Innovative Game-Based Teaching Methods for Promoting Nursing Students’ Cultural Competence and Attitudes Toward Refugees: An Explanatory Sequential Mixed Study

h ps://doi.o g/10.1177/10436596241297986 Jou nal o T anscul u al Nu sing 1 –13 © The Au ho (s) 2024 A icle euse guidelines: sagepub.com/jou nals-pe missions DOI: 10.1177/10436596241297986 jou nals.sagepub.com/home/ cn Educa ion In oduc ion Mig a ion is a signi ican , complex, and g owing global phe- nomenon. Millions o people mig a e a ound he wo ld o a a ie y o causes, including wa , e o ism, displacemen , e hnic con lic , en i onmen al c ises, economic and poli ical easons, educa ion, o job oppo uni ies (McAuli e & T ianda yllidou, 2021). Some o hese indi iduals a e e u- gees, while o he s a e mig an s o asylum seeke s. These e ms a e some imes used in e changeably; howe e , hey ha e dis inc legal meanings. A e ugee is someone who has been compelled o lee hei home coun y due o pe secu- ion, wa , o e hnic, ibal, o eligious iolence. In mos cases, hey a e unable o e u n home, as doing so would endange hei li es. Re ugees a e de ined and p o ec ed unde in e na ional law. Asylum seeke s, on he con a y, ha e no ye been legally ecognized as e ugees and a e awai ing a decision on hei asylum claim. A mig an is someone who chooses o eloca e, no because hey ace pe - secu ion o a h ea o hei li e, bu o seek be e oppo uni- ies, such as employmen , educa ion, o amily euni ica ion. Mig an s e ain he p o ec ion o hei home go e nmen and a e no p o ec ed unde in e na ional law. Each coun y accep s mig an s acco ding o i s immig a ion laws and p o- cesses (UNHCR The UN Re ugee Agency, 2022). The inc easing numbe o e ugees has g ea ly impac ed coun- ies in e ms o poli ical, economic, social, e hnic, eligious, and heal h- ela ed issues (McAuli e & T ianda yllidou, 2021). Re ugees a e unable o bene i om heal h ca e se - ices su icien ly o such easons as he language ba ie , low heal h li e acy, cul u al di e ences, and he heal h ca e s a ’s nega i e a i udes owa d e ugees (Önal & Keklik, 2016; Schwei e al., 2016). The In e na ional Council o 1297986TCNXXX10.1177/10436596241297986Jou nal o T anscul u al Nu singBaysal e al. esea ch-a icle2024 1Manisa Celal Baya Uni e si y, Tü kiye 2Uni e si y o Alme ia, Spain 3Uni e si a de València, Spain Co esponding Au ho : Miguel Rod iguez-A as ia, Vice Dean and Associa e P o esso , Depa men o Nu sing Science, Physio he apy and Medicine, Facul y o Heal h Sciences, Uni e si y o Alme ia, Ca e e a Sac amen o s/n, Alme ia 04120, Spain. Email: [email p o ec ed] Inno a i e Game-Based Teaching Me hods o P omo ing Nu sing S uden s’ Cul u al Compe ence and A i udes Towa d Re ugees: An Explana o y Sequen ial Mixed S udy Eb u Baysal, PhD, RN1, Miguel Rod iguez-A as ia, PhD, MSc, RN2,3 , and Pablo Roman, PhD, MSc, RN2 Abs ac In oduc ion: Nu sing cul u al compe ence is c ucial o enhancing he quali y o ca e o e ugees. While inno a i e game- based eaching me hods ha e been used o os e in a wide ange o clinical compe ences, li le is known abou i s use on e ugees’ ca e. This s udy aims o e alua e he e ec o hese me hods on nu sing s uden s’ cul u al compe ence and a i udes owa d e ugees. Me hodology: An explana o y sequen ial mixed design was conduc ed om Ma ch o May 2023. Resul s: One-hund ed o y-one nu sing s uden s pa icipa ed. The e we e no s a is ically signi ican di e ences in o al Ou g oup Th ea Pe cep ion Scale and Cul u al Compe ence Assessmen Scale sco es be ween he expe imen al and con ol g oups, p e- o pos -in e en ion. Howe e , s uden s epo ed inc eased awa eness and empa hy o e ugee issues. Discussion: The s udy showed ha inno a i e game-based eaching me hods e ec i ely inc eased nu sing s uden s’ awa eness o heal h- ela ed issues aced by e ugees. I ecommends inco po a ing anscul u al nu sing cou ses in o cu icula and p o essional aining, wi h upda ed con en on mig a ion and e ugee issues. Keywo ds cul u al compe encies, gami ica ion, nu sing s uden s, e ugees, i ual eali y 2Jou nal o T anscul u al Nu sing 00(0) Nu ses (ICN) indica es ha heal h is a human igh and mus be made uni e sal and mee he needs o e ugees and o p o- ide cul u ally sensi i e ca e o hem (Gunn e al., 2021; H.-L. Lin e al., 2021). As a esul o mig a ion, he numbe o indi iduals om di e en cul u al backg ounds has inc eased in socie ies, which has b ough abou he issue o heal h ca e p o ession- als’ cul u al compe ence. The Ame ican Associa ion o Colleges o Nu sing (AACN) de ines cul u al compe ence as he a i udes, knowledge, and skills necessa y o p o iding quali y ca e o di e se popula ions in a a ie y o heal h ca e se ings (Ame ican Associa ion o Colleges o Nu sing, 2008). Leininge ’s Cul u e Ca e Theo y sugges s ha nu ses’ knowledge and skills o cul u al di e ences should be imp o ed. The heo y also highligh s he necessi y o being awa e o pa ien s’ alues, belie s, and li es yles (Leininge , 1996). In his sense, nu ses may expe ience p oblems in ol - ing cul u al di e ences, belie s, communica ion, and lan- guage, as well as a di e en unde s anding o heal h and hygiene while p o iding ca e o e ugees. Such issues may hu nu ses’ opinions o e ugees, leading o xenophobic sen- imen s and mic oagg essions in hei ca e (Munyaneza & Mhlongo, 2019). Resea ch esul s a y ega ding nu sing s uden s’ cul u al compe ence and a i udes owa d e ugees. While some s ud- ies epo ha nu sing s uden s’ cul u al compe ence is a he desi ed le el (Choi & Kim, 2018; Kohlb y, 2016) and hey hold posi i e a i udes owa d e ugees (Ba u cu & Zengin, 2018; Uga e-Gu u xaga e al., 2020), some o he s show ha hey ha e insu icien cul u al compe ence (H.-L. Lin e al., 2021; P eposi-C uz e al., 2018) and hei a i udes owa d e ugees a e nega i e (Akca & Ayaz-Alkaya, 2023; Alici, 2021). Acco ding o s udies, a lack o cul u al compe- ence ela es o heal h inequi ies and poo heal h ou comes (Be ancou e al., 2014). In he Ins i u e o Medicine epo , i is s a ed ha nu ses’ insu icien cul u al compe ence, awa eness, and ela ed aining may some imes cause e hno- cen ic beha io s and inequi y in he deli e y o heal h ca e se ices (Be ancou & Maina, 2004). To elimina e hese p oblems, i is ecommended ha cou se con en add essing cul u al di e ences be included in all heal h ca e cu icula (Be ancou & Maina, 2004; Liu e al., 2018). Acco ding o s udies, app op ia e and embedded cul u al compe ence edu- ca ion can p omo e cul u al awa eness and sensi i i y (Kohlb y, 2016; M.-H. Lin e al., 2019). Howe e , some common p oblems s ill a ise in eaching plans and educa ion in nu sing. These include a lack o ag eemen on wha should be augh , ela ed iming, a lack o s anda d e e ences, and limi ed and inconsis en o mal e alua ions o educa ional in e en ions (González-Ricoy & Gosse ies, 2017). In addi ion o he adi ional eaching me hods, a ious eaching app oaches a e used in in e cul u al nu sing cou ses such as e lec i e epo s (Hal e e al., 2015), case discussions (Allen e al., 2013), communi y se ice p og ams, and s an- da d pa ien (Ozka a San, 2019). As well as enhancing s uden s’ cul u al compe ence, such eaching app oaches a e epo ed o imp o e analy ical hinking skills, clinical eason- ing, decision-making skills, communica ion skills, eam coop- e a ion, sel -e icacy, and psychomo o skills (Allen e al., 2013; Hal e e al., 2015; Ozka a San, 2019). Ha ing said ha , no s udy esul has been ound in he li e a u e o use inno a- i e game-based eaching me hods like 360-deg ee ideos, se ious games (e.g., Re ugeoly), and escape ooms o imp o e s uden s’ cul u al compe ence and a i udes owa d e ugees. These inno a i e game-based lea ning me hods o e a my iad o bene i s o s uden s, p ima ily by p o iding an in e ac i e and pe sonalized lea ning expe ience wi hin a sa e and con- olled en i onmen (I ano ić, 2024; Yang e al., 2024). Resea ch indica es ha hese me hods os e ac i e lea ning and pa icipa ion, clinical p oblem-sol ing, eamwo k, c e- a i e hinking, and enhanced sa is ac ion and mo i a ion (Anguas-G acia e al., 2021; Gómez-U quiza e al., 2022; Molina-To es e al., 2022; Roman e al., 2020). Thus, hese inno a i e eaching app oaches aimed o encou age nu sing s uden s o e lec deeply on he challenges aced by e ugees, o exp ess hei emo ions, and he eby achie e a ec i e lea n- ing. While some o hese inno a i e game-based eaching me hods a e commonly used o impa p o essional skills o nu sing s uden s o as an assessmen esou ce, his s udy is he i s o use hem o e alua e nu sing s uden s’ a i udes and cul- u al compe ency owa d e ugees. In his con ex , he esea ch indings a e expec ed o con ibu e o he nu sing li e a u e by add essing a gap in his a ea. Me hod S udy Design A sequen ial explana o y mixed-me hod s udy was con- duc ed om Ma ch o May 2023. The explana o y sequen ial design comp ised wo independen s ands applied sequen- ially: (a) a quan i a i e s and, which collec ed and analyzed nume ical da a and (b) a quali a i e s and, which collec ed and analyzed ex ual da a. The quan i a i e s and is o en p io i ized, and he wo s ands can be connec ed in a ious ways du ing he in e media e s age (I anko a e al., 2006). In his s udy, in eg a ion occu ed du ing he selec ion o Phase 2 pa icipan s, based on he esul s o Phase 1. The ou comes o bo h phases we e combined o p o ide a mo e comp ehensi e and meaning ul unde s anding o he impac o inno a i e game-based eaching me hods on nu sing s u- den s’ cul u al compe ence and a i udes owa d e ugees (C eswell & C eswell, 2018). All hings conside ed, he esea ch ques ions we e: Resea ch Ques ion 1 (RQ1): Wha is he impac o inno- a i e game-based lea ning me hods on s uden s’ a i- udes owa d e ugees and cul u al compe ence? Resea ch Ques ion 2 (RQ2): How do nu sing s uden s desc ibe hei expe iences in he use o inno a i e Baysal e al. 3 game-based me hods o os e ing a i udes owa d e u- gees and cul u al compe ence? The ollowing mixed me hods esea ch ques ion was answe ed in he in e p e a ion phase o he s udy, subsequen o an au onomous analysis o he da a om each s udy componen : Resea ch Ques ion 3 (RQ3): How do nu sing s uden s pe cei e ha hese inno a i e game-based eaching me h- ods a ec ed hei a i udes and cul u al compe ence owa d e ugees? Se ing and Pa icipan s This s udy was ca ied ou a he Uni e si y o Alme ia wi h 141 nu sing s uden s in he second semes e o he academic yea 2022–2023. The selec ion c i e ia included hose s u- den s who we e (a) en olled in he Resea ch Me hods mod- ule, (b) a ended a leas 80% o lessons, (c) 18 o olde , and (d) willing o p o ide w i en in o med consen be o e pa - icipa ing in he s udy. P ocedu e The ac i i y was designed o be pe o med in he inal ses- sion o he Resea ch Me hods module, a manda o y module in he i s yea o nu sing deg ee ha is de eloped o e a 15-week pe iod. In his case, he expe imen al g oup ecei ed an inno a i e game-based eaching app oach, whe eas he con ol g oup ecei ed a adi ional-based eaching app oach. The expe imen al g oup s uden s we e di ided in o g oups o six o eigh pe sons, o a ed and wa ched (a) Clouds o e Sid a Documen a y wi h i ual eali y (VR) glasses and played he (b) Re ugeoly game. A week la e , bo h g oups we e di ided in o g oups o six o eigh pe sons and pa ici- pa ed in an (c) escape oom. All p og ams we e scheduled acco ding o s uden s’ a ailabili y ou side he class hou s and we e communica ed o he s uden s. Clouds O e Sid a Documen a y. The s uden s in he expe i- men al g oup wa ched he 8-min “Clouds o e Sid a” docu- men a y c ea ed wi h 360-deg ee ideo echnology, wea ing VR headse s. The documen a y ocuses on he Za’a a i Re u- gee Camp in Jo dan, which is home o 80,000 Sy ians leeing om iolence. Child en make up mo e han hal o he popu- la ion. The documen a y ells he s o y o he 12-yea -old Sid a. Viewe s can imme se hemsel es in he ilm using a VR headse . The use s wa ching he sho s made using 360-deg ee came as blended in o he documen a y wi h hei physical eali y (Suzuki, 2022). Re ugeoly. The s uden s in he expe imen al pa icipa ed in a se ious game ac i i y based on na a i e s o y elling sched- uled ou side o class hou s. Re ugeoly was designed by Vinny Mon ag based on he game called “Monopoly” o unde s and he d ama ic jou ney o e ugees ying o ind hemsel es a ha en (Mon ag, 2020). I allows he playe o s ep in o he shoes o a e ugee and expe ience he eal-li e condi ions ha a e ugee mus go h ough on he jou ney o a sa e coun y. The main p inciple o he game is o each and aise awa eness. The game consis s o ca ds numbe ed om 0 o 39. Each o hese ca ds is p in ed in size A1-A0 and placed o ollow one ano he , c ea ing la ge squa e-shaped a eas (3 × 3 m). The playe s a e expec ed o oll he dice and mo e clockwise along he game a ea acco ding o he num- be on he dice. On he subsequen ca ds, di e en condi ions (ad e se wea he condi ions, disease dea h, depo a ion, e c.) encoun e ed by e ugees on hei jou ney a e p esen ed ch onologically. The e is a symbol on each box (ca d) gi ing in o ma ion abou he si ua ion o e en ha he playe mus go h ough. The meanings o hese symbols we e ead aloud by he esea che s, and he s uden s we e asked o ac acco d- ing o he ins uc ions (Figu e 1). The Escape Room. This ac i i y in ol ed a e ugee s anda d pa ien who had a language ba ie and was unable o com- munica e e ec i ely. The pa ien was locked in a oom, and he s uden s we e old o ind wo sepa a e codes o unlock he doo . The s uden s we e in o med abou he ules and he scena io be o e he ac i i y. The s uden s we e di ided in o g oups o six o eigh , each g oup was u he di ided in o wo and was locked in wo sepa a e ooms. They we e expec ed o sol e he opic- ela ed puzzles and iddles and, ul ima ely, unlock he padlock in 20 min using hei knowl- edge o he Resea ch Me hods module. Meanwhile, he s u- den s we e in cons an communica ion h ough a walkie- alkie and ound he codes by answe ing he ques ions oge he wi h eam coope a ion. To acili a e communica ion wi h he pa ien wi h a language ba ie and o de ine he pa ien ’s p oblem co ec ly, a pic og am was placed in he oom whe e he s uden s we e locked, and hey we e expec ed o ind and use he pic og am. A e he s uden s sol ed all he puzzles and iddles, hey unlocked he pa ien inside he oom using he wo codes hey ound. Phase 1. Quan i a i e S udy Quan i a i e Design and Pa icipan s. The quan i a i e s and ollowed a compa a i e c oss-sec ional design. Pa icipan s we e asked o ill in he ques ionnai e, which was comp ised o sociodemog aphic o m, Ou g oup Th ea Pe cep ion Scale (OTPS), and Cul u al Compe ence Assessmen Scale (CCA-S). S uden s we e assigned o he expe imen al and con ol g oups using he pu posi e sampling me hod based on hei “Ou g oup Th ea Pe cep ion Scale-OTPS” sco es (Na as-Luque e al., 2012). S uden s illed ou he OTPS and CCA-S scales wice, 3 mon hs apa . The s udy in ol ed a o al o 153 s uden s, including 76 in he expe imen al g oup and 77 in he con ol g oup. Howe e , because hey did no 4Jou nal o T anscul u al Nu sing 00(0) pa icipa e in all game-based eaching ac i i ies, 12 s uden s in he expe imen al g oup we e elimina ed om he s udy. The s udy was comple ed wi h 141 nu sing s uden s mee ing he inclusion c i e ia (Figu e 2). Quan i a i e Da a Collec ion and Measu es. The ins umen o da a collec ion comp ised: (a) a sel -adminis a ed ques- ionnai e wi h sociodemog aphic da a, as well as (b) OPTS and (c) CCA-S scales. The OTPS consis s o 13 i ems (nine ealis ic h ea s and ou symbolic h ea s) (Na as-Luque e al., 2012). The scale is a 5-poin Like - ype ype one (1 = none; 5 = a lo ). The pa icipan s a e asked o indica e “To wha ex en hey eel a isk because o e ugees (ou - g oups)” in e ms o educa ional alues, amily alues, eli- gious belie s, cul u al adi ions (symbolic h ea s), access o employmen , heal h ca e sys em, educa ion sys em, social wel a e sys em, social secu i y, economic s abili y o he coun y, heal h, pe sonal secu i y, public o de in he coun y, and he secu i y o he coun y ( ealis ic h ea s). Mean sco es a y be ween 1 and 5. In s udies conduc ed wi h he Spanish popula ion, C onbach’s alpha coe icien was ound o be be ween .85 and .94 depending on he e ugee g oup. The C onbach’s alpha alue in he p esen s udy was de e - mined as .92. The CCA-S consis s o 25 i ems and wo subscales o Cul u al Compe ence Beha io s and Cul u al Awa eness and Sensi i i y (Raigal-A an e al., 2019; Schim e al., 2003). The 11-i em Cul u al Awa eness and Sensi i i y sub- scale measu es cul u al awa eness and sensi i i y. The Cul u al Awa eness and Sensi i i y subscale uses a 7-poin Like - ype scale (7 = s ongly ag ee o 1 = s ongly dis- ag ee) and has a no opinion op ion. The 14-i em Cul u al Compe ence Beha io s subscale measu es cul u al compe- ence beha io s. The Cul u al Compe ence Beha io s sub- scale uses a 7-poin Like - ype scale (7 = always o 1 = ne e ) and has a no su e op ion. Highe sco es indica e highe le els o knowledge, mo e posi i e a i udes, and a g ea e equency o compe ence beha io s. C onbach’s alpha o CCA-S was .91. C onbach’s alpha o his s udy was .91 as well. Quan i a i e Da a Analysis. The quan i a i e da a we e ana- lyzed using he SPSS 21.0 (S a is ical Package o Social Sciences, IBM Co p., A monk, New Yo k, USA, ABD) Figu e 1. Re ugeoly Game Design. Baysal e al. 5 so wa e. No mali y was es ed using he Shapi o–Wilk no mali y es . As he da a we e dis ibu ed no mally, an independen sample - es was used o compa e he sco es o he independen g oups, and a pai ed sample - es was used o compa e he sco es be o e and a e he in e en- ion. The s a is ical signi icance was se a .05 in he s udy. Figu e 2. Flow Diag am o S udy. 6Jou nal o T anscul u al Nu sing 00(0) Phase 2. Quali a i e S udy Quali a i e Design and Pa icipan s. The quali a i e s and ollowed a desc ip i e quali a i e con en analysis (K ip- pendo , 2019) a e quan i a i e analysis was comple ed. The pu pose was o unde s and nu sing s uden s’ expe i- ences o he p ocedu e and explo e hei pe cep ions o i s use o os e ing cul u al compe ence and a i udes owa d e ugees. Quali a i e Da a Collec ion. All pa icipan s we e asked o w i e a e lec ion epo . Gibb’s model and esul s om quan i a i e analysis we e used o de elop he e lec ion epo o m. Gibb’s Re lec i e Cycle was de eloped by G a- ham Gibbs in 1988 o s uc u e lea ning h ough expe ience. The e lec ion cycle o e s a amewo k o examining expe- iences and enables you o lea n om wha wo ks well o does no and o make plans, conside ing i s cyclical na u e. The e lec ion cycle consis s o six s ages: desc ip ion o he expe ience, e alua ion o bo h good and bad expe ience, eelings and opinions abou he expe ience, analysis o he si ua ion, conclusion on wha can be done di e en ly, and an ac ion plan on how o deal wi h simila si ua ions in he u u e (The Uni e si y o Edinbu g, 2020). Quali a i e Da a Analysis. MAXQDA Analy ics P o p o- g am 2020 was used o e alua e quali a i e da a. The w i - en da a ob ained om he s uden s we e analyzed using con en analysis. K ippendo ’s (2019) me hod o quali- a i e con en analysis ia “clus e ing” was used o analyze da a. This me hod allows esea che s o make conclusions om in e iew ansc ip s by g ouping da a “based on in ui i ely meaning ul simila i ies among uni s o analy- sis.” Following ansc ip ion, an in-dep h analysis was pe - o med, and s uden s’ simila exp essions we e clus e ed as uni s. These g ouped exp essions we e used o de e - mine subca ego ies and hen ca ego ies. All au ho s pa - icipa ed in all s eps o he analysis p ocess o inc ease alidi y. The indings we e illus a ed wi h quo es, and each quo a ion was iden i ied wi h “s uden numbe .” The esea che s analyzed he da a sepa a ely, and ca ego ies and meaning uni s we e discussed. E hical Conside a ions This s udy was app o ed by he E hics Commi ee a he Uni e si y o Alme ia (EFM 246/23). Pa icipan s we e asked o ead and accep he in o med consen o m explaining he aim o he s udy be o e s a ing o answe he ques ionnai e. The s udy was conduc ed in acco dance wi h he e hical s anda ds o he Decla a ion o Helsinki and subsequen amendmen s. W i en pe mission was ob ained om he scale owne s and Vinny Mon ag, he de elope o he game, o he Re ugeoly game o be used in esea ch. Validi y and Reliabili y/Rigo Me hodological iangula ion was he main s a egy employed o ensu e igo , accomplished h ough he delibe - a e and sys ema ic collec ion, analysis, and in eg a ion o bo h quan i a i e and quali a i e da a. The mixed me hods app oach acili a ed he a ainmen o mo e comp ehensi e and co obo a ed indings. The na a i es p o ided by nu s- ing s uden s ega ding hei educa ional expe iences we e ins umen al in elucida ing “how” and “why” hey belie ed he p ocedu e in luenced hei a i udes owa d e ugees. Guided by he c i e ia o high-quali y mixed me hods s ud- ies ou lined by C eswell and Plano-Cla k (2018), he esea ch eam: (a) ga he ed bo h quan i a i e and quali a i e da a o comp ehensi ely add ess he o e a ching esea ch ques- ions; (b) ensu ed me hodological cong uence ac oss bo h e alua ion s ands; and (c) pu pose ully in eg a ed he wo s ands a mul iple s ages h oughou he e alua ion p ocess. P io o he second se o desc ip i e quali a i e con en anal- ysis, he quan i a i e da a we e analyzed, acili a ing he iden i ica ion o opics o u he explo a ion in he subse- quen discussions. The accu acy o he quan i a i e indings was independen ly e i ied by membe s o he esea ch eam (E.B. and P.R.). Fu he mo e, he us wo hiness o he qual- i a i e indings was bols e ed h ough esea che iangula- ion du ing he analysis and in e p e a ion s ages (M.R.-A. and P.R.), ex ended engagemen in he ield wi h longi udinal da a collec ion, and e lexi i y. Findings Phase 1. Quan i a i e Findings The e we e no s a is ical di e ences be ween he expe imen- al and con ol g oups in e ms o desc ip i e cha ac e is ics (Table 1). The e was no s a is ically signi ican di e ence in he desc ip i e cha ac e is ics o he s uden s based on he mean o al OTPS and he mean o al CCA-S sco e (p > .05) (da a no shown). The mean o al OTPS sco e o he s uden s was below he a e age (expe imen al g oup: 1.992 ± 0.75, con ol g oup: 2.07 ± 0.72), while he o al CCA-S sco es (expe imen al g oup: 126.484 ± 27.08, con ol g oup: 122.480 ± 28.47) we e abo e he a e age. I was de e mined ha he mean o al OTPS and o al CCA-S sco es we e no s a is ically sig- ni ican di e ences be ween he expe imen al and con ol g oups ei he be o e o a e he in e en ion. When he change in he mean o al OTPS and o al CCA-S sco es o he g oups be o e and a e he in e en ion was examined, no signi ican di e ences we e obse ed be ween he changes ha occu ed in he g oups’ sco es (Table 2). Phase 2. Quali a i e Findings De i ed om he con en analysis, h ee majo ca ego ies eme ged om ou da a: (a) expe iences ega ding he Baysal e al. 7 360-deg ee ilm, wi h six subca ego ies; (b) expe iences a e playing Re ugeoly Game, wi h ou subca ego ies; and (c) expe iences ela ed o he Escape Room, wi h ou sub- ca ego ies. All ca ego ies a e summa ized in Table 3. Expe iences Rega ding he 360-Deg ee Film. A e wa ching he ilm, he s uden s exp essed ha hey el lucky; hey we e as onished, desensi ized, and el imme sed. They also epo ed ge ing mo e empa he ic and de eloping an inc eased awa eness o he e ugee issue. I was de e mined ha he s uden s lacked some knowledge and skills conce n- ing anscul u al nu sing and ha hey wan ed o add ess hese de iciencies h ough an empa he ic app oach, indi idu- alized ca e, ac i e lis ening, lea ning di e en languages, and ecei ing educa ion. The s uden s eel sadness, ange , and guil abou he e ugee issue. Thei ecommenda ions o he solu ion o he e ugee issue include helping, aising awa eness in socie y, p o iding psychological suppo , and acili a ing hei in eg a ion in o socie y. Expe iences A e Playing Re ugeoly Game. The s uden s ound he game design educa i e, un, engaging, ealis ic, and in e ac i e. They s a ed ha hey lea ned abou he e ugee issue by expe iencing, gaining awa eness, and de eloping empa hy. They con eyed eelings o sadness, as onishmen , ange , and disappoin men in esponse o he challenges aced by e ugees du ing he mig a ion p ocess and exp essed ha hey we e g a e ul o hei own ci cums ances. In addi- ion, hey ecommended he inclusion o he game in o nu s- ing educa ion and he p o ision o p ac ical aining on he e ugee issue. Expe iences Rela ed o he Escape Room. The s uden s de ined he design o he escape oom as un, engaging, educa i e, and well-o ganized. Howe e , hey ecommended ha mo e ime and clues should be p o ided, and echnical p oblems should be an icipa ed o u u e implemen a ions o he escape oom. They s a ed ha hey had he oppo uni y o pu hei heo e ical knowledge in o p ac ice, imp o e hei anscul u al nu sing skills, eam collabo a ion, and commu- nica ion skills in he escape oom, as well as aise awa eness and be mo e empa he ic. Discussion We conduc ed his s udy o e alua e he e ec o inno a i e game-based eaching me hods on nu sing s uden s’ a i udes owa d e ugees and cul u al nu sing compe encies. In he Table 1. Desc ip i e Cha ac e is ics o he Pa icipan s. Cha ac e is ics Expe imen al g oup (n = 64) Con ol g oup (n = 77) To al (n = 141) pn %n%n% Age (M ± SD) 21.734 ± 7.77 21.051 ± 4.67 21.361 ± 6.25 = 0.643* p = .521 Gende , (%) 52 81.3 58 75.3 110 78.0 χ2 = 0.715** p = .398 Female 12 18.7 19 24.7 31 22.0 Male Ha ing mig an o e ugee ela i es o iend(s), (%) χ2 = 1.447 p = .229 Yes 7 10.9 14 18.2 21 14.9 No 57 89.1 63 81.8 120 85.1 Ha ing iend(s) om a di e en cul u e, (%) χ2 = 0.003 p = .953 Yes 60 93.8 72 93.5 132 93.6 No 4 6.3 5 6.5 9 6.4 Li ing ab oad, (%) χ2 = 0.040 p = .841 Yes 6 9.4 8 10.4 14 9.9 No 58 90.6 69 89.6 127 90.1 Is you amily a i s -gene a ion immig an ?, (%) χ2 = 0.126 p = .722 Yes 4 6.3 6 7.8 10 7.1 No 60 93.7 71 92.2 131 92.9 Ca ing e ugee pa ien (s), (%) χ2 = 2.804 p = .094 Yes 38 59.4 56 72.7 94 66.7 No 26 40.6 21 27.3 47 33.3 Feeling compe en while ca ing o e ugee pa ien (s)? (%) χ2 = 0.769 p = .380 Yes 60 93.7 69 89.6 129 91.5 No 4 6.3 8 10.4 12 8.5 *S uden ’s - es . **Fishe ’s exac es . 8 Table 2. Compa ison o he OTPS and CCA-S Sco es in G oups Be o e and A e he In e en ion (n=141). Va iables Times Expe imen al g oup (n=64) Con ol g oup (n=77) Tes M ± SD Mdn (IQR)** 95% CI o mean (lowe bound- uppe bound) M ± SD Mdn (IQR)** 95% CI o mean (Lowe Bound- Uppe bound) To al OTPS sco e P e-in e en ion 1.992 ± 0.75 1.92 (1.32) [1.813, 2.182] 2.07 ± 0.72 2.00 (1.53) [1.897, 2.236] = −0.646* p= .519 Pos -in e en ion 2.057 ± 0.72 1.92 (1.38) [1.888, 2.245] 2.220 ± 0.77 2.15 (1.61) [2.044, 2.392] = −1.279* p = .203 aDi e ence o o al OTPS sco e −0.064 ± 0.802 −0.11 (−0.44) [−0.269, 0.140] −0.146 ± 0.631 −0.15 (−0.61) [−0.278, 0.003] = 0.678* p = .499 Tes = −0.647*** p = .520 = −2.041*** p = .05 To al CCA-S sco e P e-in e en ion 126.484 ± 27.08 130.50 (42.75) [119,719, 133,249] 122,480 ± 2,847 126.00 (48.00) [116,016, 128,944] = 0.850* p = .397 Pos -in e en ion 123.078 ± 28.48 130.00 (39.0) [115.962, 130.193] 126.090 ± 25.33 130.00 (35.0) [120.340, 131.841] = −0.664* p = .508 bDi e ence o o al CCA-S sco e 3.406 ± 35.00 7.0 (47.50) [−5.336, 12.149] −3.610 ± 34.08 −3.0 (34.08) [−11.346, 4.125] = 1.202* p = .231 Tes ** = 0.779*** p = .439 = −0.929*** p = .356 aDi e ence o o al OTPS sco e: P e-in e en ion minus pos -in e en ion. b Di e ence o o al CCA-S sco e: P e-in e en ion minus pos -in e en ion. *Independen sample - es . **IQR: in e qua ile ange. *** Pai ed sample - es . Baysal e al. 9 p esen s udy, he abo e-a e age cul u al compe ence and below-a e age ex e nal h ea pe cep ions o nu sing s u- den s we e conside ed posi i e indings. The li e a u e includes con o e sial in o ma ion ega ding nu sing s u- den s’ cul u al compe ence and a i udes owa d e ugees (Choi & Kim, 2018; P eposi-C uz e al., 2018; Uga e- Gu u xaga e al., 2020). The disc epancy in esea ch ind- ings may ha e esul ed om he cul u al cha ac e is ics o he coun ies, di e ences in hei demog aphic s uc u es, and he eaching me hods employed in nu sing cu icula. The AACN highligh s ha nu ses need cul u al unde s anding and sensi i i y o p o ide sa e and high-quali y ca e, sug- ges ing ha he inc easing globaliza ion equi es a ocus on di e si y and he use o inno a i e s a egies in nu sing edu- ca ion (Ame ican Associa ion o Colleges o Nu sing, 2008). In he li e a u e, i was s a ed ha educa ion in e en ions can imp o e heal h p ac i ione s’ cul u al compe ency in e ms o knowledge, a i udes, and abili ies, ega dless o he du a ion, design, o con en s o he in e en ions (Alici, 2021; Kohlb y, 2016). A a ie y o eaching s a egies we e epo ed, including adi ional lec u es, in e na ional se ice- lea ning, e lec i e epo s, case discussions, in e en ions based on he con ac hypo hesis, communi y se ice p ac- ices, co po a e social esponsibili y ac i i ies, ole-play, na - a i e s o y elling, and s anda d pa ien s (Hal e e al., 2015; Kohlb y, 2016; Ozka a San, 2019). Unlike p e ious educa ional p ac ices, in he p esen s udy, we aimed o e alua e s uden s’ cul u al compe ence and pe cep ions o ou -g oup h ea s using me hods like 360-deg ee ilm iewing wi h VR headse s and inno a i e game-based eaching me hods like he se ious game “Re ugeoly” and escape ooms. An inc ease was expec ed in he mean o al CCA-S and OTPS sco es o he s uden s ol- lowing he implemen a ion o he in e en ions. Howe e , i was seen ha he e was no signi ican di e ence in bo h scale sco es, and in ac , a sligh dec ease was disce ned in bo h he expe imen al and con ol g oups. Simila ly, Kohlb y (2016) ound ha nu sing s uden s’ cul u al compe ence le - els dec eased a e a aining in e en ion. This could be explained by pa icipan s ha ing a be e unde s anding o he meanings o he associa ed i ems a e he in e en ions, allowing hem o judge hemsel es mo e objec i ely and he e o e lowe hei sco es. This ype o expe ience helps s uden s expand hei wo ld iew and o ces hem o conside i hey comple ely comp ehend he equi emen s o a pe son om ano he cul u e (Liu e al., 2018). Lea ning h ough expe iences is conside ed one o he mos pe manen and e ec i e ways o lea ning (Anguas- G acia e al., 2021). In he p esen s udy, in which we employed a ious eaching me hods oge he , i was aimed o p o ide s uden s wi h a ec i e lea ning in he con ex o anscul u al nu sing, mig a ion, and e ugee issues. When we e alua ed he s uden s’ opinions abou he game-based eaching me hods, we ound ha all h ee o he me hods made s uden s con empla e he issue o mig a ion and e u- gees and ga e hem some nega i e eelings abou hese Table 3. Mos Rep esen a i es Subca ego ies, Meaning Uni s and Quo es o Pa icipan s. Ca ego ies Subca ego ies Meaning uni s Rep esen a i e quo es Expe iences ega ding he 360-deg ee ilm Emo ional e ec s o he ilm Desensi iza ion (n = 9) “I eel a li le bi emp y . . . We ha e no malized e e y hing so much because o ele ision and media ha I belie e we ha e de eloped immuni y o such ideos” (D61) Recommenda ions o he solu ion o he e ugee p oblem Raising awa eness in socie y (n = 11) “People need o be in o med mo e abou he e ugee p oblem. Many people a e no e en awa e o he issue. I hink he media should pu mo e e o because hey ha e a g ea impac on socie y” (D40) Expe iences a e playing Re ugeoly Game Game Design In e ac i e (n = 9) “The game was so dynamic . . . I gi es in o ma ion abou he di icul ies aced by e ugees on each box and you lea n abou he p ocess hey go h ough by playing in o de o each he a ge ” (D37) Lea ning ou comes De eloping empa hy (n = 16) “You pu you sel in o he shoes o hese people and y o empa hize wi h hem as much as possible because you can’ know wha hey go h ough unless you ha e been he e” (D49) Expe iences ela ed o he Escape Room Wha hey liked abou he game design Educa i e (n = 37) “The escape oom is an engaging and al e na i e me hod o e alua e ou exis ing knowledge as well lea ning new hings. We eally ob ained mo e in o ma ion abou a cul u ally di e en pa ien in an in e es ing way” (D45) Wha hey wan ed o change in he game design Technical p oblems should be an icipa ed (n = 11) “The communica ion be ween he wo g oups was no e y good. We had di icul y using he walkie- alkies. Such ac o s as echnology should also be conside ed. We we e acing agains ime, echnical issues caused us o lose ime” (K47)