Cultural competence in critical care nurses and its relationships with empathy, job conflict, and work engagement: a cross-sectional descriptive study

Culture can affect most aspects of human life and influence people’s behaviors, beliefs, and values [1]. Iranian society is the cradle of various cultures; local and foreign cultures live there, and it has a rich historical framework that is culturally, linguistically, ethnically, and religiously diverse [2, 3]. In addition, there is a rise in intercultural diversity due to immigration from the two surrounding nations of Iraq and Afghanistan and Iran’s flourishing medical tourism industry [3]. Increased cultural diversity is considered a severe challenge to healthcare systems, and these systems should provide high-quality care to patients with different needs and cultural backgrounds [4]. Nurses, as the largest group of healthcare workers, need to consider patients’ cultures as a component of health-focused care and should be able to communicate effectively with patients from diverse cultures [3]. The study findings from Iranian nurses’ experience caring for patients from other cultures showed that minorities and small cultures were neglected, and hospitalization of such people in hospitals and other clinics was unclear [2].

Iran, with a population of 80 million, is one of the most populous countries in West Asia, and three pillars of Iranian healthcare are the public-governmental system, the commercial sector, and non-governmental groups [5]. The country spent 6.7% of its gross domestic product on health in 2019, and almost 90% of Iranians have health insurance [6]. The Iranian nursing education system is crucial to achieving the objectives of the healthcare system, and in comparison to other developed and developing nations, it does not hold an unsuitable position [7]. Iran’s nursing education includes three programs bachelor, master, and doctoral. There are different nursing master’s fields in Iran, including critical care nursing, medical-surgical nursing, pediatric nursing, psychiatric nursing, neonatal intensive care nursing, community health nursing, military nursing, rehabilitation nursing, geriatric nursing, emergency nursing, nursing management, pediatric critical care nursing [7].

Mobaraki et al. define cultural competence as “a dynamic process that can be generalized and taught that improves over time with more experience and leads to effective communication with people from other cultures” [1]. To care for people of different religions, ethnic groups, countries, and races, we do not need to know each culture’s social practices, dominant beliefs, or rules; instead, in moments of vulnerability and fear, we should treat patients how we want to be treated [8]. A patient-centered approach and exhibiting respect, sensitivity, composure, partnership, honesty, understanding, curiosity, tolerance, and a positive attitude toward them are the keys to developing cultural competence that can improve patient outcomes [8, 9]. The results of previous studies in Iran show that cultural competence is moderate in general nurses [10], weak in undergraduate students [11] and critical care nurses (CCNs) [12].

The CCNs are team workers with the training, experience, and knowledge necessary to provide critical care units and care for patients in complex conditions [13, 14]. American association of colleges of nursing defines “progressive and critical care nursing as a specialty that manages the human responses to actual or potentially life-threatening problems” [13]. Culturally sensitive includes understanding one’s culture, open and sensitive communication, and collaborating strategies with the patient and family [15]. Providing culturally sensitive nursing care is essential; nevertheless, it can be more difficult in the critical care unit than in other clinical settings. It is only possible for CCNs to deliver high-quality care for patients from diverse cultural backgrounds if they can demonstrate some fundamental cultural competence [16]. Here, the patient’s situation is complex and vulnerable, family members are involved, and the nature of the nursing activity calls for a high level of cultural competence [14]. Unawareness of cultural differences can lead to misunderstandings, reduce patient satisfaction, and even result in nursing errors [16].

The World Federation of Critical Care Nurses published a policy paper on culturally sensitive; It emphasized the need for CCNs to have the knowledge, skills, and qualities necessary to provide culturally sensitive care [17]. Nurses’ cultural competence can significantly affect health system efficiency worldwide [3]. Almutairi et al.‘s study showed that nurses’ country of birth might influence their perceptions of cultural competence. Also, this study showed that cultural competence requires exposure to caring for patients from various cultures and countries and is associated with cultural knowledge and awareness [18]. Iran is one of the countries exporting nurses to Anglo-Saxon countries (US, UK, Australia, NZ & Canada) [19]. According to our field observations, since the CCNs in Iran have higher expertise than others, they are more welcome to work in Anglo-Saxon countries. Despite the importance of cultural competence for Iranian CCNs, more is needed to know how to improve it.

Empathy is a crucial component influencing therapeutic relationships and the capability to comprehend the patients’ feelings, worries, and perspectives [20]. The nurse-patient interaction is built on empathy, which is seen as a core ability for medical professionals and is essential for the desired patient outcomes [20, 21]. Stavropoulou et al.‘s study showed that empathy in the critical care unit was perceived as closely related to patients’ outcomes and quality of care [22]. Despite the importance of this issue, the results of Gahaedi et al.‘s study showed that the mean level of empathy in nurses working in ICUs was lower than those in other departments [23]. However, another study in Jordan found that CCNs had high levels of empathy [24]. In Bernhard et al.‘s study, cultural emotions/empathy was recognized as one of the healthcare professionals’ components of cultural competence [25]. Barzykowski et al.‘s study showed that Polish health professionals have a significant relationship between intercultural competence and empathic sensitivity [26]. Also, Sohrabi et al. showed that cultural competence training enhances learners’ empathy in clinical settings [27]. Cultural competence can be the cornerstone of the two sides to build empathy dialogue and are intertwined with empathy and reinforce each other [20]. The previous studies confirmed that nurses’ cultural competence and empathy have a positive correlation [20, 28]. The relationship between cultural competence and empathy in CCNs must be investigated despite this literature.

Conflict on the job is an undesirable dynamic process between parties that arises from perceived disagreements and interference with the parties’ goals and results in adverse emotional reactions [29]. Interpersonal conflict is a common workplace feature for nurses, and conflict among nurses is a persistent problem [29, 30]. The level of conflict between Iranian CCNs has been reported as moderately high [30]. Abd El-Moneim Ahmed and Gaballah’s study showed that more than half of Egyptian CCNs had moderate or high conflict [31]. Conflicts are related to nursing consequences, such as the quality of nursing care [32]. Conflict management is associated with better nurse performance, which could ultimately improve patient care in critical care units [33]. A study showed that intercultural competence was related to conflict resolution strategies [34]. Job conflicts management and promoting cultural competence can effectively improve the quality of care [32, 35, 36]. Based on our hypotheses, job conflict can be a negative factor in promoting cultural competence. Our searches did not find any studies showing the relationship between job conflict and cultural competence, so it seems necessary to determine the relationship between them. Also, It can strengthen the existing literature on cultural competence and be helpful for future studies.

Work engagement is a pleasant, contented mental state associated with vitality, dedication, and absorption. For nurses to be engaged at work, there needs to be both trust and autonomy [37, 38]. Higher stages of personal initiative, lower hospital mortality rates, and much higher financial profitability of organizations can all result from nurses feeling engaged at work [37]. Van Mol et al. demonstrated that work engagement in CCNs was correlated with agreeableness, conscientiousness, and emotional stability; they also showed that work engagement balanced responses to work-related stress [39]. The study’s results by Kim et al. showed that work engagement could raise nursing services’ quality by encouraging nurses to use their full range of competence and expertise [38]. Since work engagement affects the competence of nurses, it may also be related to cultural competence.

According to this literature review and our hypotheses, the current study aimed to determine; (a) the levels of cultural competence, empathy, job conflict, and work engagement; (b) the relationship between cultural competence, demographic information, and main variables; (c) the predictors of cultural competence in CCNs.

A multicenter, descriptive cross-sectional study was conducted from August to October 2022.

The study settings were 14 critical care units, including eight ICUs, four CCUs, and two dialysis wards selected from three educational hospitals affiliated with Lorestan University of Medical Sciences, Khorramabad, Iran. Khorramabad is the capital of Lorestan province, located in the southwest of Iran.

Critical care units are a subset of ICUs, CCUs, and dialysis wards in Iranian hospitals’ organizational charts. Nursing students complete critical care courses in these settings, per the nursing curricula. Most of the CCNs in Iran have a bachelor’s degree [40].

Participants comprised nurses working in critical care units. The following criteria were required for inclusion: nurses with a bachelor’s degree or higher who were employed in the critical care units and have at least six months of work experience there. An exclusion criterion was unwilling to participate in the study, failing to respond to at least one of the five questionnaires.

Based on a related study, the Pearson correlation coefficient between cultural competence and empathy was calculated at r = 0.3 [20]; the sample size was computed using the following formula (n = 102). The final sample size was 153 people after multiplying this number by 1.5 to account for the design impact and specifying a power of 90%, α = 0.05, β = 0.1, Z (1-α / 2) = 1.96, and Z (1-β) = 1.28.

A convenience sampling technique was used to select the participants. A total of 197 CCNs met the inclusion criteria. Sampling was stopped when we reached the calculated sample size.

The research tool comprised five questionnaires, including demographic data, cultural competence, empathy, job conflict, and work engagement. Demographic data included age, gender, marital status, academic degree, and length of work experience.

To develop a native theoretical model of cultural competence, Mobaraki et al. (2019) conducted qualitative research using the grounded theory approach. The initial tool was designed after a qualitative study and searching similar studies. Then, the tool validity was assessed by evaluating the face and content validity and performing surveys and psychometrics. Finally, the data were statistically analyzed through exploratory factor analysis. The tool’s dimensions were based on the theoretical model, and the initial items were then extracted. The final 25-item questionnaire was developed for the Iranian population in five areas of theoretical and practical learning, clinical application, cultural skill, cultural excellence, and cultural competence. A five-point Likert scale was used for scoring (1 = rarely, 5 = almost always). These categories for the score range from 93 to 100 (very strong), 81–92 (strong), 80 − 64 (moderate), 44–63 (weak), and 20–43 (very weak). This questionnaire has a Cronbach’s alpha coefficient of 0.91 and an ICC of 0.93 [1].

This 20-item scale of empathy for healthcare professionals has been psychometrically validated. A seven-point Likert scale was used for scoring (totally disagree = 1, totally agree = 7). The maximum and minimum scores were 20 and 140, respectively. Higher scores indicate more empathetic care behaviors with the patients. The Persian version of this scale has good face and content validity, Cronbach’s alpha coefficient is 0.83, and its ICC is 0.82 [41].

This scale consists of 20 questions with two options (totally disagree = 0, totally agree = 1) and mainly scored on positive and negative responses. The ratings ranged from 0 to 20, respectively. The score categorization would be designed as 15–20 (high), 4–14 (moderate), and 0–3 (low). Hosseini et al. (2012) validated it for the Iranian population. This scale’s Cronbach’s alpha coefficient is 0.95 [42].

This scale consists of 17 items, and scoring was done using a five-point Likert scale (1 = rarely, 5 = almost always). The scores ranged from zero to 102, respectively. Higher scores indicate a higher level of work engagement. Torabinia et al. (2017) validated the Persian version to measure work engagement in Iranian nurses and other medical professionals. This scale’s Cronbach’s alpha coefficient is 0.84, and the ICC is 0.91 [43].

Following approval from the Semnan and Lorestan University of Medical Sciences, the data were collected using paper self-report questionnaires. The researcher briefed the nurses on the purposes of the study and what was covered in the questionnaires. The participants who agreed to participate in the study provided written consent. Afterward, the questionnaires were distributed to the participants.

Data on the general characteristics and responses of the participants related to cultural competence, empathy, job conflict, and work engagement were summarized using descriptive statistics. Mean comparison techniques were used to assess the variations in cultural competence according to the participant’s demographic variables. The Spearman (i.e., ordinal scale or non-normally distributed variables), Pearson (i.e., normally and linear distributed variables) correlation tests, intragroup correlation coefficient, and linear regression analyses were used to assess the study hypotheses in the inferential section. Before performing the regression analysis, we confirmed that our data satisfied the basic regression assumptions, such as homogeneity of variance and multi-collinearity. We utilized imputation for the missing data (mean substitution). The alpha error level was set to a maximum of 0.05. In order to analyze the data, IBM SPSS Statistics 22.0 was used [44].