided into 4 levels from good to poor, which were very good, good, poor, and very bad, respectively corresponding to Z <−1, −1 ≤Z ≤0, 0 <Z ≤1, and Z >1. The number of participants and percentage at each level are shown in the Table 6.

According to the data in Tables 5 and 6, the acculturation level of trainee nurses mainly focuses on the score of −1 ≤Z ≤0 and 0 <Z ≤1, which was at a medium level.

For the convenience of statistical analysis, the 2 groups with “good adaptability” and “very good adaptability” were combined as good adaptability, and the 2 groups with “poor adaptability” and “very poor adaptability” were combined as poor adaptability. According to statistics, the number of trainee nurses with poor sociocultural acculturation was slightly higher than that with good acculturation, with a difference of 5 (1.2%). In terms of the psychological adaptation of trainee nurses, 109 were well adapted, accounting for 46.0%, and 128 were poorly adapted, accounting for 54.0%, a difference of 19 (8%).

In general, the number of Tibetan trainee nurses with poor adaptability was slightly higher than the number with good adaptability. The statistical results of this paper were also consistent with the previous research results of other scholars [4,31].

THE OVERALL SITUATION OF ACCULTURATION OF TIBETAN TRAINEE NURSES OF DIFFERENT GENDERS:

From the Table 7, it can be seen that the sociocultural adaptation of Tibetan trainee nurses of different genders was P=0.112>0.05, which meant there was no statistically significant differences in sociocultural adaptation between male and female Tibetan trainee nurses. In terms of psychological adaptation, P=0.846>0.05, which means there was no statistically significant differences in psychological adaptation between male and female Tibetan trainee nurses.

THE OVERALL SITUATION OF TRANSCULTURAL ADAPTATION OF TIBETAN TRAINEE NURSES FROM DIFFERENT STUDENT HOME REGIONS:

The variance of the data in each group was uniform after the homogeneity of variance test. The data are expressed as mean±standard deviation. According to a one-way analysis of variance, there was no statistically significant difference in the overall level of cultural adaptation of Tibetan trainee nurses from different home regions. The CWWS score of sociocultural adaptation was: F (2234)=1.599, P=0.204, and the CWWS score of psychological adaptation was: F (2234)=2.103, P=0.124 (Table 8).

THE OVERALL SITUATION OF TRANSCULTURAL ADAPTATION OF TIBETAN TRAINEE NURSES FROM SINGLE-CHILD OR MULTI-CHILD FAMILIES:

The independent sample t test was used to judge the difference in the overall situation of transcultural adaptation of Tibetan trainee nurses from single-child or multi-child families. The research data had uniform variance. The results showed that the sociocultural adaptation of Tibetan trainee nurses from single-child or multi-child families was P=0.097 >0.05, and psychological adaptation of Tibetan trainee nurses from single-child or multi-child families was P=0.207 >0.05. Therefore, there was no statistically significant differences in psychological adaptation and sociocultural adaptation from single-child or multi-child families (Table 9).

THE OVERALL SITUATION OF TRANSCULTURAL ADAPTATION OF CITY ADMINISTRATION LEVEL WHERE THE INTERNSHIP HOSPITAL WAS LOCATED:

The variance of each group of data proved by the test of homogeneity of variance was uniform. The data are expressed as mean±standard deviation.

According to the univariate analysis of variance, there was no statistically significant differences in the influence of the city administration level where the internship hospital was located. The CWWS scores of sociocultural adaptation were: F (3, 233)=233)=0.337, P=0.799, and the CWWS scores of psychological adaptation were: F (3, 233)=233)=1.207, P=0.308 (Table 10).

Discussion

Countermeasures and suggestions on improving the transcultural adaptability

2. PAY ATTENTION TO THE TRAINING OF KNOWLEDGE, ATTITUDE, AND ABILITY OF TRANSCULTURAL ADAPTATION: On the topic of national culture, it mainly includes the following contents: first, the knowledge about the basic connotation of ethnic education and multicultural education; second, the knowledge about various aspects of ethnic minorities, that is, the knowledge of the history of political development, economic status, religious beliefs and cultural traditions of ethnic minorities; and the third is about national habits and behaviors that are prone to misunderstandings and cultural discrimination and prejudice [49].

In the teaching of national culture, the simple understanding of multicultural curriculum should not only impart the theoretical knowledge of national culture and multicultural theory, but should guide students on the basis of understanding the theoretical knowledge of multiculturalism. Inspire them to think deeply about multiculturalism, and pay attention to students’ emotional experience while learning the theoretical knowledge of national culture. Constantly enhance the internal relationship between cultural learning and the cultivation of national culture, identity, and pride [50].

1. Strengthen self-adjustment and cultural participation.

1) Respect local culture and customs, and enhance the awareness of cultural diversity.

China is a multi-ethnic country, which naturally presents diversity in the cultural field.

Different ethnic groups and regions have their own unique cultural traditions, but they also have their drawbacks. Interns should understand the historical development, clothing characteristics, dietary customs, and other aspects of the place where the hospital is located, so as to understand and respect the local culture.

2) Learn to self-adjust.

For the majority of interns, the process of cultural adaptation is a process of psychological growth and maturity, which can be difficult [51].

In this process, nurses not only have to face the tremendous changes in their living environment, the differences in dietary customs, religious culture, and bear the pressure and challenges from these aspects, they even have to experience doubts about their own identity and thinking.

If growth is divided into 2 parts, then “first growth” is the process of continuous growth under the influence of local culture, then “second growth” occurs during the process of gradually adjusting, adapting, accepting, and integrating into a new culture [52].

If a person can use a proactive attitude to recognize cultural differences, consciously respect cultural differences, and actively and objectively coordinate cultural differences, transcultural adaptability is basically formed [53]. Of course, it also means that they complete the process of “second growth”. However, there are always some problems caused by differences in their own experience that are difficult to solve and eliminate. At this time, only by constantly adjusting their psychological ability to constantly refine their cognitive system to adapt to different cultures with an open mind can they gradually alleviate the various discomforts caused by “conflict” [54].

3) Strengthen cultural integration and cultural participation.

Tibetan trainee nurses should abandon incorrect cultural stereotypes, cultural relativism, and ethnocentrism, and focus on strengthening the integration of their own national culture and local culture [53]. To be specific, while the interns identify with their own national culture, they actively understand and identify with the people’s ideas, values, beliefs, ways of thinking and behavior, folk customs, living habits, and other cultural elements in the place where the hospital is located [48]. If Tibetan students want to better adapt to the local culture, they should try not to judge everything in a local culture by their own cultural standards, nor to deal with all kinds of things in life with their own way of thinking and behavior [7].

Conclusions

In this study, we investigated the transcultural adaptation of Tibetan trainee nurses from the 2 dimensions of sociocultural adaptation and psychological adaptation. The result revealed that there was still transcultural maladjustment among Tibetan nurses in the internship stage, and the psychological maladjustment was more obvious in the sociocultural maladjustment.

Aiming at the problem of cross-cultural adaptation reflected in the study, we put forward some suggestions and strategies. It was hoped that this article can provide more theoretical support and guidance for the cultivation of cross-cultural adaptability of young Tibetans and other ethnic minorities in China.

However, there was still a shortcoming in this study. This paper mainly discussed the transcultural adaptation of Tibetan nurses in the internship stage, but in fact, this group had received theoretical teaching in mainland schools for 2 years before entering the internship stage. In other words, during the period from the original Tibetan cultural circle to the internship stage and full contact with Chinese culture, they had a 2-year buffer adaptation period. As sampled individuals, their own adaptability was different, which will also have had a certain impact on the survey results. In the subsequent similar research design, nursing students of Tibetan origin can be followed up to investigate their intercultural adaptation in the first year, the second year, and the internship stage to establish a dynamic and comparative survey database.