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. 2026 Sep 25;23(4):e70080. doi: 10.1111/jjns.70080

Institutional Support and Educator Workload in Global Nursing Education: A Cross‐National Comparative Study

Congcong Wang 1,2, Akiko Kondo 1,✉, Kazuko Naruse 2, Kosuke Niitsu 3, Dingyi Long 1
PMCID: PMC13615164  PMID: 42791487

ABSTRACT

Aim

To examine and compare global nursing education content, institutional support, and workload‐related factors among nurse educators in Japan and China. “Global nursing education” refers to educational interventions that enable nursing students to develop the knowledge, skills, practical experience, and cultural competence needed to provide high‐quality care across diverse cultural, social, and healthcare contexts.

Methods

A cross‐sectional international comparative study was conducted using an online survey between October and December 2023. Nurse educators from 587 universities in Japan and China were invited to participate. Data from 445 educators with experience in global nursing education were analyzed. Hierarchical linear regression analyses were performed to examine factors associated with workload in each country.

Results

Educators in Japan delivered a broader range of global nursing education content, whereas Chinese universities provided greater institutional support for educators. Educators in Japan reported higher workloads; however, these differences were largely explained by non‐native language use and proficiency, intercultural sensitivity, and institutional support. In Japan, higher intercultural sensitivity, broader global nursing content coverage, and greater perceived institutional support were associated with lower workload, with notable regional variations. In China, more frequent use of non‐native languages and employment in western regions were associated with lower workload.

Conclusion

Determinants of workload in global nursing education differed across national contexts. Institutional support, intercultural sensitivity, and non‐native language‐related factors were associated with workload, although the specific patterns varied by country. These findings highlight the importance of considering national and regional contexts when supporting nurse educators involved in global nursing education.

Keywords: China, globalization, Japan, nursing education, nursing faculty, workload

1. Introduction

As globalization advances, healthcare systems are facing increasing cultural diversity and complexity. Educational institutions have responded by internationalizing their curricula (Li 2021). Nursing education plays a key role in preparing students with cultural competence and cross‐cultural communication skills (Gradellini et al. 2021).“Global nursing education” refers to educational interventions that enable nursing students to develop the knowledge, skills, practical experience, and cultural competence needed to provide high‐quality care across diverse cultural, social, and healthcare contexts, which could be provided by offline or online courses, exchange programs, clinical placements, and other international learning (Kondo et al. 2024). Nurse educators across many countries have implemented global nursing education, resulting in positive student outcomes, such as more adaptive attitudes toward culturally diverse patients and improved cultural intelligence and global health competence (Galan‐Lominchar et al. 2024; Heiberg et al. 2019; Lee et al. 2020; Tosun and Sinan 2020).

Japan has promoted various initiatives to internationalize education. For example, in 2014, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) launched the Top Global University Project to develop globally competent human resources (MEXT, n.d.). Although non‐Japanese residents constitute less than 3% of the population (Statistics Bureau of Japan 2024), 50% of hospitals serve foreign patients (Ministry of Health, Labour and Welfare 2022), indicating a growing need for culturally competent healthcare. Currently, 82.9% of nursing schools offer global nursing‐related subjects (Nagamine et al. 2024), and improvements in intercultural sensitivity among nursing students have been reported (Hua et al. 2023). Kondo et al. (2025) identified factors related to global nursing education among nursing educators, including intercultural interactions, intercultural sensitivity, job title, and overseas experience. Although previous studies have examined aspects of global nursing education, limited research has explored institutional support, and regional differences have not been investigated.

In China, the internationalization of higher education has been strongly promoted, with active efforts to support outbound student mobility and attract international students (Yang 2020), positioning China as a major contributor to global student mobility (Education Fair 2022). Increasingly, nurses are also seeking employment abroad, accounting for 2.4% of foreign‐trained nurses in Australia and 2.8% in Canada (Organization for Economic Co‐operation and Development [OECD] 2023), although they face challenges such as language barriers (Zhong et al. 2023). To address international demands, some universities have established joint nursing education programs with foreign institutions to cultivate nurses with international perspectives and competencies (JAMK University of Applied Sciences 2025; Ju et al. 2025). In addition, English‐medium instruction programs have been introduced in nursing education to enhance students' international competencies (Liang et al. 2025). Despite these developments, limited evidence is available regarding the content of global nursing education, institutional support, and the workload of educators involved.

“Workload in global nursing education among nurse educators” refers to the time, tasks, responsibilities, and expectations placed on nurse educators, both directly and indirectly, as they teach and support nursing students in global nursing, multicultural nursing, and related education (Cotter and Clukey 2019; Kondo et al. 2024). Educator workload has been associated with stress, burnout, engagement, intention to leave, teaching quality, and student outcomes (e.g., academic performance, learning experience, and student engagement) (Kanwal et al. 2023). In Japan, although many nursing universities promote international exchanges, organizational support remains limited, resulting in workload being concentrated among a small number of educators (Chiba University Graduate School of Nursing 2021). In China, internationalizing faculty teams has become an important strategy in nursing education, with institutions recruiting faculty with overseas experience and providing international training opportunities to enhance global competencies (Ju et al. 2025). Kondo et al. (2024) reported that nurse educators in Japan experienced higher teaching burdens than those in four English‐speaking countries and that higher intercultural sensitivity was associated with lower workload. However, this study was limited to top universities with a small sample size, and the relationship between institutional support and workload remains unclear. To our knowledge, no previous study has comprehensively examined educators' workload in global nursing education across countries.

Improving global education is critical for preparing students to collaborate and deliver patient‐centered care across cultures. However, in both Japan and China, limited research has systematically examined the structure and content of global nursing education, institutional support, and factors associated with educators' workload. In addition, both countries exhibit regional disparities in education (Araki 2025; Ling et al. 2022), yet it remains unclear whether such disparities exist in global nursing education.

Therefore, this study aimed to explore and compare Japan and China in terms of (1) the content of global nursing education, (2) institutional support for global nursing education, and (3) factors associated with workload in global nursing education among nurse educators. In addition, regional differences within each country were examined.

2. Methods

2.1. Design

This cross‐sectional international comparative study adhered to the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

2.2. Study Setting and Sampling

We invited nurse educators from 284 nursing universities in Japan (Nursing University NAVI, n.d.) and 303 universities in mainland China (University List—Nursing, n.d.). Eligible participants were those affiliated with nursing‐related departments in universities in Japan or mainland China and holding national nursing qualifications. Participants without experience in teaching global nursing or related fields were excluded.

The required sample size was calculated using G*Power (version 3.1). For linear multiple regression analysis with a medium effect size (f 2 = 0.15) (Cohen 1992), a statistical power of 0.80, and a significance level of 0.05, the required sample sizes were as follows: 146 participants for 17 predictors, 135 participants for 14 predictors, and 98 participants for six predictors.

2.3. Data Collection

Data were collected in Japan and China between October and December 2023. We identified 12,161 nurse educators (10,199 in Japan and 1962 in China) from university websites. Invitation emails were sent to 5097 available email addresses (3475 in Japan and 1622 in China) (Figure 1). The invitation email included information about the study, a link to the online survey and an informed consent form. Data were collected using Google Forms (Google LLC, Mountain View, CA, USA) for participants in Japan and Tencent Survey (Tencent Holdings Ltd., Shenzhen, China) for participants in China.

FIGURE 1.

FIGURE 1

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Selection diagram of nursing universities and participants.

2.4. Instrument and Variables

The survey consisted of five components: (1) institutional factors; (2) demographics and other factors potentially related to workload in global nursing education; (3) content of global nursing education; (4) institutional support for global nursing education; and (5) educator workload in global nursing education. The initial survey draft was developed based on a literature review and discussions among the research team, which included Japanese nurse educators with experience in global nursing education, two international graduate students who had completed undergraduate nursing education in China, and a faculty member in the United States with experience in international education. To ensure content validity, the survey was reviewed by external experts from Japan and China with experience in global nursing education. Their feedback was used to refine the survey items and improve cultural relevance and clarity. The revised survey was subsequently re‐evaluated by the same experts, and further modifications were made based on their feedback. Finally, the survey was pilot‐tested with a small group of nurse educators to assess clarity and feasibility, and minor adjustments were made accordingly.

2.4.1. Potential Factors Associated With the Workload in Global Nursing Education

Potential variables were identified based on previous studies on workload, global nursing education, and intercultural competence (Arian et al. 2018; Badanapurkar et al. 2024; H. Chen and Hu 2023; Kaya et al. 2021; Nagamine et al. 2024; Rodríguez‐Izquierdo 2022), and further refined through discussions among the research team. The variables included the following (see Table 1, Supporting Information Table S1): (1) institutional factors (8 items); (2‐a) demographic factors (8 items); (2‐b) foreign experience‐related factors (5 items); (2‐c) non‐native language‐related factors (3 items); (2‐d) cross‐cultural interpersonal factors (3 items); (2‐e) global nursing education factors (6 items); and (2‐f) intercultural sensitivity, measured using the Intercultural Sensitivity Scale (ISS) developed by G. Chen and Starosta (2000) (Chen and Starosta 2000).

TABLE 1.

Institutional, demographic, and other factors (N = 445, Japan = 328, China = 117).

Factors Japan China Sig. Test statistics a Effect size b Test
n (%)/Mean ± SD (Median) n (%)/Mean ± SD (Median)
Institutional University type < 0.001 74.31 0.41 χ
Private 150 (45.7) 2 (1.7)
National/Public 178 (54.3) 115 (98.3)
Location
Hokkaido/Tohoku 37 (11.3)
Kanto 99 (30.2)
Hokuriku/Tokai 69 (21.0)
Kinki 53 (16.2)
Chugoku/Shikoku 29 (8.8)
Kyushu/Okinawa 39 (11.9)
East 57 (48.7)
Middle 30 (25.6)
West 19 (16.2)
Northeast 11 (9.4)
Missing 2 (0.6) 0 (0.0)
Nursing courses in non‐native languages, (Yes) 112 (34.1) 104 (88.9) < 0.001 103.46 0.48 χ
International nursing students, (Yes) 133 (40.5) 68 (58.1) 0.001 10.59 0.15 χ
Foreign nurse educators, (Yes) 95 (29.0) 57 (48.7) < 0.001 14.80 0.18 χ
Non‐native language courses, (Yes) 322 (98.2) 115 (98.3) 0.893 0.02 0.01 χ
Number of supports 5.1 ± 3.6 (4.0) 6.6 ± 4.3 (5.0) 0.001 3.27, 1.50 [0.60–2.40] 0.39 I
Sufficiency of institutional support (1: Strongly disagree with sufficiency ~5: Strongly agree) 2.4 ± 1.0 (2.0) 3.3 ± 1.0 (3.0) < 0.001 7.61, 0.82 [0.61–1.04] 0.84 I
Demographic Age < 0.001 −5.84 (242.2, 165.7) 0.28 M
30 or below 3 (0.9) 1 (0.9)
31–40 37 (11.3) 31 (26.5)
41–50 111 (33.8) 54 (46.2)
51–60 122 (37.2) 30 (25.6)
61 or above 53 (16.2) 1 (0.9)
Missing 2 (0.6) 0 (0.0)
Gender 0.012 6.38 0.12 χ
Man 49 (14.9) 7 (6.0)
Woman 277 (84.5) 110 (94.0)
Missing 2 (0.6) 0 (0.0)
Education level < 0.001 −3.76 (233.8, 190.5) 0.18 M
Diploma 1 (0.3) 0 (0.0)
Associate degree 3 (0.9) 1 (0.9)
Bachelor 2 (0.6) 15 (12.8)
Master 93 (28.4) 38 (32.5)
PhD 229 (69.8) 62 (53.0)
Missing 0 (0.0) 1 (0.9)
Home country < 0.001 417.36 0.97 χ
China 5 (1.5) 117 (100.0)
Japan 319 (97.3) 0 (0.0)
Korea 1 (0.3) 0 (0.0)
Missing 3 (0.9) 0 (0.0)
Job title 0.736 −0.34 (217.4, 221.9) 0.02 M
Assistant 5 (1.5) 0 (0.0)
Assistant Professor 65 (19.8) 3 (2.6)
Lecturer 45 (13.7) 20 (17.1)
Associate Professor 79 (24.1) 57 (48.7)
Professor 134 (40.9) 28 (23.9)
Missing 0 (0.0) 9 (7.7)
Work status < 0.001 37.93 0.29 χ
Part time 2 (0.6) 16 (13.7)
Full time 326 (99.4) 101 (86.3)
Years of working as a full‐time nurse educator 14.5 ± 8.2 (14.0) 13.3 ± 9.7 (13.0) 0.127 −1.52 (228.5, 207.5) 0.07 M
Incomes (10,000 US dollars) 5.1 ± 1.4 (5.1) 3.6 ± 2.2 (3.1) < 0.001 −7.65 (207.6, 109.6) 0.36 M
Foreign experience‐related Foreign education degree, (Yes) 38 (11.6) 18 (15.4) 0.287 1.13 0.05 χ
Number of foreign countries worked in 0.047 −1.99 (217.8, 237.5) 0.09 M
None 266 (81.1) 84 (71.8)
One 44 (13.4) 25 (21.4)
Two 5 (1.5) 7 (6.0)
Three 3 (0.9) 0 (0.0)
More than three 10 (3.0) 1 (0.9)
Number of countries visited (0: Never ~7: More than 50) 2.2 ± 1.2 (2.0) 1.3 ± 0.8 (1.0) < 0.001 −8.17 (251.3, 143.7) 0.39 M
Duration spent abroad 0.559 0.34 0.03 χ
Less than 1 year 226 (68.9) 84 (71.8)
1 year or more 102 (31.1) 33 (28.2)
Purpose of going abroad, (Yes)
Tourism/Travel 285 (86.9) 55 (47.0) < 0.001 72.81 0.41 χ
Academic conference 201 (61.3) 57 (48.7) 0.028 4.81 0.10 χ
Visit family members, friends, or others 109 (33.2) 9 (7.7) < 0.001 28.12 0.25 χ
Volunteer work 49 (14.9) 1 (0.9) < 0.001 16.83 0.19 χ
Study/research/training 191 (58.2) 93 (79.5) < 0.001 18.96 0.21 χ
Internship 17 (5.2) 5 (4.3) 0.723 0.13 0.02 χ
Live with family members, friends, or others 21 (6.4) 2 (1.7) 0.052 3.76 0.09 χ
Competition 2 (0.6) 2 (1.7) 0.271 1.21 0.05 χ
Asylum seeker or refugee 1 (0.3) 0 (0.0) 0.553 0.35 0.03 χ
Non‐native language‐related Number of non‐native languages utilized < 0.001 −3.91 (211.0, 256.8) 0.19 M
None 74 (22.6) 0 (0.0)
One 197 (60.1) 93 (79.5)
Two 45 (13.7) 22 (18.8)
Three 8 (2.4) 2 (1.7)
More than three 4 (1.2) 0 (0.0)
Non‐native language ability (1: Very poor‐ 5: Very good) 2.5 ± 1.1 (3.0) 3.4 ± 0.7 (3.0) < 0.001 −8.11 (194.7, 302.2) 0.38 M
Frequency of non‐native language use (0: Never ~7: Every day) 3.7 ± 2.0 (3.0) 4.7 ± 1.8 (5.0) < 0.001 −4.64 (206.3, 269.8) 0.22 M
Cross‐cultural interpersonal Number of cross‐cultural friends 0.378 −0.88 (225.9, 214.7) 0.04 M
0 53 (16.2) 11 (9.4)
1–5 159 (48.5) 75 (64.1)
6–10 43 (13.1) 18 (15.4)
More than 10 73 (22.3) 13 (11.1)
Frequency of participation in cross‐cultural exchanges (0: Never ~7: Every day) 2.4 ± 1.7 (2.0) 1.7 ± 1.0 (2.0) < 0.001 −3.35 (234.6, 190.4) 0.16 M
Family members with foreign experience, (Yes) 117 (35.7) 40 (34.2) 0.770 0.09 0.01 χ
Global nursing education Number of contents teaching in global nursing 5.0 ± 3.6 (4.0) 4.1 ± 3.5 (3.0) 0.016 −2.43, −0.97 [−1.76 to −0.19] 0.27 I
Sufficiency of global nursing education (1: Strongly disagree with sufficiency ~5: Strongly agree) 2.4 ± 0.9 (2.0) 3.3 ± 1.1 (3.0) < 0.001 7.82, 0.92 [0.69–1.15] 0.94 I
Teaching in non‐native language, (Yes) 42 (12.8) 56 (47.9) < 0.001 68.56 0.40 χ
Providing cross‐cultural chance, (Yes) 269 (82.0) 83 (70.9) 0.104 2.64 0.08 χ
Providing study abroad, (Yes) 223 (68.0) 58 (49.6) 0.003 9.07 0.14 χ
Required courses 0.550 1.20 0.05 χ
Optional courses 182 (55.5) 56 (47.9)
Some courses are required, while others are optional 82 (25.0) 33 (28.2)
Required courses 54 (16.5) 20 (17.1)
Missing 10 (3.0) 8 (6.8)
ISS Total score 87.3 ± 10.7 (87.0) 93.6 ± 9.1 (92.0) < 0.001 5.73, 6.34 [4.16–8.51] 0.62 I
I: Interaction Engagement 26.6 ± 3.1 (27.0) 27.9 ± 2.7 (27.0) < 0.001 4.01, 1.29 [0.66–1.92] 0.43 I
II: Respect for Cultural Differences 25.0 ± 2.8 (25.0) 24.8 ± 2.8 (25.0) 0.541 −0.61, −0.18 [−0.77–0.41] 0.07 I
III: Interaction Confidence 14.5 ± 4.7 (15.0) 17.5 ± 3.3 (18.0) < 0.001 7.45, 2.97 [2.19–3.76] 0.69 I
IV: Interaction Enjoyment 11.1 ± 2.3 (11.0) 12.0 ± 2.1 (12.0) < 0.001 4.18, 0.95 [0.50–1.40] 0.43 I
V: Interaction Attentiveness 10.1 ± 1.7 (10.0) 11.4 ± 1.5 (11.0) < 0.001 7.29, 1.30 [0.95–1.66] 0.79 I
Workload 1: Strongly disagree with a heavy workload ~5: Strongly agree 2.8 ± 1.0 (3.0) 2.5 ± 0.8 (2.0) 0.004 −2.92, −0.32 [−0.54 to −0.10] 0.32 I
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Abbreviations: χ, Chi‐square test; I, Independent t‐test; ISS, Intercultural Sensitivity Scale; M, Mann–Whitney U‐test.

a

Z (Japan mean rank, China mean rank)/χ2/t, mean difference[95.0% CI].

b

r/Cramer's V/Cohen's d.

The ISS consists of 24 items rated on a 5‐point Likert scale (1 = strongly disagree to 5 = strongly agree). Total scores range from 24 to 120, with higher scores indicating greater intercultural sensitivity. The internal consistency of the scale has been demonstrated in different contexts, including the original American version (Cronbach's α = 0.86) (G. Chen and Starosta 2000), the Japanese version (Cronbach's α = 0.84) (Kuwano et al. 2016), and the Chinese version (Cronbach's α = 0.85) (Wang et al. 2025). Written permission for the use and translation of the scale was obtained from the original developer and the translator.

2.4.2. Content of Global Nursing Education

The content of global nursing education was categorized into 11 areas (see Table 2, Supporting Information Table S1) based on previous studies (Gradellini et al. 2021; Ministry of Health, Labour and Welfare 2020; Nagamine et al. 2024; Torres‐Alzate et al. 2020; World Health Organization [WHO], n.d.; Yamada et al. 2022) and discussions among the research team and external experts in Japan and China. These categories were developed to reflect key domains of global nursing education and to capture the breadth of educational content delivered across institutions.

TABLE 2.

Comparisons between Japan and China & among regions.

Global nursing education contents, (Yes) Japan VS. China Japan China
n = 314 n = 109 Comparisons among regions (n = 312) Cramer's V‡ Comparisons among regions (n = 109) Cramer's V‡
Japan, n(%) China, n (%) Cramer's V† J1, n (%) J2, n (%) J3, n (%) J4, n (%) J5, n (%) J6, n (%) C1, n (%) C2, n (%) C3, n (%) C4, n (%)
1. The content of the current global health situation (e.g., globalization, global health goals, primary health care, global nursing and healthcare, the involvement of international health/medical organizations such as the World Health Organization, non‐governmental organizations) 183 (58.3) 58 (53.2) 0.04 16 (48.5) 63 (65.6) 39 (59.1) 30 (56.6) 17 (58.6) 17 (48.6) 0.12 29 (52.7) 13 (44.8) 10 (55.6) 6 (85.7) 0.19
2. Taking into consideration the roles and contributions of nursing in the international society to understand the characteristics of healthcare/medical care/welfare in your country 170 (54.1) 43 (39.4) 0.13* 19 (57.6) 49 (51.0) 36 (54.5) 32 (60.4) 16 (55.2) 17 (48.6) 0.08 25 (45.5) 11 (37.9) 6 (33.3) 1 (14.3) 0.17
3. Social and environmental determinants of health (e.g., Sustainable Development Goals) 167 (53.2) 41 (37.6) 0.14* 21 (63.6) 50 (52.1) 31 (47.0) 32 (60.4) 14 (48.3) 18 (51.4) 0.11 18 (32.7) 14 (48.3) 6 (33.3) 3 (42.9) 0.14
4. Nursing adapted to the characteristics of various settings (e.g., culturally sensitive nursing, assessing the cultural backgrounds of countries and individuals, understanding the necessary skills to support individuals from diverse cultural backgrounds, considering the needs of people as nursing objectives from an international perspective) 165 (52.5) 38 (34.9) 0.15* 15 (45.5) 55 (57.3) 34 (51.5) 30 (56.6) 16 (55.2) 14 (40.0) 0.12 17 (30.9) 11 (37.9) 7 (38.9) 3 (42.9) 0.09
5. Basic knowledge about culture (e.g., beliefs and values pertaining to people's health, ethnocentrism and cultural relativism, cultural perspectives, cultural diversity/multicultural coexistence) 150 (47.8) 34 (31.2) 0.15* 13 (39.4) 49 (51.0) 28 (42.4) 25 (47.2) 17 (58.6) 17 (48.6) 0.11 13 (23.6) 13 (44.8) 6 (33.3) 2 (28.6) 0.19
6. The interaction between human rights and health (e.g., health equity, social justice, ethics) 145 (46.2) 26 (23.9) 0.20** 13 (39.4) 48 (50.0) 25 (37.9) 29 (54.7) 14 (48.3) 15 (42.9) 0.12 13 (23.6) 6 (20.7) 6 (33.3) 1 (14.3) 0.11
7. Cross‐cultural adaptation (e.g., cultural awareness and sensitivity, cultural skills, engaging with individuals from diverse ethnic backgrounds) 137 (43.6) 32 (29.4) 0.13* 15 (45.5) 38 (39.6) 26 (39.4) 27 (50.9) 16 (55.2) 14 (40.0) 0.11 14 (25.5) 10 (34.5) 6 (33.3) 2 (28.6) 0.09
8. Nursing for populations in low‐resource countries (e.g., healthcare in low‐resource settings, professional practice, and leadership, management, advocacy) 99 (31.5) 20 (18.3) 0.13* 3 (9.1) 32 (33.3) 20 (30.3) 20 (37.7) 13 (44.8) 10 (28.6) 0.19* 12 (21.8) 5 (17.2) 2 (11.1) 1 (14.3) 0.10
9. The challenges and issues of global health (e.g., human security, the global burden of disease, the health implications of pandemics, displacement (a situation that forces relocation), wars, disasters, migration, travel, and refugees) 151 (48.1) 61 (56.0) 0.07 11 (33.3) 50 (52.1) 31 (47.0) 29 (54.7) 15 (51.7) 14 (40.0) 0.13 29 (52.7) 15 (51.7) 11 (61.1) 6 (85.7) 0.17
10. Professional development for global health nurses (e.g., understanding nursing roles and responsibilities, identifying healthcare needs in foreign countries, and promoting international cooperation. It involves collaboration, partnership, communication, developing sociocultural and political awareness) 103 (32.8) 48 (44.0) 0.10* 8 (24.2) 37 (38.5) 25 (37.9) 17 (32.1) 11 (37.9) 14 (40.0) 0.10 22 (40.0) 10 (34.5) 7 (38.9) 3 (42.9) 0.05
11. Teaching to adapt to globalization (e.g., fostering the establishment of global/international nursing specialties, introducing new methods and technologies in nursing practices from various countries and regions) 112 (35.7) 42 (38.5) 0.03 7 (21.2) 34 (35.4) 19 (28.8) 23 (43.4) 8 (27.6) 12 (34.3) 0.14 21 (38.2) 15 (51.7) 8 (44.4) 4 (57.1) 0.13
Institutional support contents, (Yes) n = 326 n = 112 Cramer's V† Comparisons among regions (n = 324) Cramer's V‡ Comparisons among regions (n = 111) Cramer's V‡
Japan, n(%) China, n (%) J1, n (%) J2, n (%) J3, n (%) J4, n (%) J5, n (%) J6, n (%) C1, n (%) C2, n (%) C3, n (%) C4, n (%)
1. Opportunities for contact with people from other countries 194 (59.5) 50 (45.0) 0.13* 18 (48.6) 66 (67.3) 45 (66.2) 28 (52.8) 12 (41.4) 23 (59.0) 0.18 27 (49.1) 11 (37.9) 10 (52.6) 2 (25.0) 0.16
2. Having subjects for training abroad 177 (54.3) 45 (40.5) 0.12* 8 (21.6) 66 (67.3) 40 (58.8) 33 (62.3) 11 (37.9) 17 (43.6) 0.30** 21 (38.2) 12 (41.4) 9 (47.4) 3 (37.5) 0.07
3. Encouraging and supporting teachers and students to participate in international academic conference exchanges, short‐term and long‐term exchange programs abroad, as well as the publication of academic papers in international academic journals and other international activities 161 (49.4) 53 (47.7) 0.01 17 (45.9) 47 (48.0) 35 (51.5) 30 (56.6) 13 (44.8) 17 (43.6) 0.08 25 (45.5) 14 (48.3) 10 (52.6) 4 (50.0) 0.05
4. Credit recognition system for students studying abroad 128 (39.3) 20 (18.0) 0.20** 11 (29.7) 40 (40.8) 34 (50.0) 23 (43.4) 10 (34.5) 10 (25.6) 0.16 11 (20.0) 4 (13.8) 4 (21.1) 1 (12.5) 0.08
5. Financial assistance for students studying abroad 126 (38.7) 35 (31.5) 0.06 15 (40.5) 45 (45.9) 28 (41.2) 18 (34.0) 9 (31.0) 10 (25.6) 0.14 16 (29.1) 11 (37.9) 6 (31.6) 2 (25.0) 0.09
6. Promotion of exchange programs with foreign universities 176 (54.0) 77 (69.4) 0.14* 16 (43.2) 57 (58.2) 37 (54.4) 27 (50.9) 14 (48.3) 23 (59.0) 0.10 39 (70.9) 17 (58.6) 14 (73.7) 7 (87.5) 0.17
7. Training abroad program for faculty members 61 (18.7) 66 (59.5) 0.39** 7 (18.9) 16 (16.3) 15 (22.1) 13 (24.5) 4 (13.8) 6 (15.4) 0.09 36 (65.5) 17 (58.6) 10 (52.6) 3 (37.5) 0.16
8. Implementation of international seminars at the university 128 (39.3) 55 (49.5) 0.09 9 (24.3) 47 (48.0) 27 (39.7) 23 (43.4) 12 (41.4) 10 (25.6) 0.18 31 (56.4) 12 (41.4) 10 (52.6) 2 (25.0) 0.18
9. Having specialized subjects in multicultural education 78 (23.9) 52 (46.8) 0.20** 8 (21.6) 22 (22.4) 16 (23.5) 20 (37.7) 2 (6.9) 9 (23.1) 0.18 23 (41.8) 15 (51.7) 7 (36.8) 5 (62.5) 0.14
10. Increase the number of global nursing‐related subjects in the past 5 years 38 (11.7) 52 (46.8) 0.38** 2 (5.4) 15 (15.3) 9 (13.2) 6 (11.3) 4 (13.8) 2 (5.1) 0.12 24 (43.6) 13 (44.8) 11 (57.9) 4 (50.0) 0.11
11. Efforts to implement multiple languages teaching 66 (20.2) 47 (42.3) 0.22** 3 (8.1) 22 (22.4) 21 (30.9) 11 (20.8) 3 (10.3) 6 (15.4) 0.18 20 (36.4) 14 (48.3) 8 (42.1) 5 (62.5) 0.15
12. Having faculty members with different cultural backgrounds 110 (33.7) 44 (39.6) 0.05 6 (16.2) 42 (42.9) 23 (33.8) 22 (41.5) 7 (24.1) 9 (23.1) 0.20* 18 (32.7) 15 (51.7) 9 (47.4) 2 (25.0) 0.19
13. Financial assistance for faculty members training abroad 56 (17.2) 39 (35.1) 0.19** 8 (21.6) 17 (17.3) 11 (16.2) 9 (17.0) 5 (17.2) 6 (15.4) 0.04 20 (36.4) 11 (37.9) 5 (26.3) 3 (37.5) 0.09
14. Recruit international students to study and integrate into the campus culture 96 (29.4) 34 (30.6) 0.01 11 (29.7) 34 (34.7) 21 (30.9) 15 (28.3) 7 (24.1) 7 (17.9) 0.11 15 (27.3) 8 (27.6) 10 (52.6) 1 (12.5) 0.23
15. Increase credits of global nursing‐related subjects in the past 5 years 36 (11.0) 31 (27.9) 0.20** 0 (0.0) 18 (18.4) 8 (11.8) 4 (7.5) 3 (10.3) 3 (7.7) 0.18* 15 (27.3) 6 (20.7) 5 (26.3) 5 (62.5) 0.22
16. Establish a performance evaluation and rewards system for nursing educators in global nursing or multicultural nursing or related education 20 (6.1) 21 (18.9) 0.19** 1 (2.7) 6 (6.1) 5 (7.4) 2 (3.8) 2 (6.9) 3 (7.7) 0.07 10 (18.2) 5 (17.2) 3 (15.8) 3 (37.5) 0.13
17. Utilization of people from other countries as simulated patients 16 (4.9) 13 (11.7) 0.12* 1 (2.7) 10 (10.2) 1 (1.5) 3 (5.7) 0 (0.0) 1 (2.6) 0.18 5 (9.1) 4 (13.8) 3 (15.8) 1 (12.5) 0.08
Japan, n (%) China, n (%) Cramer's V†
Factors among regions, [Mean ± SD(Median)] η 2 (H)§ Factors among regions, [Mean ± SD(Median)] η 2 (H)§
J1 J2 J3 J4 J5 J6 C1 C2 C3 C4
Workload (1 ~ 5) 2.5 ± 1.0 (3.0) 2.7 ± 1.1 (3.0) 3.1 ± 1.0 (3.0) 2.7 ± 1.0 (3.0) 2.5 ± 1.0 (2.5) 3.2 ± 1.0 (3.0) 0.03* 2.7 ± 0.8 (3.0) 2.5 ± 0.8 (3.0) 2.2 ± 0.8 (2.0) 2.1 ± 0.9 (2.0) 0.04
Number of supports (0 ~ 17) 3.8 ± 3.1 (3.0) 5.8 ± 3.7 (5.0) 5.5 ± 3.4 (5.0) 5.4 ± 3.8 (4.0) 4.1 ± 4.0 (3.0) 4.2 ± 3.2 (2.0) 0.04* 6.5 ± 4.2 (5.0) 6.6 ± 4.1 (6.0) 7.1 ± 5.1 (4.0) 6.8 ± 5.1 (5.0) 0.00
Number of contents teaching in global nursing (0 ~ 11) 4.3 ± 2.8 (4.0) 5.3 ± 3.7 (4.0) 4.8 ± 3.7 (3.0) 5.5 ± 3.8 (6.0) 5.4 ± 4.0 (4.0) 4.6 ± 3.5 (4.0) 0.00 3.9 ± 3.6 (3.0) 4.2 ± 3.5 (3.0) 4.2 ± 3.3 (3.5) 4.6 ± 3.4 (3.0) 0.00
Correlations, (ρ) J1 J2 J3 J4 J5 J6 C1 C2 C3 C4
Workload‐Number of supports 0.36 0.03 0.59 0.10 0.65 0.66 0.25 0.84 0.08 0.50 0.59 0.43
Workload‐Number of contents teaching in global nursing −0.20 −0.13 −0.05 −0.11 −0.20 −0.24 −0.33 −0.30 −0.08 −0.12 0.05 −0.54
Number of supports‐Number of contents teaching in global nursing 0.27** 0.21* 0.46** 0.28** 0.35** 0.23 0.23 0.20 0.20 0.12 0.20 0.66
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Note: *p < 0.05, **p < 0.001. † Pearson chi‐square test, ‡ Fisher's exact test, § Kruskal–Wallis test, ¶ Spearman's rho. J1:Hokkaido/Tohoku, J2:Kanto, J3:Hokuriku/Tokai, J4:Kinki, J5:Chugoku/Shikoku, J6:Kyushu/Okinawa, C1:East, C2:Middle, C3:West, C4:Northeast.

2.4.3. Content of Institutional Support for Global Nursing Education

Due to the limited availability of existing literature, the content of institutional support for global nursing education was categorized into 17 areas (see Table 2, Supporting Information Table S1) based on iterative discussions among the research team, as well as input from international students involved in global nursing education. These categories were developed to reflect common institutional practices and support mechanisms that facilitate the implementation of global nursing education across different contexts.

2.4.4. Workload in Global Nursing Education

Because quantifying the workload of nurse educators—particularly indirect or less visible efforts—is challenging (Cotter and Clukey 2019), objective measures such as actual working hours or number of courses taught were not used. Instead, perceived workload was assessed using a single‐item measure: “Do you think you have a heavy workload in global nursing, multicultural nursing, or related education?” Responses were rated on a 5‐point Likert scale (1 = strongly disagree, 5 = strongly agree), with higher scores indicating greater perceived workload.

2.5. Data Analysis

All statistical analyses were conducted using SPSS version 27 (IBM Corp., Armonk, NY, USA), with the significance level set at p < 0.05. Missing data were treated as missing and excluded from analyses as appropriate. The distribution of workload scores was assessed using skewness and kurtosis (within ±2) and Q‐Q plots, indicating approximate normality.

Comparisons of university and participant characteristics, workload, and factors associated with workload between Japan and China (N = 445; Figure 1, Table 1) were conducted using the Mann–Whitney U test for ordinal or non‐normally distributed continuous variables, independent t‐tests for normally distributed continuous variables, and chi‐square tests for nominal variables.

Further analyses compared global nursing education (N = 423), institutional support (N = 437), and workload between countries and across regions within each country (Table 2). For nominal variables, chi‐square tests were used for between‐country comparisons, and Fisher's exact tests were used for regional comparisons due to small sample sizes. For continuous variables, the Kruskal–Wallis test was used for regional comparisons. Associations between continuous variables were examined using Spearman's rho.

Univariate analyses were conducted to identify factors associated with workload (Supporting Information Table B). Independent t‐tests were used for binary variables, one‐way analysis of variance for variables with three or more groups, and Spearman's rho for ordinal or continuous variables. Variables with p < 0.05 were entered into linear regression models (Tables 3, 4).

TABLE 3.

Factors related to workload in the linear regression model (combined data, N = 426).

Model 1 Demographic factors Model 2 Add foreign experience‐related factors Model 3 Add cross‐cultural interpersonal factors Model 4 Add global nursing education factor Model 5 Add non‐native language‐related factors Model 6 Add ISS Model 7 Add institutional factors
Predictors B (95% Confidence Interval) VIF
Japan (ref. China) 0.30 (0.03–0.58)* 0.35 (0.07–0.63)* 0.39 (0.11–0.67)** 0.39 (0.11–0.68)** 0.22 (−0.10–0.55) 0.12 (−0.19–0.44) 0.02 (−0.31–0.34) 1.98
Age −0.11 (−0.24–0.03) −0.07 (−0.21–0.06) −0.08 (−0.21–0.06) −0.04 (−0.18–0.09) −0.05 (−0.18–0.08) −0.06 (−0.19–0.07) −0.07 (−0.20–0.06) 1.43
Education level −0.04 (−0.22–0.14) −0.01 (−0.19–0.17) 0.00 (−0.18–0.18) 0.00 (−0.18–0.18) 0.04 (−0.15–0.23) 0.01 (−0.17–0.20) 0.00 (−0.17–0.18) 1.33
Incomes 0.01 (−0.07–0.08) 0.00 (−0.07–0.08) 0.01 (−0.07–0.09) 0.01 (−0.07–0.09) 0.01 (−0.07–0.09) 0.02 (−0.06–0.09) 0.04 (−0.04–0.11) 1.72
Number of foreign countries worked in −0.17 (−0.34–0.01) −0.15 (−0.32–0.02) −0.12 (−0.29–0.05) −0.08 (−0.26–0.09) −0.07 (−0.24–0.10) −0.06 (−0.23–0.11) 1.53
Number of countries visited −0.07 (−0.19–0.05) −0.05 (−0.17–0.07) −0.04 (−0.16–0.08) −0.05 (−0.17–0.07) −0.04 (−0.16–0.07) −0.05 (−0.16–0.07) 1.87
Stay abroad of 1 year or more (ref. less than 1 year) −0.04 (−0.32–0.24) 0.06 (−0.24–0.37) 0.09 (−0.22–0.39) 0.18 (−0.14–0.49) 0.20 (−0.10–0.50) 0.23 (−0.07–0.52) 1.87
Number of cross‐cultural friends 0.00 (−0.16–0.16) 0.01 (−0.14–0.17) 0.07 (−0.09–0.23) 0.12 (−0.04–0.28) 0.12 (−0.04–0.28) 2.17
Frequency of participation in cross‐cultural exchanges −0.08 (−0.16–0.00)* −0.07 (−0.15–0.01) −0.04 (−0.13–0.06) −0.03 (−0.11–0.06) −0.04 (−0.12–0.05) 1.98
Family members with foreign experience (ref. without) −0.17 (−0.41–0.06) −0.18 (−0.41–0.05) −0.20 (−0.43–0.04) −0.16 (−0.38–0.07) −0.18 (−0.40–0.05) 1.14
Number of contents teaching in global nursing −0.04 (−0.07 to −0.01)* −0.04 (−0.07 to −0.01)* −0.03 (−0.06–0.00) −0.04 (−0.07–0.00)* 1.33
Number of non‐native languages utilized −0.15 (−0.34–0.03) −0.10 (−0.28–0.08) −0.09 (−0.26–0.09) 1.54
Non‐native language ability −0.12 (−0.27–0.02) −0.03 (−0.17–0.12) −0.02 (−0.17–0.13) 2.43
Frequency of non‐native language use 0.00 (−0.07–0.07) 0.00 (−0.07–0.07) 0.00 (−0.07–0.06) 1.76
ISS −0.03 (−0.04 to −0.02)*** −0.03 (−0.04 to −0.02)*** 1.65
Number of supports 0.02 (−0.01–0.05) 1.19
Sufficiency of institutional support −0.17 (−0.27 to −0.06)** 1.24
R 2 0.019 0.050 0.072 0.089 0.110 0.171 0.198
Adjusted R 2 0.008 0.030 0.044 0.058 0.071 0.132 0.155
△Adjusted R 2 0.022 0.014 0.014 0.013 0.061 0.022
F 1.639 2.481* 2.546** 2.891** 2.837*** 4.419*** 4.621***
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Note: *p < 0.05, **p < 0.01, ***p < 0.001, ref.: reference, ISS: Intercultural Sensitivity Scale, VIF: variance inflation factor (model 7), Durbin‐Watson ratio (model 7) = 1.979.

TABLE 4.

Factors associated with workload in Japan and China (N = 426).

Countries Predictors B 95.0% CI for B β Sig. R 2 VIF
Lower Upper
Japan (n = 316) Age −0.017 −0.171 0.137 −0.015 0.831 0.015 1.466
Incomes −0.003 −0.108 0.101 −0.005 0.948 0.008 1.522
Number of foreign countries worked in −0.022 −0.219 0.175 −0.017 0.824 0.026 1.765
Number of countries visited −0.060 −0.187 0.067 −0.069 0.352 0.005 1.718
Stay abroad of 1 year or more (ref. less than 1 year) 0.331 −0.032 0.695 0.145 0.074 0.000 2.056
Number of non‐native languages utilized −0.149 −0.351 0.052 −0.109 0.145 0.025 1.744
Non‐native language ability 0.016 −0.145 0.177 0.017 0.842 0.004 2.254
Number of cross‐cultural friends 0.118 −0.057 0.294 0.112 0.185 0.001 2.237
Frequency of participation in cross‐cultural exchanges −0.024 −0.111 0.064 −0.039 0.594 0.004 1.694
Family members with foreign experience (ref. without) −0.193 −0.452 0.066 −0.088 0.144 0.012 1.140
ISS −0.033 −0.049 −0.018 −0.327 < 0.001 0.082 1.769
Number of contents teaching in global nursing −0.042 −0.080 −0.004 −0.144 0.030 0.013 1.362
Location (ref. Kyushu/Okinawa) 0.043
Hokkaido/Tohoku −0.699 −1.191 −0.207 −0.207 0.006 1.721
Hokuriku/Tokai −0.087 −0.511 0.338 −0.033 0.688 2.181
Kanto −0.317 −0.727 0.093 −0.135 0.129 2.486
Kinki −0.300 −0.748 0.148 −0.107 0.189 2.079
Chugoku/Shikoku −0.626 −1.170 −0.081 −0.163 0.024 1.627
Sufficiency of institutional support −0.172 −0.297 −0.048 −0.164 0.007 0.024 1.139
Countries Predictors B 95.0% CI for B β Sig. R 2 VIF
Lower Upper
China (n = 110) Education level −0.006 −0.240 0.227 −0.006 0.958 0.045 1.474
Non‐native language ability −0.037 −0.275 0.200 −0.032 0.755 0.034 1.427
Frequency of non‐native language use −0.143 −0.238 −0.048 −0.316 0.003 0.069 1.524
ISS −0.017 −0.034 0.000 −0.182 0.057 0.023 1.224
Location (ref. East) 0.073
Middle −0.319 −0.676 0.037 −0.168 0.079 1.227
West −0.645 −1.059 −0.230 −0.294 0.003 1.250
Northeast −0.444 −1.006 0.117 −0.139 0.120 1.082
Number of supports −0.019 −0.054 0.016 −0.100 0.279 0.012 1.167
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Note: Linear regression analysis (enter): Adjusted R 2  = 0.205, F = 4.592 (p < 0.001), Durbin‐Watson ratio = 2.028. Linear regression analysis (enter): Adjusted R 2  = 0.213, F = 4.648 (p < 0.001), Durbin‐Watson ratio = 2.000.

Abbreviations: ISS, Intercultural Sensitivity Scale; ref., reference; VIF, variance inflation factor.

Because university identifiers were not collected for ethical reasons, a composite variable was constructed using institutional characteristics (location, type, non‐native language courses, international students, foreign educators, and global nursing programs) to approximate clustering. This variable was used to define level‐2 units in exploratory multilevel models. The intraclass correlation coefficients (ICCs) were as follows: Japan, ICC(1) = 0.006 and ICC(2) = 0.018; China, ICC(1) = 0.000 and ICC(2) = 0.000. ICC(1) represents the proportion of variance attributable to between‐group differences and was calculated as the ratio of between‐group variance to total variance. ICC(2) represents the reliability of group‐level means and was calculated based on ICC(1) and the average group size. These ICC values were very low, indicating minimal clustering effects and poor group‐level reliability (Koo and Li 2016). Therefore, multilevel modeling was considered inappropriate for the present study.

Hierarchical regression analyses were first conducted to compare workload between Japan and China by sequentially entering demographic, foreign experience‐related, cross‐cultural interpersonal, global nursing education, non‐native language‐related, intercultural sensitivity, and institutional factors, based on the social‐ecological model (Abuliezi et al. 2022; CDC, n.d.; Scarneo et al. 2019; UNICEF, n.d.). Subsequently, separate linear regression analyses were conducted for Japan and China.

Finally, a bootstrap sensitivity analysis with 1000 resamples was conducted. Model robustness was evaluated by comparing bootstrap and original 95% confidence intervals; coefficients were considered stable when bootstrap confidence intervals did not cross zero and were consistent with the original estimates.

2.6. Ethical Considerations

This study was approved by the Ethics Review Committee of the Institute of Education at Institute of Science Tokyo (former Tokyo Medical and Dental University) (Approval No. C2023–30). Informed consent was obtained from all participants at the beginning of the online survey. Participation was voluntary and anonymous. Participants who completed the survey and provided their email addresses received small incentives as a token of appreciation for participation (1000 yen in Japan or 50 yuan in China; approximately USD 6.8–6.9). To ensure anonymity, email addresses were collected separately from the survey responses. Among 61 survey items, while 39 items were set as required questions, 22 items, including age, gender, and income, were not to improve response rates and protect participants' privacy (see Supporting Information Table S1).

3. Results

A total of 1240 nurse educators (1026 from Japan and 214 from China) participated in the survey, yielding an overall response rate of 24.3% (29.5% in Japan and 13.2% in China). For the analysis, 445 nurse educators (328 from Japan and 117 from China) who reported experience in teaching global nursing or related fields were included (Figure 1).

3.1. Data Assessment

In Japan, the age distribution of the respondents was comparable to national data (e.g., 51–60 years: 35.4% vs. 33.4%) (Japan Association of Nursing Programs at Universities and Japan Association of Private Universities of Nursing 2021), with no significant difference (χ 2, p = 0.146), suggesting that the sample was broadly representative. In China, although national‐level comparison data were not available, no significant regional differences in response rate were observed (χ 2, p = 0.130), indicating relatively balanced participation across regions.

3.2. Characteristics of Participants' Universities

Compared with Japan, a higher proportion of educators in China were affiliated with national or public universities (p < 0.001). Universities in China were also more likely to offer nursing courses in non‐native languages (p < 0.001), enroll international nursing students (p = 0.001), and employ foreign nurse educators (p < 0.001). In addition, universities in China provided greater institutional support (p = 0.001), and educators in China were more likely to perceive institutional support as sufficient (p < 0.001) (Table 1).

3.3. Characteristics of Participants

Table 1 presents the demographic characteristics and other factors potentially associated with workload in global nursing education. Educators in Japan were older (p < 0.001), had higher educational levels (p < 0.001), and reported higher incomes (p < 0.001). A higher proportion of educators in China were women (p = 0.012) and part‐time workers (p < 0.001). All participants in China were nationals, whereas six educators (1.8%) in Japan reported their home country as China or South Korea (p < 0.001).

Educators in Japan had visited a greater number of foreign countries (p < 0.001) and more experience abroad for tourism/travel (p < 0.001), academic conferences (p = 0.028), visiting family members, friends, or others (p < 0.001), and volunteer work (p < 0.001). In contrast, educators in China had worked in more countries (p = 0.047) and more experience with study/research/training abroad (p < 0.001).

Educators in China reported using a greater number of non‐native languages (p < 0.001), higher levels of non‐native language proficiency (p < 0.001), and more frequent use of non‐native languages (p < 0.001). Educators in Japan participated more frequently in cross‐cultural exchanges (p < 0.001).

Educators in Japan taught a greater number of global nursing contents (p = 0.016), and a higher proportion provided study abroad programs for students (p = 0.003). A higher proportion of educators in China taught in non‐native languages (p < 0.001) and perceived their universities' global nursing education as sufficient (p < 0.001).

Total ISS score (p < 0.001), as well as subscale scores for interaction engagement (p < 0.001), interaction confidence (p < 0.001), interaction enjoyment (p < 0.001), and interaction attentiveness (p < 0.001), were significantly higher among educators in China. Finally, the mean workload score was higher among educators in Japan (2.8) than among those in China (2.5) (p = 0.004).

3.4. Comparison of Global Nursing Education

Among the 11 categories, seven were taught significantly more frequently in Japan than in China (p < 0.05; Table 2). In Japan, content emphasizing global health perspectives was more commonly delivered, including “2. taking into consideration the roles and contributions of nursing in the international society to understand the characteristics of healthcare/medical care/welfare in your country” (p < 0.05), “3. social and environmental determinants of health” (p < 0.05), “6. the interaction between human rights and health” (p < 0.001), and “8. nursing for populations in low‐resource countries” (p < 0.05).

Cross‐cultural nursing topics were also more frequently covered in Japan, including “4. nursing adapted to the characteristics of various settings”, “5. basic knowledge about culture”, and “7. cross‐cultural adaptation” (all p < 0.05).

In contrast, “10. professional development for global health nurses” (p < 0.05) was taught more frequently in China. Across both countries, more than 50% of educators reported that they taught “1. the content of the current global health situation”.

Regarding regional differences, in Japan, the proportion of educators teaching “8. nursing for populations in low‐resource countries” differed significantly across regions (p < 0.05). No significant regional differences were observed in China.

3.5. Comparison of Institutional Support

Among the 17 categories of institutional support, nine were provided significantly more frequently by universities in China (p < 0.05; Table 2). Universities in Japan tended to focus on student‐oriented opportunities, including “1. opportunities for contact with people from other countries” (p < 0.05), “2. having subjects for training abroad” (p < 0.05), and “4. credit recognition system for students studying abroad” (p < 0.001).

In contrast, universities in China more frequently emphasized faculty development, including “7. training abroad program for faculty members”, “13. financial assistance for faculty members training abroad”, and “16. establish a performance evaluation and rewards system for nursing educators in global nursing or multicultural nursing, or related education” (all p < 0.001).

Curriculum‐related support was also more commonly reported in China, including “9. having specialized subjects in multicultural education” (p < 0.001), “10. increase the number of global nursing‐related subjects in the past five years” (p < 0.001), “11. efforts to implement multiple languages teaching” (p < 0.001), “15. increase credits for global nursing‐related subjects in the past five years” (p < 0.001), and “17. utilization of people from other countries as simulated patients” (p < 0.05).

Furthermore, “6. promotion of exchange programs with foreign universities” was more commonly reported in China (p < 0.05), and more than 50% of educators in both countries reported its implementation.

Regarding regional differences, in Japan, the overall level of institutional support for global nursing education differed significantly across regions (p < 0.05). Significant regional differences were also observed for “2. Having subjects for training abroad” (p < 0.001), “12. Having faculty members with different cultural backgrounds” (p < 0.05), and “15. Increasing credits of global nursing‐related subjects in the past five years” (p < 0.05). No significant regional differences were observed in China.

3.6. Comparison of Factors Related to Workload

A total of 426 participants (95.7%), including 316 of 328 educators in Japan (96.3%) and 110 of 117 educators in China (94.0%), provided responses on workload. In univariate analyses, 17 variables were significantly associated with workload in either Japan (14 variables) or China (6 variables) (Supporting Information Table S1).

Table 3 presents the results of hierarchical linear regression analyses including “country (Japan or China).” In Model 1, educators in Japan had significantly higher workload scores than those in China (B = 0.30, p < 0.05). After sequential adjustment for foreign experience‐related factors (Model 2: B = 0.35, p < 0.05) and cross‐cultural interpersonal factors (Model 3: B = 0.39, p < 0.01), the regression coefficient (B) increased. However, after adjustment for non‐native language‐related factors (Model 5), the difference was no longer statistically significant. As additional variables were entered in Models 5–7, including non‐native language‐related factors (B = 0.22), intercultural sensitivity (B = 0.12), and institutional factors (B = 0.02), the regression coefficient (B) progressively decreased.

Table 4 shows the results of separate linear regression analyses for Japan and China. In Japan, higher intercultural sensitivity (ISS total score: β = −0.327, p < 0.001), a greater number of global nursing contents taught (β = −0.144, p = 0.030), and higher perceived sufficiency of institutional support (β = −0.164, p = 0.007) were associated with lower workload. Compared with educators in the Kyushu/Okinawa region, those in the Hokkaido/Tohoku (β = −0.207, p = 0.006) and Chugoku/Shikoku (β = −0.163, p = 0.024) regions reported lower workload. In China, more frequent use of non‐native languages (β = −0.316, p = 0.003) was associated with lower workload. Compared with educators in the eastern region, those in the western region (β = −0.294, p = 0.003) reported lower workload.

4. Discussion

This study contributes to the literature by providing cross‐national and regional evidence on global nursing education among nurse educators in Japan and China, offering insights for developing global nursing education systems while maintaining a sustainable educator workload.

This study demonstrated notable differences between the two countries. Educators in Japan reported delivering a broader range of global nursing education content, whereas universities in China provided greater institutional support. Regional disparities in global nursing education content and institutional support were observed in Japan but not in China. In Japan, higher intercultural sensitivity, broader global nursing education content coverage, and greater perceived sufficiency of institutional support were associated with lower workload. In China, more frequent use of non‐native languages was associated with lower workload. In both countries, workload varied across geographical regions.

4.1. Global Nursing Education

Although a higher proportion of nurse educators in China reported teaching global nursing courses, those in Japan covered a broader range of content. Japanese nursing education places greater emphasis on topics such as human rights, social determinants of health, and cross‐cultural adaptation, reflecting a more holistic approach to global health (Ministry of Health, Labour and Welfare, n.d.). The inclusion of nursing for populations in low‐resource countries may also reflect Japan's role as a developed country contributing to global health through international cooperation initiatives, such as those supported by the Japan International Cooperation Agency (Japan International Cooperation Agency, n.d.).

In contrast, Chinese nursing education focuses on professional development for global health nurses, reflecting the country's emphasis on specialized skills and internationality (Ma et al. 2021). In addition, challenges faced by nurses in China, including heavy workloads, job burnout, and relatively low financial rewards (Gao et al. 2025; Zhang et al. 2021), may contribute to intentions to seek employment abroad. This context may help explain the emphasis on language proficiency and practical competencies in preparing students for international nursing practice.

Across both countries, the overall number of global nursing education contents did not differ significantly across regions, suggesting limited regional variation. However, in Japan, the content “nursing for populations in low‐resource countries” showed notable regional differences, being least frequently taught in Hokkaido/Tohoku (9.1%) and most frequently in Chugoku/Shikoku (44.8%). These differences may reflect regional characteristics, particularly the presence of long‐standing international collaborations between universities in the Chugoku/Shikoku region and developing countries (Hiroshima University, n.d.; Okayama University, n.d.).

4.2. Support From University

Universities in China appeared to provide more comprehensive institutional support, which can be reflected in higher perceived sufficiency among educators. Forms of support, including multilingual instruction, faculty development, and performance evaluation systems, suggest a more strategic and system‐level approach to strengthening nursing faculty capacity (Ju et al. 2025), consistent with broader national efforts to promote the internationalization of higher education (Yang 2020).

In contrast, universities in Japan tended to emphasize specific forms of support, such as opportunities for interaction with people from other countries and study abroad programs. These initiatives reflect Japan's emphasis on international exchange (MEXT, n.d.) and align with broader trends in developed countries to integrate cultural perspectives into educational systems to promote multicultural coexistence (Yang 2020). This pattern suggests that Japanese institutions may prioritize direct cross‐cultural engagement as a key strategy in global nursing education.

In China, no significant regional differences in institutional support were observed, which may reflect the influence of centralized national policies and standardized higher education systems that limit regional variation (Ministry of Education of the People's Republic of China 2022). In contrast, the present study found that institutional support in Japan varied significantly across regions. Metropolitan areas, such as the Kanto region, reported higher levels of support, including the availability of study abroad programs, international faculty, and increased credits for global nursing‐related courses. These differences may reflect the concentration of international resources, partnerships, and foreign residents in urban areas (Immigration Services Agency of Japan 2024; Statistics Bureau of Japan 2024).

4.3. Workload and Related Factors

This study identified notable differences in perceived workload and its associated factors between nurse educators in Japan and China. However, after adjustment for non‐native language‐related, intercultural sensitivity, and institutional factors, the between‐country difference in workload was no longer statistically significant, suggesting that these individual and institutional factors largely accounted for the observed disparities. Educators in China reported greater use and proficiency in non‐native languages, higher intercultural sensitivity, and stronger institutional support, which may contribute to lower perceived workload. Exposure to global environments may enhance intercultural competence and teaching efficiency, thereby facilitating global nursing education and reducing perceived burden.

In Japan, regional differences in workload suggest the influence of multiple contextual factors. Educators in Kyushu/Okinawa reported higher workload, which may be related to increased demands for global responsiveness. For example, in Okinawa, 31% of non‐Japanese residents requested hospital translation services (Okinawa Prefecture 2024). Although the proportion of non‐Japanese residents in Okinawa (1.4%) is lower than the national average (2.7%) (Statistics Bureau of Japan 2024), Okinawa receives a large number of international visitors (Okinawa Prefecture 2025a) and hosts substantial U.S. military communities (Okinawa Prefecture 2025b). These demographic characteristics may increase the overall demand for multilingual and culturally responsive healthcare services. In contrast, educators in Hokkaido/Tohoku reported both lower institutional support and lighter workload, possibly reflecting fewer internationalized educational activities, such as study abroad programs and culturally diverse faculty. This interpretation is consistent with the present findings, which showed that the amount of global nursing content taught was associated with institutional support in this region. In addition, a lower proportion of foreign residents (Kanto: 3.8% vs. Hokkaido/Tohoku: 1.1%) may reduce the demand for global nursing education (Immigration Services Agency of Japan 2024; Statistics Bureau of Japan 2024).

The negative association between intercultural sensitivity and workload is consistent with previous findings indicating that higher intercultural sensitivity is associated with reduced work‐related strain (Badanapurkar et al. 2024). The negative association between the breadth of global nursing content taught and workload may suggest that educators with greater competence (e.g., higher intercultural sensitivity and broader cross‐cultural experience) are able to manage diverse content more efficiently. Alternatively, educators with greater experience in global nursing may perceive lower workload despite covering a wider range of content. This interpretation is supported by the correlation patterns observed in the present study, where associations between the amount of content taught and workload were generally negative, although not statistically significant. The observed negative association between workload and perceived sufficiency of institutional support further highlights the importance of organizational support in alleviating educators' burden, particularly in Japan.

In China, workload was negatively associated with the frequency of non‐native language use, suggesting that frequent engagement in multilingual environments may facilitate the delivery of global nursing education and reduce perceived workload. Compared with Japan, Chinese universities more frequently offer courses in non‐native languages and have greater exposure to international students and foreign faculty, which may reflect better‐integrated international programs and create a more supportive environment for global nursing education. This association may also reflect higher baseline competence among educators in China, as the present study found greater use of non‐native languages and higher levels of non‐native language proficiency. Regional variation was also observed in China, with lower workload in western regions. This finding is consistent with previous research suggesting higher workload in eastern regions where international engagement and population density are greater (Ling et al. 2022).

4.4. Implications

The findings from Japan and China provide important implications for nursing education systems seeking to expand global nursing education while maintaining sustainable educator workloads. In high‐income or nurse‐destination contexts such as Japan—where educators delivered a broader range of global nursing content yet reported higher workload in several regions—administrators should strengthen institutional support systems for global nursing education. Enhancing structured faculty development, expanding opportunities for international engagement, and allocating protected time for curriculum development may help reduce educator burden while maintaining program quality. Given that higher intercultural sensitivity was associated with lower perceived workload, nursing school leadership may also consider promoting cross‐cultural training and international exchange opportunities to enhance educators' readiness and efficiency. In addition, future efforts may be needed to strengthen institutional support and expand international collaboration opportunities in less‐urbanized regions, including increased access to international partnerships, online global learning programs, faculty development initiatives, and governmental support for resource sharing across universities.

In rapidly internationalizing or nurse‐source contexts—such as the Chinese settings in this study—where structured faculty development and institutional support are more prominent, administrators may continue leveraging multilingual environments and international collaboration to sustain educator effectiveness. Expanding curricula to include global health, human rights, and multicultural nursing, and integrating these elements into institutional and national educational frameworks, may further strengthen students' global competencies and prepare the workforce for international mobility. The observed association between frequent non‐native language use and lower workload suggests that program directors could promote multilingual instruction and intercultural learning opportunities to enhance educators' confidence and reduce the burden associated with global nursing education.

Across both contexts, addressing workload‐related challenges requires context‐sensitive institutional strategies. Strengthening institutional support structures, recognizing educators' contributions to global nursing education, and fostering intercultural competence among faculty may help promote educator well‐being and enhance the capacity of nursing education programs. In addition, mutual learning across different educational contexts may further support the sustainable development of global nursing education.

4.5. Limitations and Further Research

This study has several limitations. First, the cross‐sectional design precludes causal inferences between variables. Future research should adopt longitudinal designs to assess causal relationships and further examine workload in global nursing education. Second, although multiple participants may have been affiliated with the same university, university identifiers were not collected to protect participants' privacy. ICC analyses indicated minimal clustering effects; therefore, multilevel modeling was not applied. Future studies should consider collecting anonymized institutional identifiers to enable more rigorous multilevel analyses.

Third, the response rate was low, particularly in China, and self‐selection bias may have influenced the sample, as individuals with greater interest in intercultural or global nursing education may have been more likely to participate. The particularly low response rate in China may also have increased the risk of non‐response bias, which could have resulted in higher ISS scores among Chinese participants compared with those in Japan. Therefore, the generalizability of the findings is limited. Moreover, although small incentives were provided (1000 yen in Japan and 50 yuan in China), these amounts represented less than 0.3% of the average monthly income in each country, suggesting that their influence on participation was likely minimal. Future comparative studies should also include a broader range of countries and regions to further examine the influence of educational, cultural, and institutional contexts on global nursing education.

Finally, workload was assessed using a single subjective self‐reported item. Future studies should develop more objective and quantifiable measures of educator workload, such as teaching hours, time spent on global nursing education activities, supervision of international students, coordination of international programs, and overseas training or exchange activities.

5. Conclusions

Educators in Japan covered a broader range of global nursing education content. Universities in China provided stronger institutional support for global nursing education. In Japan, higher workload was associated with lower intercultural sensitivity and narrower content coverage in global nursing education, whereas in China, more frequent use of non‐native languages was associated with lower perceived workload. Regional differences in global nursing education and institutional support were observed in Japan but not in China.

These findings underscore the central role of institutional structures and educator preparation in sustaining global nursing education across diverse contexts. Strengthening institutional support and intercultural competence may help support educators' capacity and reduce workload in high‐income or nurse‐destination settings. In rapidly internationalizing or nurse‐source contexts, expanding global health–related curricula and promoting multilingual collaboration may further support effective global nursing education. Overall, aligning institutional support, faculty development, and non‐native language‐related initiatives with educators' needs may contribute to the sustainable development of global nursing education.

Author Contributions

Congcong Wang: study design, data collection, data analysis, manuscript writing, critical revisions for important intellectual content. Akiko Kondo: study design, data analysis, study supervision, manuscript writing, critical revisions for important intellectual content, obtaining research funding. Kazuko Naruse: study design, critical revisions for important intellectual content. Kosuke Niitsu: study design, critical revisions for important intellectual content. Dingyi Long: data collection. All authors read and approved the final manuscript.

Funding

This work was supported by the Japan Society for the Promotion of Science (22K10627).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Table A: Factors/Questions. Table B: Factors associated with workload (N = 426).

JJNS-23-e70080-s001.xlsx (24.9KB, xlsx)

Acknowledgments

The authors thank former professor Chieri Yamada at Fukushima Medical University and Associate Professor Jingjing Wang at Zhengzhou University for serving as external experts in reviewing the survey instrument. During the preparation of this study, we used Copilot and ChatGPT to improve the readability and language of the manuscript. After using these tools/services, the authors reviewed and edited the content as required and took full responsibility for the content of the published article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Data S1: Table A: Factors/Questions. Table B: Factors associated with workload (N = 426).

JJNS-23-e70080-s001.xlsx (24.9KB, xlsx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Articles from Japan Journal of Nursing Science are provided here courtesy of Wiley

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