98 © 2023 by the author; licensee Asian Online Journal Publishing Group Asian Journal of Education and Training Vol. 9, No. 4, 98-107, 2023 ISSN(E) 2519-5387 DOI: 10.20448/edu.v9i4.5077 © 2023 by the author; licensee Asian Online Journal Publishing Group Development of a self-directed workplace learning program to enhance cultural competence for the registered nurses from the international hospitals in Thailand Dech-siri Nopas Division of Lifelong Learning Promotion for Social Development, Department of Vocational Education, Faculty of Education, Kasetsart University, Bangkok, Thailand. Email: dechsiri.n@ku.th Abstract Thailand is now a medical center in Asia. There has been an increase in the number of foreign patients receiving medical services in Thailand. The employees in the healthcare industry, like the registered nurse, are the center of the relationship with that service. The vital learning promotion course for these registered nurses dealing with patients of various nationalities is cultural competence promotion. With the nature of the learning style of the registered nurse, they need more flexibility and respond to their learning nature. Ultimately, the enhancement of cultural competency learning still needs to be achieved. Therefore, this research study aimed to 1) develop a self-directed learning program in the workplace to promote cultural competence for registered nurses in international hospitals and 2) study the effect of implementing a self-directed workplace learning program to promote cultural competency. The researcher adopted a Research and Development methodology divided into two phases. The first phase is to develop a self-directed workplace learning program to enhance cultural competency. The second phase is to study the effect of implementing a self-directed learning program. The findings revealed that: 1) a draft of a self- directed workplace learning program to enhance cultural competence consisting of concepts and principles, the primary goal of the program, the guideline for promoting cultural competence learning based on the idea of self-directed workplace learning, the learning program, the learning facilitators of the program, the learning spaces are locations or areas within an organization, the international hospital's networks and the learning resources include information sources from diverse places. Plus, 2) registered nurses had better levels of cultural competency learning in attitudes, knowledge, and skills than before participating in the program trial and had improved scores in all areas. Keywords: Andragogy, Cultural competence, Non-formal education, Registered nurse, Self-directed workplace learning program, Training. Citation | Nopas, D.- siri (2023). Development of a self-directed workplace learning program to enhance cultural competence for the registered nurses from the international hospitals in Thailand. Asian Journal of Education and Training, 9(4), 98–107. 10.20448/edu.v9i4.5077 History: Received: 2 August 2023 Revised: 28 September 2023 Accepted: 10 October 2023 Published: 20 October 2023 Licensed: This work is licensed under a Creative Commons Attribution 4.0 License Publisher: Asian Online Journal Publishing Group Funding: This research is supported by Kasetsart University Research and Development Institute, Thailand (Grant number: YF(KU)27.65). Institutional Review Board Statement: The Ethical Committee of the Kasetsart University Research Ethics Committee, Thailand has granted approval for this study on 29 May 2023 (Ref. No. COE66/062). Transparency: The author confirms that the manuscript is an honest, accurate, and transparent account of the study; that no vital features of the study have been omitted; and that any discrepancies from the study as planned have been explained. This study followed all ethical practices during writing. Competing Interests: The author declares that there are no conflicts of interests regarding the publication of this paper. Contents 1. Introduction ................................................................................................................................................................................................... 99 2. Conceptual Framework of the Study ....................................................................................................................................................100 3. Methodology ................................................................................................................................................................................................101 4. Research Finding ........................................................................................................................................................................................103 5. Research Discussion ..................................................................................................................................................................................105 6. Research Suggestion..................................................................................................................................................................................106 References .........................................................................................................................................................................................................107 mailto:dechsiri.n@ku.th https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://www.doi.org/10.20448/edu.v9i4.5077 https://orcid.org/0009-0004-6183-4671 Asian Journal of Education and Training, 2023, 9(4): 98-107 99 © 2023 by the author; licensee Asian Online Journal Publishing Group Contribution of this paper to the literature The employees in the healthcare industry, like the registered nurse, are the center of the relationship with the healthcare service. The vital learning promotion course for these registered nurses dealing with patients of various nationalities is cultural competence enhancement. With this aspect, the research study will present a self-directed learning program in the workplace to promote cultural competence for registered nurses in international hospitals. 1. Introduction 1.1. Background and Problem of the Study Thailand is now a medical center. There has been an increase in the number of foreign patients receiving medical services in Thailand. The medical service business implements the strategic plan to develop Thailand into the Center of Excellent Health Care in Asia. The Ministry of Public Health has determined that it reflects the importance of policies that make Thailand a medical hub for foreigners. The medical service business is one way to earn income for the country. These are the three main products of the strategic plan: the healthcare service business, the health promotion business, and the business of health products and Thai herbs. The Thai government intends to continuously promote and support the policy of becoming a medical center to generate income for the country, even in implementing the strategic plan to develop Thailand as a world-class healthcare provider. That is the strategic plan in phase 2, with the addition of Thai traditional and alternative medicine services into the strategic plan as well. It is from the Cabinet's policy statement to the National Assembly on August 23, 2012, at the policy. This appears in the fourth policy on social policy and quality of life. This Public health development policy aims to drive Thailand to be excellent in products and services in health and medical treatment by coordinating to create academic advancement with all relevant sectors. The Ministry of Public Health Policy, which announced the policy of becoming a medical center, is also an essential policy of the Ministry of Public Health. The number of foreign healthcare patients has increased rapidly since 2000. The statistics have shown that the number of foreign healthcare patients and the growth rate have increased by an average of 27.2 percent per year. It had the highest number of foreigners receiving medical services in Asia, more than Singapore. Some factors contributing to such expansion include the liberalization of trade in services in Thailand's healthcare sector, which is based on the potential to provide world-class and affordable services, including a reputation for excellent service and hospitality (Whittaker & Chee, 2015). It is undeniable that providers in the healthcare sector in Thailand inevitably have to work with people from different cultures. Over the past two decades, the role of registered nurses in international hospitals caring for patients from around the world has changed dramatically. Research about the role of registered nurses with cultural competencies has found that culturally diverse patients are involved and affect all aspects of all professions in the hospital that serve these patients. The "registered nurse" is the center of the relationship with that service. In particular, traveling by air from one country to another has always been challenging. This allows the patient to choose the country to treat their illness. Thailand is regarded as one of the most visited countries in the world by foreign tourists. As a result, income from tourism is worth several million baht per year (Westbrook, Duffield, Li, & Creswick, 2011). Each society has a variety of cultures, which can be viewed in two dimensions: 1) The dimension of the process that considers culture as a way of life of people in society that is constantly changing, such as the way of eating, the way of sleep, coexistence training process, Cultivate different stories for people in society. These can be different or the same in each community. There is a transfer between societies. And 2) the outcome dimension views culture as the sum of systems of knowledge, beliefs, arts, ethics, laws, traditions, as well as abilities and character. It results from membership in a society, a fundamental characteristic of a culture. Multicultural people come together. There will be an expression of lifestyle and wisdom, including a pattern of health care according to their culture. It was found that people of different cultures will have different healthcare styles according to that group's beliefs and culture in society. In every human society, culture is an essential element that determines the state or nature of humanity. It is a pattern of behavior and value in living and living of people in society that determines the behavior or behavior of human beings in each community and defines the definition and pattern of health through culture and health. Therefore, it is a relationship that connects and interacts in a dynamic way that differs in each society and culture. Nopas, Pathhumcharoenwattana, and Ratana-Ubol (2022) confirmed that people should never forget that everyone is different. Even though people come from the same place, they still have different understandings of norms and implications of cultures. However, if people believe that everyone is different, they will learn to be more aware of their verbal and non-verbal when dealing with people from different cultural backgrounds. Promoting cultural competency learning for new registered nurses works effectively with international hospital patients. There are various international hospitals in Thailand, such as Simitivej Hospital, Bangkok Hospital, Bumrungrad Hospital, Med Park Hospital, etc. It is developing a curriculum on cultural competence integrated with Training for many registered nurses. However, in the end, there needed to be more continuity in the operation. Even in some hospitals, groups of registered nurses are gathered to learn cultural competencies in the workplace. Nevertheless, with the nature of the learning style of the registered nurse, they need more flexibility and respond to the nature of registered nurses' learning. Ultimately, the promotion of cultural competency learning still needs to be achieved. This is the difference in the time to work for each person. It is another factor that hinders learning together in the classroom. Therefore, Self-directed learning is essential to increase learners' opportunity to identify problems and discover what to learn—by designing a self-learning method. This self-directed learning is an essential process for learning to acquire cultural competence. Furthermore, learning in the organization is considered one of the managements of education outside the school system. Education plays an essential role in improving the quality of life. From the National Education Act of 1999 (No. 3), Section 22, which has an important principle based on people- centered development, has determined that education management must emphasize the ability of learners to develop. It can be learned where the learners matter the most. The educational management process must focus on enabling learners to develop to their full potential. According to the Secretariat of the Council of Education, the educational management process must encourage learners to develop naturally and to their full potential, which has conducted a research and development project on learner-centered learning styles by using learning styles of prototype Asian Journal of Education and Training, 2023, 9(4): 98-107 100 © 2023 by the author; licensee Asian Online Journal Publishing Group instructors to research and develop. It is consistent with Article 22 that education management must adhere to the principle that all learners can learn and develop themselves. The educational management process must encourage learners to build from nature and focus on thinking skills training, skills training in acquiring self-knowledge from a variety of learning sources, practical training, and the application of knowledge to prevent and solve problems. This aligns with the government's education policy drive (Ratana-Ubol & Henschke, 2015). The operational plan for the fiscal year 2017 of the Office of Non-formal Education and Informal Education focuses on allowing students to learn, think, analyze, and apply in daily life, including solving problems and improving their quality of life creatively. In actual practice, it was found that promoting learning for registered nurses to have cultural competence is essential. However, if able to create guidelines or guidelines for learning to be appropriate according to their abilities, learning atmosphere, way of seeking knowledge, learning methods, and assessments to achieve the goal is more individual. Therefore, the researcher is interested in developing a self-directed workplace learning program to promote cultural competence through concepts of non-formal education and lifelong learning that are flexible and suitable for workplace learning to be a model for each department to train professional nurses in international hospitals interested in promoting cultural competence. The organization can adapt the learning program to different contexts by believing that a program is a tool that is appropriate to the learning nature of registered nurses. It should be a flexible program in practice. Plus, it can effectively promote cultural competence when comb ined with self- directed learning. It is also an educational innovation at the International Hospital Training Department. The training departments of international hospitals can be utilized to promote learning for the cultural competency of registered nurses to their fullest potential and cultural competence. They can effectively work and deal with workplace cultural diversity and have a good attitude toward service users. 1.2. Research Statement This study aimed to 1) develop a self-directed learning program in the workplace to promote cultural competence for Registered Nurses in International Hospitals in Thailand and 2) study the effect of implementing a self-directed learning program in the workplace to promote cultural competency for registered nurses in international hospitals in Thailand. 1.3. Research Questions The questions that guided this research were: 1) what is a self-directed learning program in the workplace to promote cultural competence for Registered Nurses in International Hospitals in Thailand? And 2) what is the effect of implementing a self-directed learning program in the workplace to encourage cultural competency for registered nurses in international hospitals in Thailand? 2. Conceptual Framework of the Study Conrad and Barker (2010) stated that culture is an essential element that determines the conditions in every human society. It is also the nature of society as a pattern of conduct valuing living and living of people in society. It also determines the behavior or behavior of human beings in each community, including being a determinant, definition, and health patterns. Culture and health are, therefore, interconnected and interact with each other dynamically. Kleinman (1978) proposed that Western medicine treats disease through adaptation and psycho-physiologic processes. Instead, patients and families perceive and create definitions, meanings, and descriptions of illnesses with influences generated from the refinement of their culture and society, resulting in responses to illnesses. Seeking a cure for patients and families, Kleinman (1978) also offers health workers to look at health and illness through the patient's point of view by asking questions about the definition of illness, recognition of abnormal symptoms, the severity of illness, recognition of the cause of illness, and belief in treatment expectation of treatment outcome to create mutual understanding. Leininger (1984) proposed the concept of cultural care Madeleine Leininger, a nurse who received a doctorate in sociocultural anthropology from the University of Washington, proposed that caring for the sick must conform to requirements. It depends on the ethnicity and culture of the patient, and nursing management needs to analyze all factors influencing the health or Illness of the individual in that sociocultural context with the "Sunrise Model" to understand the worldview and social structure of the individual in each cultural society. Pilkington (2005) also defined cross-cultural nursing competency as having skills, knowledge, and other information leading to the question being asked. They can point to knowledge, skills, and personal characteristics of attributes that the behavior is necessary and sufficient for that person to check for responsibility constantly. It is superior to others, and the committee will join the situation that is about to arrive. Campinha-Bacote and Campinha- Bacote (1999) applied the theory of cultural health care to develop providers' cultural competence. He developed a health service delivery model that directly focused on cultural competence, emphasizing that the cultural competency of providers was a process. Matteliano and Street (2012) aimed to examine the causal model and identify the causal variables affecting the cultural competence and cultural care behavior of professional nurses working in international hospitals in Bangkok, Thailand. They revealed that appropriate cultural care behaviors could be developed by increasing cultural competence and having perceived organizational support. This research recommends that organizations support training courses to enhance nurses' experience and attitudes. Vidusha and Manjunatha (2015) aimed to increase students' awareness about the essence of culture in care to enable them to implement holistic care. He revealed the feedback from the cohort groups in 2008–2009 to improve undergraduate nursing students' cultural knowledge, awareness, and skills. Multiple approaches are required, such as increasing an understanding of self and other values, exposing the reality of culturally diverse groups, and facilitating individual and group interaction through media or scenarios related to culturally sensitive issues and possible conflicts in the health care system. Songwathana and Timalsina (2021) aimed to describe the perception of cultural competence among nurses in four Asian countries. The participants defined cultural competence as similar to cultural care. They expressed their Asian Journal of Education and Training, 2023, 9(4): 98-107 101 © 2023 by the author; licensee Asian Online Journal Publishing Group cultural competence in four main themes: 1) caring focus for patients with different cultures, 2) valuing holistic care/patient-centered nursing, 3) preparing for living with God or Buddha, and 4) considering the social norms and patient rights. The components of cultural competence were assessing the patient’s cultural background and myths contrary to medicine, along with having professional nursing knowledge, skills, and experience. The participants have addressed their cultural competence in providing culturally congruent care with a universal, holistic, and empathetic approach. Nurses should be trained to develop multicultural care and language skills and be made aware of their patient’s cultural beliefs. Cai, Kunaviktikul, Klunklin, Sripusanapan, and Avant (2017) aimed to develop and psychometrically test the Cultural Competence Inventory for Nurses in China. Cultural competence is expected worldwide from nurses due to the increasing cultural diversity of people in healthcare establishments. However, no cultural competence framework or instrument for nurses has been identified to guide nursing practice in China, where the population's cultural diversity and the healthcare system's characteristics differ from those of the West. The study prov ed that the Cultural Competence Inventory for Nurses in China is reliable, valid, and culturally sensitive for measuring nurses' cultural competence. The instrument development process facilitates the understanding of cultural competence globally. They also suggested that the Cultural competence of nurses can be evaluated for self-development, workforce management, and quality assurance. The instrument can also serve as the foundation to develop education curricula and nursing procedures or protocols to improve culturally competent nursing practice. Whittaker and Chee (2015) reported on work undertaken within a Thai hospital in 2012, including observations and interviews with thirty foreign in-patients and nine informal interviews with hospital staff. Although theorized as a culturally neutral transnational ‘space of connectivity.’ They also revealed how cross-cultural tensions affect the experience of the hospital with implications for the organization of the hospital and notions of ‘cultural competence’ in care. There is no universal experience of this space; instead, there are multiple experiences of the ‘international hospital,’ depending on who patients are, where they are from, their expectations, and their relationships. Such hospitals straddle the expectations of both local patients and international clientele and present highly complex cross- cultural interactions between staff and patients but also between patients and other patients. Figure 1 presents the conceptual framework of the study. Figure 1. Conceptual framework of the study. 3. Methodology The researcher adopted a Research and Development methodology divided into two phases. The first phase is to develop a self-directed workplace learning program to enhance cultural competency for registered nurses in Thailand’s international hospitals. The second phase: is to study the effect of implementing a self-directed learning program in the workplace to encourage cultural competency for registered nurses in international hospitals in Thailand. These are details of operations in each phase as follows. Figure 2 exhibits the research framework of the study. Asian Journal of Education and Training, 2023, 9(4): 98-107 102 © 2023 by the author; licensee Asian Online Journal Publishing Group Figure 2. Research framework of the study. The First Phase: The development of a self-directed workplace learning program to enhance cultural competence for registered nurses of Thailand’s international hospitals (R1 and D1) . This study phase aims to develop a self-directed learning program in the workplace to foster cultural competency for professional nurses in international hospitals in Thailand, which divided the process into three steps: Step 1: Study of problems and needs in promoting cultural competency (R1). The researcher used purposive sampling to select the registered nurses from Thailand’s international hospitals. The research instrument in this step was a group discussion form of discussing issues. There were two issues: 1) problems of learning to enhance cultural competency. Plus 2) the need for learning for cultural competency in the future. The researcher collected data by organizing small group discussion meetings according to the appointment of each hospital. The researcher transcribed text from group discussions and grouped keywords with similar content into subgroups. After that, sub-information that is related or consistent was created as the main point of the study and presented the information by descriptive writing as the main point, sub-information, and sample reference. There were two main points which were 1) problems in the workplace with learning about cultural competency, and 2) the need to learn by using a self-directed learning approach to enhance for registered nurses in international hospitals in Thailand. Step 2: Interview experts to develop a draft of a self-directed learning program in the workplace to enhance the cultural competence of registered nurses in international hospitals in Thailand (D1). The researcher employed purposive sampling to select experts in nurses, lifelong learning promotion, education, and training. The research instrument was the interview form to develop a self-directed workplace learning program (draft) to promote cultural competency for registered nurses in Thailand's international hospitals in Thailand. After the researcher collected all the data from the interview, the researcher performed a triangular examination to prove that the data were reliable, accurate, and with minimal to no error. The methods used by the researcher to examine the data were: 1) data triangulation and 2) investigation Triangulation. The researcher employed data analysis by using data obtained from the interviews of all informants to conclude through descriptive writing and evidence from textual interviews categorized by issues in the interview, which are: 1) Goals and outcomes of cultural competency learning in terms of attitudes, knowledge, and skills. 2) Principles necessary for self-directed learning in the workplace to promote cultural competence. 3) Guidelines for fostering self-directed learning to enhance cultural competence. 4) Stakeholders in promoting and organizing learning promotion activities to promote cultural competency. Plus 5) Supporting factors for fostering learning to promote cultural competency and barriers in promoting learning to promote cultural competency. Step 3: Assessment (draft) of a self-directed learning program in the workplace to enhance the cultural competence of registered nurses in international hospitals in Thailand (D1). The researcher used purposive sampling to select three experts promoting lifelong learning or non-formal education. The research instrument used for this process was the assessment form (draft) of a self-directed learning program in the workplace to promote cultural competence for registered nurses in international hospitals in Thailand. The assessment is divided into three parts: Part 1) To assess the accuracy according to the principles and the viability of the elements in the program. The evaluation was a five-level rating scale (Rating scale). After collecting all the data, the researcher assessed the theoretical validity and practicality of the elements in the model. The researcher determined the mean (M) and the standard deviation (SD) with the interpretation of the data. Part 2) to evaluate the learning contract plan to promote learning about cultural competency. It has the assessment's characteristics to find the content's consistency with the objectives. (Item-Objective Congruency Index: IOC). The researcher evaluated experiential plans for a self-directed workplace learning program to promote cultural competency. The researcher performed the mean (M) to interpret the data—plus, Part 3) Additional Recommendations. The researcher employed content analysis to summarize the issues that need to be adjusted according to the expert's opinions in the assessment. The Second Phase: The development of a self-directed workplace learning program to enhance cultural competence for registered nurses of Thailand’s international hospitals (R2 and D2) . This study phase aims to develop a self-directed learning workplace program to enhance cultural competency for professional nurses in international hospitals in Thailand. The area for trialing the draft for the program designed in phase 1 was Med Park International Hospital. It is a hospital that was willing to participate in the research. The Asian Journal of Education and Training, 2023, 9(4): 98-107 103 © 2023 by the author; licensee Asian Online Journal Publishing Group sample group that participated in this research voluntarily joined 46 people, comprising 15 nurses from three departments: 1) eight Outpatient-Inpatient Department nurses, 2) four Emergency Room Department nurses, and 3) four Medicine Department nurses with a research period from May to July 2023. Before and after the experiment, the researcher employed a self-evaluation form to learn about the cultural competence of registered nurses in international hospitals in the self-assessment experimental group. The research instrument was a 5-level rating scale (Rating Scale), divided into three aspects: knowledge, skills, and attitude, totaling 12 items, and checking content validity from three experts using the index to measure the consistency between the questions and the objectives (Item-objective congruency index: IOC). It must be between 0.60-1.00 for data analysis categorized as an analysis of each individual's mean values, attitudes, knowledge, and skills. The researcher compared the number of participants with the changed scores in post-experimental learning by finding the frequency and percentage to find the individual development score. The researcher also compared the number of learners with changes in development scores regarding attitudes, knowledge, and skills by presenting the frequency and percentage values. To improve the prototype of the activity to be complete. 4. Research Finding 4.1. The Findings of Using a Self-Directed Workplace Learning Program to Enhance Cultural Competence for Registered Nurses of Thailand’s International Hospitals The study of problems and needs in promoting cultural competency of the registered nurses from Thailand’s international hospital can be divided into four aspects: 1) the attitude of the registered nurses toward cultural competence, 2) the need to promote cultural competence learning, 3) methods of learning about cultural competence for registered nurses in international hospitals, and 4) the importance of promoting cultural competency learning of registered nurses in international hospitals. The results revealed that: 1) they want learning about cultural competence to be something everyone in the hospital must learn. 2) They want the nature of their learning to be personal. Individuals can design their learning style according to the context and nature of each person's learning nature and style. 3) They want their learning facilitators to give them the freedom to learn. At the same time, learners must be responsible for learning what they must learn, reflecting on what they have learned with the facilitator of learning and fellow learners. 4) They want the learning facilitators to allow learners to self-determine the topics they want to learn in their cultural competencies because they believe each learner has different problems and interests in learning according to their previous knowledge and experience. Moreover, 5) They want hospitals or related departments to the learning facilitation in the organization to participate in the instruction design and bring what is obtained from each teaching and learning process to improve, edit, and apply for the benefits in the following classes. The findings of Interview experts to develop a draft of a self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand. The details are as follows: The concepts and principles of a draft of a self-directed workplace learning program and the key principles of lifelong learning promotion and non-formal education. This learning program has key principles: 1) Understanding the learner’s nature and behavior. 2) Applying the learner’s experiences. 3) Enhancing learner’s competence. 4) Promoting the learner’s full potential, including the senses, emotions, actions, and intellect. Plus, 5) Relevant to career path development. The main goal for a draft of a self-directed workplace learning program is to enhance registered nurses' cultural competence in four dimensions: 1) cultural awareness, 2) cultural attitude, 3) cultural knowledge, and 4) cultural skills to registered nurses in Thailand’s international hospitals. A guideline in promoting cultural competence learning based on the concept of self-directed workplace learning, consisting of six steps. 1) Learners identify their learning needs. 2) Learners pinpoint the problem they want to solve. 3) Learners set a goal for the learning process. 4) Learners create something from what they learn. A self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand, consisting of activities developed as an example of cultural competency learning by integrating self-directed workplace learning concepts with these key learning processes: identifying the need in learning, identifying the problem for learning, identifying goals for learning, identifying content for learning, prioritize and manage the time, and evaluate the learning outcomes. Learning facilitators of the program organize learning activities to promote cultural competence learning to be successful from the beginning to the end of the learning process. It comprises nurse trainers, language & cultural facilitators in healthcare, activity processors, and executives and employees in the human resources department. Learning spaces are locations or areas within an organization where learning activity providers can access and run the self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand, including people in international hospitals who can learn by themselves to achieve learning objectives. The international hospital's networks include organizations, agencies, network alliances, groups, or individuals who play a role in the healthcare industry, and support activities to promote cultural competence learning should support self-directed learning in the workplace. Learning resources include information sources from diverse places that can support and encourage learning activities in cultural competence to achieve the goals, especially 'anywhere-anytime' spaces on the platform that the registered nurses can use to dig deeply into what they want to learn, where they want to learn, and when they want to learn. They can interview those who can provide them with their data to obtain the necessary information to learn about cultural competence. The findings of the assessment of a self-directed learning program (draft) in the workplace to enhance the cultural competence of registered nurses in international hospitals in Thailand. The findings revealed that all program components are valid, following the principles of the program in all respects. They were 1) concepts and principles, 2) goals of the program, 3) guidelines for promoting cultural competence based on the concept of self-directed workplace learning, 4) self-directed learning space area, and 5) media & learning resources. Furthermore, the program has the highest level of assessment for all components with the same mean score of 5.00 points (standard deviation = 0.00). Concerning the possibility of implementation, all components were assessed Asian Journal of Education and Training, 2023, 9(4): 98-107 104 © 2023 by the author; licensee Asian Online Journal Publishing Group at the highest-level regarding concepts and principles, and the self-directed learning space area had a mean score of 4.75 points (standard deviation = 0.54). The goal of the program and guidelines for promoting cultural competency learning through self-directed learning concepts include a learning facilitator, a learning resource, and the activities in the self-directed learning workplace learning program to promote cultural competence. There was a mean score of 4.60 points (standard deviation = 0.45). 4.2. The Findings of the Development of a Self-Directed Workplace Learning Program to Enhance Cultural Competence for Registered Nurses of Thailand’s International Hospitals The findings of learning cultural competence on registered nurses' attitudes before and after participating in the program. Before participating in the program, the registered nurses revealed that they had self-assessment scores at a moderate level, with ten people representing 67.67%, and a high level, with five people representing 33.33%. Furthermore, after participating in the program, the registered nurses revealed that they had self-assessment scores at the highest level, with 13 people representing 86.67%, and a high level, with two people representing 13.33 %. All registered nurses had an attitude change of 100%. The learning outcomes of cultural competency in knowledge of registered nurses before and after participating in the learning program. Before participating in the program, the registered nurses revealed that they had self - assessment scores at a moderate level, with 11 people representing 73.33% and a high level, with four people representing 26.67%. Furthermore, after participating in the program, the registered nurses revealed that they had self-assessment scores at the highest level, with eight people representing 53.33% and a high level, with seven people representing 46.67%. All registered nurses had a knowledge change of 100%. The cultural competency learning outcomes in terms of skills of registered nurses before and after participating in the program. Before participating in the program, the registered nurses revealed that they had self-assessment scores at a moderate level, with 11 people representing 73.33% and a high level, with four people representing 26.67%. Furthermore, after participating in the program, the registered nurses revealed that they had self-assessment scores at the moderate level, with eight people representing 53.33% and a high level, with seven people representing 46.67%. All registered nurses had a skill change of 100%. The results of the study of the level of development classified by each factor found that 1) attitude had a middle level of development, representing 60 percent; 2) knowledge had a moderate level of development, representing 53.33 percent; and 3) skill had a moderate level of development, representing 53.33 percent. Detailed information is shown in the following Table 1. Table 1. A study of the level of development of cultural competence of registered nurses classified by aspects (N = frequency and P = percentage). Factors Level of development Highest High Moderate Low N P N P N P N P Attitude 3 20.00 7 46.67 5 33.33 0 0.00 Knowledge 3 20.00 5 33.33 7 46.67 0 0.00 Skill 3 20.00 5 33.33 7 46.67 0 0.00 After trying, the draft of a self-directed workplace learning program to enhance cultural competence for registered nurses of Thailand’s international hospitals was completed. The researcher has revised the program draft with the following significant issues for revision. 1. Concepts and principles. There were details in each principle to be clear and cover the actual use. Regarding the learning climate, facilitators must allow absolute freedom to choose the time and place. In the consulting field, the facilitators should plan a convenient time for learners to consult about learning if learners have any questions about learning. Regarding learning reflection, facilitators must provide a convenient and suitable time for all learners to simultaneously present and reflect on the learning outcomes to achieve shared learning outcomes. Moreover, to empower learners, facilitators must help learners believe in self-learning and encourage them to continue their learning endlessly. 2. The main goal of the program. It has been added, and the expected outcomes are consistent with the objectives. 3. A guideline for promoting cultural competence learning based on self-directed workplace learning. The information obtained from the actual experiments has been detailed to see the processes and goals in each step for easy implementation. 4.3. Criticism Based on the research results on developing a self-directed learning program in the workplace to enhance cultural competence for registered nurses in international hospitals. The researcher has comments as follows. 1. According to the research results of studying the problems and needs of registered nurses' attitudes towards learning cultural competencies, it was found that, at present, most registered nurses have an attitu de towards learning about cultural competencies as being challenging to learn. Thailand needs to give more importance to learning about cultural competence in the primary education system. Cultural competencies are essential to make it easier for registered nurses to work with patients of diverse cultures. After all, cultural competencies help nurses work more efficiently and live in the real world, in line with Barnes and Seemiller (2021) who stated that cultural competence is vital for health services and the development of nursing and public health professions. It was found that cultural competence is a process of providing holistic healthcare services and management, especially for people with cultural differences. There are many theoretical concepts related to cultural competence that should be learned. This knowledge review will increase nurses' understanding and awareness of improving themselves and others. To have more cultural competence, as well as provide the facilitators with guidelines for developing cultural competencies of nursing students. The researchers believe that empowering students to build confidence in learning is the key to encouraging them to initiate the learning process independently at every stage. Including ensuring that they can learn by applying knowledge and skills gained from learning to work life, which is relevant to the opinions Asian Journal of Education and Training, 2023, 9(4): 98-107 105 © 2023 by the author; licensee Asian Online Journal Publishing Group of registered nurses from the focus group that reflected that "…I would like to see a day when we as learners can design our way of learning from start to finish. We are adults, we are working. The context we live in today is not like ten or twenty years ago. Also, work hours are changing all the time, sometimes during the day and sometimes at night, so if you want to sit in a course and study, you will not be able to study fully…" In this regard, Mapiam and Sriwongsitanon (2009) confirmed the findings of developing a self-guided learning promotion program model to develop cross-cultural nursing competencies for nursing learners at the Faculty of Nursing, Burapha University. The outcomes revealed that the self-directed learning promotion program model can improve cross-cultural nursing competencies for nursing learners. Learners confidently design their learning styles, the effective enhancement that is critically effective for registered nurses as learners have truly designed their learning. 2. The results revealed that the components of a self-directed learning program for cultural competency for registered nurses in international hospitals include 1) Concepts and Principles, 2) Program Goals, 3) Practice Guidelines for Promoting Cultural Competence-Based Learning self-directed learning concepts in the workplace, 4) Learning facilitators, 5) Learning Space or places or areas within the organization for learning management, 6) Networks and learning supporters, 7) Media and learning resources, and 8) a set of learning activities to promote cultural competence. These components are consistent with the self-directed learning process. There are subcomponents: applying learned concepts and principles in life, self-study, anytime, anywhere. Observe and adjust the learning behavior as a guideline to apply to learners. They are choosing new learning methods and practical exercises to gain learning experience and free time to learn by listening, reading, watching, and acquiring knowledge from various sources. In this regard, Meesuaisint, Pathumcharoenwattana, and Boonprakob (2018) stated that learning by self-direction is creativity in the educational process of a person, starting from the intention to want to learn arising from the internal drive of each person to suit their own needs. Then, they set goals for learning and selecting the information to study, including self-assessment. 5. Research Discussion From the data analysis, the researcher brought the findings to discuss. 1. The findings of Interview experts to develop a draft of a self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand consisted of 1) concepts and principles, 2) the primary goal of the program, 3) the guideline in promoting cultural competence learning based on the concept of self-directed workplace learning, 4) the self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand, 5) the learning facilitators of the program, 6) the learning spaces are locations or areas within an organization where learning activity providers can access, 7) the international hospital's networks, and 8) the learning resources include information sources from diverse places that can support and encourage learning activities in cultural competence to achieve the goals. The elements are consistent with the conceptual process of a self-directed workplace learning concept relevant to Merriam (2001), who wrote the philosophical orientation of self-directed learning goals. The first goal of self-directed learning, the grounded-in humanistic philosophy posit, should have as its goal the development of the learner's capacity to be a self-directed learner. A second goal is fostering transformational learning, which sets critical reflection by the learner as the center of the process. Critical reflection is understanding the historical, cultural, and biographical reasons for one's needs, wants, and interests. Furthermore, Melkonian and Rolle (2002) explained that self-directed learning as independent learning provides learners the freedom to learn something new or challenging when and how learners enjoy it. Learners get to manage the time frame. Many learners find time blocking helpful for juggling their responsibilities and personal growth. However, it is more than just personal preference. In self-directed learning, learners must be involved and engaged in a way that often does not happen in training. Moving at learners' own pace, following their interests, and applying learnings in their environment can help enlighten what they learn and make it meaningful. 2. A draft of a self-directed workplace learning program to enhance cultural competence. In this research study, the competence of registered nurses in international hospitals in Thailand is based on self- directed learning as a practice of workplace learning (Lemmetty & Collin, 2020). They stated that organizations call for employees’ autonomy and self-directedness executed by agile operations and low hierarchies, where learning is also increasingly the responsibility of the individuals and teams themselves and occurs in practice without solid control of the organization. They examine how employees describe self-directed learning practices in the context of workplace learning. The findings revealed that the workers discussed self-directed learning as an obliged, creative- enhanced, flexible, fast-paced practice. Self-directed learning was also described as a practice tied to work itself. Confessore and Kops (1998) also articulated the connection between self-directed learning (SDL) and the learning organization. Although there is much literature on developing learning organizations, and there has been some work addressing SDL in the workplace, there needs to be more work analyzing the connection between self-directed learners and their place in a learning organization. Furthermore, the findings from this research study revealed seven key principles of self-directed workplace learning as follows. Learners identify their learning needs. The main focus is for learners to identify their needs in what they love to know and learn before they immerse themselves in learning. When learners clearly define their learning needs, they are comfortable with the next steps in their learning process, which must be designed to guide their learning in the workplace context. Learning like this can help boost learners' self-confidence, the ability to empower themselves, and confidence in their learning. This is relevant to Toit-Brits and Van Zyl (2017) suggested that teacher-students should challenge themselves in this process of self-directed learning development to participate in learning opportunities. The characteristics of self-directed learning teacher-students must be strengthened to promote their self- directedness about learning, and it is also the lecturer's task to create a class atmosphere of self-directed learning to inculcate and develop self-directed learning characteristics in students. Learners pinpoint the problem they want to solve. The main focus is for learners to identify problems in what they want to learn by learning from asking questions. Powerful questioning is another excellent starting point for learning. When the learner can clearly define the learning problem, the learner finds a way to learn to deal with the Asian Journal of Education and Training, 2023, 9(4): 98-107 106 © 2023 by the author; licensee Asian Online Journal Publishing Group problem. Cai et al. (2017) confirmed that problem-based learning programs that fostered the development of self‐ directed learning are discussed. Development of these skills depended on the curriculum's adherence to using student‐ generated learning issues as a guide for defining content to be learned and several other factors. Learners set a goal for the learning process. The main focus is for the learners to specify their learning goals to define themselves clearly with the learning outcomes, including the evaluation of learning outcomes. Defining a learning goal is like creating a clear learning purpose and learning objective in what learners want to learn. When students can set their learning goals, they will stay aware of their own designed learning process, including gaining insights. Hematian, Rezaei, and Mohammadyfar (2017) also revealed that teaching goal-setting significantly affected the improvement of self-directed learning and achievement motivation; however, it had no significant effect on students' academic achievement. According to the obtained results, it is recommended that goal setting be taught to promote self-directed learning and achievement motivation. Learners create something from what they learn. There is a crucial focus on learners to create works out of learning contracts, whether they are presentations, inventions, innovations, or even test results. Nevertheless, the outcomes of these learnings will be the learning outcomes that the learners have chosen their learning style from the beginning. Accordingly, the results will demonstrate that the development of the learners has entirely changed. Learners can be thoroughly proud of what they have learned, their learning outcomes, development, pace, and the learning process they have chosen from the beginning. Learners are more satisfied with the product of their Learning than the final result of their Learning. On the other hand, learning outcomes will be memories that reflect the learner's learning process from the beginning. Yoesya, Nurihsan, and Adiwinata (2020) concluded that several aspects can affect the learning outcomes of learners in the learning process. One of them is self-directed learning. Self-directed is a form of learners' activities or activities that they want to study voluntarily without compulsion. The environment influences Self-directed Learning. Self-directed Learning is expected to foster students' responsibilities in the face of learning tasks, including learning difficulties. A self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand, consisting of activities developed as an example of cultural competency learning by integrating self-directed workplace learning concepts with these key learning processes: identifying the need in learning, identifying the problem for learning, identifying goals for learning, identifying content for learning, prioritize and manage the time, and evaluate the learning outcomes. Shi and Witte (2018) studied the opportunities to apply cognitive load theory and four-component instructional design to self-directed learning. Learning tasks contain three elements: performing the duties, assessing the task performance, and selecting future tasks to improve the performance. Principles to manage intrinsic and extraneous load for performing learning tasks, such as simple- to-complex ordering and fading-guidance strategies, also apply to assessing performance and selecting tasks. Learning facilitators of the program organize learning activities to promote cultural competence learning to be successful from the beginning to the end of the learning process. It comprises nurse trainers, language & cultural facilitators in healthcare, activity processors, and executives and employees in the human resources department. Smith (2017) discussed the facilitator actions that actively positioned teachers as self-directed learners, enabling them to explore the potential learning entangled in learning experiences within an in-service program. All learning experiences within this program were supported by purposeful and considered facilitator actions designed to maintain the program's learning intentions and effectively position teachers as self-directed learners. Therefore, each learning experience cannot be separated from the program's overall philosophical underpinnings; meaningful professional learning is derived through actively positioning teachers as producers of professional knowledge and expertise. Consequently, the facilitator worked to ensure that the learning experiences not only provided teachers with rich opportunities for personally meaningful learning but that these experiences also built teachers' ability to recognize, value, and share their expertise and professional knowledge. The findings of learning cultural competence on registered nurses' attitudes before and after participating in the program revealed that the registered nurses had self-assessment scores at a moderate level. The learning outcomes of cultural competency in knowledge of registered nurses before and after participating in the learning program revealed that the registered nurses had self-assessment scores at a moderate level before participating in the program. Plus, the cultural competency learning outcomes regarding the skills of registered nurses before and after participating in the program revealed that registered nurses had self-assessment scores at a moderate level before participating in the program. Kaihlanen, Hietapakka, and Heponiemi (2019) emphasized that the significance of cultural competence is evident in healthcare quality, and more knowledge is needed about different educational models and approaches that aim to increase cultural competence. The study examines nurses' perceptions about the content and utility of cultural competence training that focuses on raising awareness of one's cultural features. Perceptions about the training were divided into three main categories: the general utility of the training, the personal utility of the training, and the utility of the training for patients. General utility pertains to the general approach to the training provided on cross-cultural care, the possibility to initiate an open discussion, and the opportunity to improve current practices. Personal utility pertains to the opportunity to become aware of one's cultural features, to change one's way of thinking, to obtain a new perspective on one's communication practices, and to receive justification for carrying out particular workable practices. Utility for patients pertains to fostering better awareness and acknowledgment of patients' differing cultural features and increased respect in healthcare delivery. 6. Research Suggestion 6.1. Recommendations Derived from Research The results revealed that a pleasing learning starting point for cultural competency should fully develop learners' learning potential. Hence, the learning facilitator in the organization is responsible for implementing the learning, or even the training department should support the establishment of learning programs that focus on empowering the learners. This is especially true for learners working in a multicultural context. This may give more time to learn for the learners or arrange an area suitable for self-learning. This allows learners to immerse themselves in learning at their own pace in the best possible way. Asian Journal of Education and Training, 2023, 9(4): 98-107 107 © 2023 by the author; licensee Asian Online Journal Publishing Group A self-directed workplace learning program to enhance the cultural competence of registered nurses in international hospitals in Thailand will be significantly strengthened if the power of the three groups is coordinated to drive it together in the hospital organization, namely learning facilitators, nursing groups, and training or learning departments in organizations. Therefore, the roles and responsibilities of these three groups should have time together to consult plans to promote cultural competency learning by making the most of the organization's learning resources. 6.2. Suggestions for Further Research Study A self-directed workplace learning program to enhance the cultural competence of registered nurses should be applied to international organizations in Thailand in various contexts to study the success factors, limitations, or potential obstacles and then used to develop a program to be more specific. Factors influencing cultural competency learning should be studied to use the information to plan and design guidelines for promoting cultural competency learning in the future. References Barnes, J., & Seemiller, C. (2021). Summarizing cultural competence. Cultural competence. Retrieved from https://doi.org/10.4135/9781071869369 Cai, D., Kunaviktikul, W., Klunklin, A., Sripusanapan, A., & Avant, P. (2017). Developing a cultural competence inventory for nurses in China. International Nursing Review, 64(2), 205-214. https://doi.org/10.1111/inr.12350 Campinha-Bacote, J., & Campinha-Bacote, D. (1999). A framework for providing culturally competent health care services in managed care organizations. Journal of Transcultural Nursing, 10(4), 290-291. https://doi.org/10.1177/104365969901000404 Confessore, S. J., & Kops, W. J. (1998). Self‐directed learning and the learning organization: Examining the connection between the individual and the learning environment. Human Resource Development Quarterly, 9(4), 365-375. https://doi.org/10.1002/hrdq.3920090407 Conrad, P., & Barker, K. K. (2010). The social construction of illness: Key insights and policy implications. Journal of Health and Social Behavior, 51(1_suppl), S67-S79. https://doi.org/10.1177/0022146510383495 Hematian, F., Rezaei, A. M., & Mohammadyfar, M. A. (2017). On the effect of goal setting on self-directed learning, achievement motivation, and academic achievement among students. Modern Applied Science, 11(1), 37-47. https://doi.org/10.5539/mas.v11n1p37 Kaihlanen, A.-M., Hietapakka, L., & Heponiemi, T. (2019). Increasing cultural awareness: Qualitative study of nurses’ perceptions about cultural competence training. BioMed Central Nursing, 18(1), 1-9. https://doi.org/10.1186/s12912-019-0363-x Kleinman, M. S. (1978). Hepatitis-associated myopathy. Annals of Internal Medicine, 88(3), 432-432. https://doi.org/10.7326/0003-4819-88-3- 432_1 Leininger, M. (1984). Qualitative research methods: To document and discover nursing knowledge. Western Journal of Nursing Research, 6(2), 151–152. Lemmetty, S., & Collin, K. (2020). Self-direction. In V. P. Glăveanu (Ed.), The Palgrave Encyclopedia of the Possible: Palgrave Macmillan. https://doi.org/10.1007/978-3-319-98390-5_147-1. Mapiam, P. P., & Sriwongsitanon, N. (2009). Estimation of the URBS model parameters for flood estimation of ungauged catchments in the Upper Ping River Basin, Thailand. ScienceAsia, 35(1), 49-56. https://doi.org/10.2306/scienceasia1513-1874.2009.35.049 Matteliano, M. A., & Street, D. (2012). Nurse practitioners’ contributions to cultural competence in primary care settings. Journal of the American Academy of Nurse Practitioners, 24(7), 425-435. https://doi.org/10.1111/j.1745-7599.2012.00701.x Meesuaisint, M., Pathumcharoenwattana, W., & Boonprakob, P. (2018). Characteristics of authentic self-esteem of violent juvenile delinquents in Thailand. The Humanistic Psychologist, 46(2), 175-187. https://doi.org/10.1037/hum0000089 Melkonian, M., & Rolle, B. (2002). Protist turns 100. Protist, 153(1), 1. https://doi.org/10.1078/1434-4610-00076 Merriam, S. B. (2001). Book reviews. Adult Education Quarterly, 51(4), 344–345. Nopas, D.-S., Pathhumcharoenwattana, W., & Ratana-Ubol, A. (2022). The understanding about cultural intelligence of cabin crew from Thailand’s international airlines. Higher Education Studies, 12(2), 84-92. https://doi.org/10.5539/hes.v12n2p84 Pilkington, F. B. (2005). Developing cross-cultural nursing knowledge. Nursing Science Quarterly, 18(4), 286-286. https://doi.org/10.1177/0894318405280343 Ratana-Ubol, A., & Henschke, J. A. (2015). Cultural learning processes through local wisdom: A case study on adult and lifelong lear ning in Thailand. International Journal of Adult Vocational Education and Technology, 6(2), 41-60. https://doi.org/10.4018/ijavet.2015040104 Shi, H., & Witte, M. M. (2018). Self-directed language learning, Asian cultural influences, and the teacher's role. In Emerging self-directed learning strategies in the digital age. In (pp. 109-140): IGI Global. https://doi.org/10.4018/978-1-5225-3465-5.ch006. Smith, K. (2017). Teacher self-directed learning: Further insights. In: Teachers as Self-directed Learners. Self-Study of Teaching and Teacher Education Practices (Vol. 18). Singapore: Springer. Songwathana, P., & Timalsina, R. (2021). Disaster preparedness among nurses of developing countries: An integrative review. International Emergency Nursing, 55, 100955. https://doi.org/10.1016/j.ienj.2020.100955 Toit-Brits, D. C., & Van Zyl, C.-M. (2017). Embedding motivation in the self-directedness of first-year teacher students. South African Journal of Higher Education, 31(1), 50-65. https://doi.org/10.20853/31-1-824 Vidusha, K., & Manjunatha, S. (2015). Awareness of eye donation among medical students of Tertiary Care Hospital, Bangalore. Asian Pacific Journal of Health Sciences, 2(2), 94–98. https://doi.org/10.21276/apjhs.2015.2.2.15 Westbrook, J. I., Duffield, C., Li, L., & Creswick, N. J. (2011). How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals. BioMed Central Health Services Research, 11(1), 1-12. https://doi.org/10.1186/1472-6963-11-319 Whittaker, A., & Chee, H. L. (2015). Perceptions of an ‘international hospital’in Thailand by medical travel patients: Cross -cultural tensions in a transnational space. Social Science & Medicine, 124, 290-297. https://doi.org/10.1016/j.socscimed.2014.10.002 Yoesya, A. P., Nurihsan, J., & Adiwinata, A. H. (2020). Contribution of self-directed learning in maximizing learning outcomes of students in schools. Paper presented at the Proceedings of the International Conference on Educational Psychology and Pedagogy - “Diversity in Education” (ICEPP 2019). Asian Online Journal Publishing Group is not responsible or answerable for any loss, damage or liability, etc. caused in relation to/arising out of the use of the content. Any queries should be directed to the corresponding author of the article. https://doi.org/10.4135/9781071869369 https://doi.org/10.1111/inr.12350 https://doi.org/10.1177/104365969901000404 https://doi.org/10.1002/hrdq.3920090407 https://doi.org/10.1177/0022146510383495 https://doi.org/10.5539/mas.v11n1p37 https://doi.org/10.1186/s12912-019-0363-x https://doi.org/10.7326/0003-4819-88-3-432_1 https://doi.org/10.7326/0003-4819-88-3-432_1 https://doi.org/10.1007/978-3-319-98390-5_147-1 https://doi.org/10.2306/scienceasia1513-1874.2009.35.049 https://doi.org/10.1111/j.1745-7599.2012.00701.x https://doi.org/10.1037/hum0000089 https://doi.org/10.1078/1434-4610-00076 https://doi.org/10.5539/hes.v12n2p84 https://doi.org/10.1177/0894318405280343 https://doi.org/10.4018/ijavet.2015040104 https://doi.org/10.4018/978-1-5225-3465-5.ch006 https://doi.org/10.1016/j.ienj.2020.100955 https://doi.org/10.20853/31-1-824 https://doi.org/10.21276/apjhs.2015.2.2.15 https://doi.org/10.1186/1472-6963-11-319 https://doi.org/10.1016/j.socscimed.2014.10.002