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Abstract

Introduction:

Cultural diversity among nurses in the Kingdom of Saudi Arabia poses problems in communication management to ensure optimal patient care. This study explored and described the perceptions of communication among nurses in a culturally diverse workforce.

Methodology:

A qualitative approach was used; a sample of seventeen (n=17) nurses was purposively selected. Data obtained from semi-structured interviews were analyzed using Braun and Clarke’s six steps of thematic qualitative analysis.

Results:

Key themes were (1) nurses’ perceptions of communication in a culturally diverse workforce, (2) barriers to communication in a culturally diverse workforce, and (3) facilitators of effective communication in a culturally diverse workforce.

Discussion:

Nurses have recognized the importance of communicating in a culturally diverse environment to provide optimal care. Strategies such as cultural competence training, open communication forums, and mentorship programs are recommended to improve cross-cultural understanding and collaboration in care teams.

Keywords

Communication cultural diversity nurse managers nurses Saudi Arabia

Introduction

Nurses play a critical role in healthcare facilities’ overall performance, contributing significantly to the overall wellness of the patient, health promotion, patient education, and patient satisfaction (Hughes, 2018). Nursing and communication are intricately linked, forming a critical aspect of every aspect of patient-centered care. Effective communication in nursing is essential for building professional relationships with patients and collaborating within the nursing teams, and thus ensuring the delivery of optimal patient care (Kourkouta & Papathanasiou, 2014).

Nursing in Saudi Arabia has historically been viewed as a less prestigious career that faces a variety of challenges influenced by cultural perceptions, stigma, educational barriers, public perception, and recognition (Almalki et al., 2011). However, the increasing cultural diversity in these healthcare settings, with a workforce comprising a large percentage (70%) of nurses from countries such as India, the Philippines, Malaysia, and other nations, is a testament to the value and integral role of each individual in the healthcare system. This diversity presents unique challenges for effective communication among nurses, but it also enriches the healthcare environment (Almutairi et al., 2015; Alsufyani et al., 2021). The hospitals face challenges requiring a more detailed understanding of communication dynamics among a multinational workforce, with an explicit focus on nurses’ communication (Horvath & Molnar, 2021).

Cultural diversity can add value to nursing by contributing different work experiences, perspectives, and skills. However, cultural diversity may also contribute to misinterpretation, misunderstanding, and conflict among the nursing teams and patients due to the distinct cultural perspectives in communication (Almutairi et al., 2017). Non-native nurses often face obstacles in adjusting to Saudi culture, particularly in understanding Islamic beliefs and morals. These cultural and religious aspects are not just incidental, but integral to nursing care in Saudi Arabia. The focus on the psychosocial and spiritual needs of the patient and family, rather than on integrity, accountability, honesty, and confidentiality, underscores the importance of this cultural and religious understanding (Lovering, 2012). According to Woldemichael (2021), communication becomes intense in a culturally diverse environment and is a source of conflict. The information shared may need to be better understood, thus leaving one of the parties feeling negative or not valued. How nurses from different cultures manage conflict is different; conflict resolution can vary across cultures. Certain cultures may prefer direct countermeasures, while others may value indirect or peaceful conflict resolution (Ahmed et al., 2021). These dissimilarities can lead to predicaments in resolving conflicts among nurses (Aljuaid & Alkarani, 2023).

In culturally diverse environments, nurses face unique challenges that extend beyond clinical expertise and need to acquire cultural competency and sensitivity in communication. Cultural sensitivity or awareness deficiency may result in disrespect or misunderstanding of nurses’ values, beliefs, and work rules (Almutairi et al., 2015).

A lack of respect or misunderstanding among nurses can negatively impact professional collaboration. Understanding communication complexity within a culturally diverse work environment is essential for fostering collaborative nursing teams and improving patient care. Miscommunication and misunderstandings among nurses can lead to errors in treatment, compromised patient safety, and diminished overall healthcare quality. Understanding the cultural contexts that shape communication is thus crucial for mitigating these risks within a multi-national workforce (Brunton & Cook, 2018).

A multinational nursing workforce has different problem-solving dimensions, such as approach-avoidance, personal control levels, and perception of problems, and is for essential effective communication. Effective communication is needed to coordinate problem-solving Aririguzoh (2022). While diverse problem-solving skills can be supplemental, they may also cause problems in reaching an agreement due to different values, beliefs, and communication styles, influencing their problem-solving methods. Cultural practices control different communication styles, such as direct versus indirect communication, high context versus low context communication, and non-verbal communication. Awareness of these differences can result in team dynamics, quality patient care, and work efficiency (Falatah et al., 2022). Non-verbal gestures during interaction among the nurses, such as body language, eye contact, and facial gestures, can have different meanings in diverse cultures (Scotta, 2018). Misapprehension of these gestures may cause ambiguity and poor communication in the team (Xiao et al., 2013).

Multinational nurses from countries where English is not the primary language often need help speaking and understanding English. Despite this, English is a common language for communication among the nursing workforces. Switching between Arabic and English, depending on the patient’s language preference, is valuable (Alsadaan et al., 2021). However, English proficiency is particularly crucial in nursing documentation and nurse communication. Albagawi and Jones’s (2016) research in KSA further supports this, highlighting the importance of English and Arabic proficiency among the nursing staff for effective patient care, professional communication, and job satisfaction. Therefore, expatriate nurses must be proficient in English and Arabic and culturally competent to contribute to better patient outcomes. The difference in pronunciation, vocabulary, meaning of words, medical terminology, doctors’ orders, and patient information may cause misinterpretation, hinder communication, and cause medical errors (Al Shamsi et al., 2020). The role of language proficiency in reducing medical errors is crucial, as it reassures the audience about the importance of their skills in patient safety. Almutairi et al. (2017) contended that unconscious biases may affect nurse communication and interaction. Stereotyping or preconceived opinions about fellow nurses based on cultural backgrounds may lead to assumptions regarding the nurse’s communication style, language ability, and work practice that can harm effective communication and teamwork. When there are preconceived ideas among nurses, the team members feel judged because of their cultural background, and trust and respect will be diminished, harming open communication (Hilel et al., 2023).

In conclusion, the literature underscores the critical role of effective communication in culturally diverse nursing environments. Addressing challenges, fostering cultural competence, and promoting supportive organizational cultures are vital factors in enhancing nurse communication and improving patient outcomes in culturally diverse healthcare settings. Shopo et al. (2023) asserted that midwives working with diverse patients must acquire practical communication skills to provide quality healthcare. Cultural competence is one of the strategies used to improve health outcomes in diverse healthcare settings, such as the multinational workforce in the setting of this study, the Kingdom of Saudi Arabia. Therefore, this study aimed to explore the perceptions of communication among nurses in a culturally diverse workforce to understand this phenomenon better. The research questions posed for this study were as follows:

What are the nurses’ perceptions regarding communication among nurses in a culturally diverse hospital in the Southern Region of Saudi Arabia?

What recommendations can be made to enhance communication among nurses in a culturally diverse regional hospital in the Southern Region of Saudi Arabia?

Materials and Method

This study was conducted at a regional military hospital in the Southern Region of Saudi Arabia. A qualitative, exploratory, descriptive design was applied following a phenomenological approach to explore perceptions of communication among nurses. The nurse was recruited after a letter was sent inviting the nurse to attend a voluntary information session regarding the overview of the research in the hospital auditorium and then express their interest in participating in the research. A non-probability, purposive sampling method was used to recruit seventeen (n=17) nurses from the target population (N=121) who provided rich data until saturation was declared (Doyle et al., 2020). The sample included all the eligible categories of nurses according to the inclusion criteria that represented the entire population of nurses (Brink et al., 2018, p. 206). The participants, representing different nationalities and nursing units, were selected for their diverse perspectives, which were crucial for the study’s overall aim (Brink et al., 2018). Participants signed an informed consent form before data collection commenced.

The study was approved by the Health Research Ethics Committee of University X, followed by permission from the Hospital Director and the Regional Ethics Committee of Military of Defence for Health Services (MODHS) Southern Region. Ethical principles of beneficence, justice, respect, autonomy, and confidentiality were applied throughout the study. Semi-structured interviews were conducted via Zoom in English in an administrative office with limited access to obtain insights from a diverse sample of nurses. Data from the participants were collected over two weeks in January 2024. The research team consisted of the researcher, gatekeeper (hospital director), interviewer, mediators, an independent and impartial person responsible for recruiting nurses, and co-coder.

The researcher formulated a set of five interview open-ended questions in a manner that allowed participants to respond and explain how they perceived communication among nurses from their understanding (Bradshaw et al., 2017). Interviews were conducted by a neutral interviewer with expertise in the field of qualitative research, due to the position of the researcher in the hospital, which could influence the responses of the participants The interview started with background information to gain insight into the participants’ culture, home language, and country of origin. This information allowed the researcher to understand the participant better and provided context and description during data analysis (Reinisch & Karimi, 2020). The five questions that lead the interviews:

Please tell me what your understanding of communication is within the context of your profession.

The unit that you are working in has a culturally diverse workforce, so please share your perception of working in such an environment.

Kindly share with me your experiences in communicating with your colleagues in the hospital.

Please share your perception of how communication with your colleagues influences patient care.

What do you think are the barriers and facilitators to communication with your colleagues in your hospital?

After the interviews, recordings were transcribed verbatim and checked by the researcher to ensure accuracy.

The information obtained from open-ended exploratory questions during the individual semi-structured interviews was analyzed by applying Braun and Clarke’s (2006) six-step thematic analysis to understand the participant’s perspective. Thematic analysis method consists of six steps: (1) familiarization with the data, (2) code generating, (3) generating themes, (4) reviewing themes, (5) defining and naming themes, and (6) locating exemplars.

Confidentiality was maintained by numerical numbering each transcript and ensuring it was not linked to personal information (Kaiser, 2009). Trustworthiness was established by applying strategies to improve the findings’ credibility, transferability, dependability, and confirmability. To enhance the credibility of the findings, during the interview process, the interviewer and the participant engaged through thoughts and conversation to elicit perceptions of communication and follow-up questions to delve deeper into the perceptions shared. Member checking was performed by asking participants to review the findings and verify that it is consistent with their perceptions shared. Furthermore, the researcher ensured the quality of the data analysis by sourcing an expert in qualitative research who independently conducted the analysis following Braun and Clarke’s steps and co-coded the data, providing a high level of expertise and reassurance in the research process. Reflexivity was used as a strategy for confirmability by not conducting the interviews due to the researcher’s position in the hospital and by taking great care to avoid influencing the participants’ responses during the interviews. The dependability of the data was achieved by maintaining detailed records of all steps in the research process, including developing interview guides, recruitment of participants, data collection procedures, and data analysis techniques.

Results

The findings of the study are presented in this section, commencing with the demographic data of participants, as illustrated in Table 1 below.

Table 1.

Demographic Data of the Interviewed Participants (P) (n=17).

P	Age in years	Gender	Highest Level of Education	Units Allocated	Country of Origin	Experience in Current Position
1	38	Male	Bachelor in Nursing Science	Nursing Education	Filipino	3 years
2	55	Female	Bachelor in Nursing Science	Nursing Administration	Filipino	23 years
3	32	Male	Diploma Nursing	Emergency room	Malaysian	5 years
4	48	Female	Bachelor in Nursing Science	Outpatients Department	Filipino	8 years
5	53	Female	Bachelor in Nursing Science	NICU	Filipino	13 years
6	38	Female	Bachelor in Nursing Science	Labour & Delivery, Nursing Education	Filipino	7 years
7	48	Female	Bachelor in Nursing Science	Family & Community Centre	Filipino	13 years
8	44	Female	Bachelor in Nursing Science	OB-Gyne	Indian	2 years
9	46	Female	Bachelor in Nursing Science	Male ward	Filipino	13 years
10	54	Female	Bachelor in Nursing Science	Paediatric ward	Filipino	14 years
11	36	Female	Diploma in Nursing	NICU	Saudi	7 months
12	29	Male	Bachelor in Nursing Science	Emergency room	Saudi	3 years
13	39	Female	Bachelor in Nursing Science	NICU	Filipino	2years
14	31	Female	Bachelor in Nursing Science	Operating room	Filipino	3years
15	37	Female	Bachelor in Nursing Science	Paediatric ward	Indian	8 years
16	29	Female	Bachelor in Nursing Science	Labour & Delivery unit	Indian	2years
17	29	Female	Bachelor in Nursing Science	OB–Gyne	Indian	2years

Demographic Data of the Participants

Seventeen (n=17) participants were interviewed from the various units within the hospital under study. These participants were a mix of foreign nationals (Indian, Malaysian, Philippines) and national nursing staff working in the various units of the selected hospital. Regarding participants’ gender, fourteen (n=14; 82%) were female and three (n=3; 18%) were males. Five (n=5; 29%) of the participants were aged 25–34 years, six (n=6; 35%) were in the 35–44 age group, five in the 45–54 age group (n=5; 29%), and one was in the >55 age group (n=1; 0.06%). The experience levels measured in the years of service in the nursing profession ranged as follows: One (n=1; 0.06%) participant had <1 year experience, eight (n=8; 47%) between 1 and 5 years, three (n=3; 18%) between 6 and 10 years, four (n=4; 24%) between 11 and 15 years, zero (n=0; 0%) between 16 and 20, and 1 (n=1; 0.06%) had >20 years of experience within this organization under study. The participants were selected from the designated unit care specializations, including general and specialized units, to better understand the effects of nurses’ communication in a broader context. The units included the following: Nursing Education Department, Nursing Administration, Emergency Room, Outpatient Department, Neonatal Intensive Care Unit, Male Ward, Family & Community Centre, the Operating Room, Obstetrics & Gynaecology Unit, Labour & Delivery Unit, Paediatric Ward, and the Nursing Education and Labour & Delivery Unit.

Data analysis for exploring the perceptions of communication among nurses in a regional hospital in Saudi Arabia yielded three themes with respective sub-themes, as illustrated in Table 2 & 3 below.

Table 2.

Exploring Perceptions of Communication among Nurses in a Regional Hospital in Saudi Arabia.

Theme 1: Nurses’ perceptions of communication in a culturally diverse workforce
Subtheme 1.1: Nurses’ understanding of communication
Communication is a two-way process of sending and receiving messages which can be verbal or non-verbal.	P1: “Communication is a 2-way process sending and receiving messages and understanding or being understood by receiving messages .” P2: “It is a way to exchange messages or relay the messages and information to each other in the unit and other departments.” P3: “It is the way we communicate can be verbal or nonverbal .” P6: “Communication is about the way we will give information to other person like sender a message and receiver and there should be feedback. Communication is a two-way process and important in our profession because we are dealing with patients and safety is important.” P7: “Communication can be verbal and nonverbal between our colleagues our staff other departments and our patients.” P8: “In the ward communication means through in the unit verbally, messages and through short meetings something and continue the communication through the WhatsApp.” P9: “Communication is an exchange of information between 2 entities . There is a sender and receiver of the message and for me a good communication is important for human machinery that helps us function smoothly.” P10: “Communication is very important in nursing profession because it’s the way of expressing the feelings the thoughts, sharing ideas, and passing of information from one nurse to another .” P13: “Communication means interaction between 2 persons can be written or verbal .” P14: Communication “is how the colleagues and how the multidisciplinary team in the health care team relay information about the patient the procedures .” P15: “Communication is exchanging of ideas or anything that we can and receiving of information .” P16: “Communication is a matter we are trying to explain to another person or whom is in front of me .” P17: “We want to communicate nicely and want to understand the communicator with a smile and we want to know about our communicating languages and expressions .”
Communication is required for optimal patient care and daily nursing activities.	P1: “Communication is important because it improves our work as a nurse educator , we are dependent on communication to provide quality service to our staff and our patients which in my opinion is essential.” P2: “Through communication we can do our work and must be clear.” P4: “Communication is important to give proper patient care and our daily activities. When doing tasks we must communicate properly to give the care the patient needs.” P11: “Communication in our department is to reduce the confusion between the staff and should be managed between the staff different culture or different country.”
Theme 2: Barriers to communication in a culturally diverse workforce
Subtheme 2.1: Cultural barriers in a culturally diverse working environment
Lack of knowledge regarding different nationalities, culture, and religion leads to misunderstanding.	P1: “We have different nationalities like the Saudi, Indian, Filipino and South African. In the beginning when I started working in this hospital, I had some challenges with understanding my colleagues .” P2: “Challenges such as language and the English is poor difficult to understand, and this results in miscommunication or doubt example the Saudis cannot speak good English, and this is difficult for us as foreign nationals to understand them .” P3: “Other barriers include the culture and the religion .” P4: “very diverse different cultures and different beliefs and religions and this does become a problem.” P5: “We grow up in different cultures there are some people like the Indians the voice is high and you thinking they shouting but they not.” P7: “the culture because people, in females, people they cover their face, they cannot speak to males. They have to be examined only by same gender.” P9: “really a great challenge because we are dealing with different nationalities , we have the Saudi we have the Pakistani we have also have Indians and Filipino nationalities, but we have one goal in our unit which is to spread and give effective communication and communicate effectively.” P13: “All have different languages and religions, beliefs and culture .” P16: “We all speak different languages and we from different cultures .”
Subtheme 2.2: Language barriers in a culturally diverse working environment
Language barrier contributes to patient dissatisfaction and affects patient care.	P1: “All our patients are Arabic speaking and not literate or cannot speak English this does cause patient experience and dissatisfaction with his care process and outcomes .” P2: “Communication does affect the patient care because whatever your staff or colleagues perceives then the communication it will affect patient care it must be correct and direct and concise so that the one that is receiving your communication must understand the goal and the subject you are trying to emphasize.” P4: “Communication does affect patient care a lot especially if not clear , if the communication is not clear among the healthcare team, then mistakes and errors can take place.” P5: “This affects the patient care because of ineffective communication and language barriers and understanding .” P6: “If nurses or any colleagues or any health care worker do not understand one another there is possibility that they will be giving the wrong care to our patient .” P6: “does disrupt the treatment plan and creates frustration amongst colleagues but we respect and work as team and help each other to avoid patients from shouting us .” P10: “Communication is very important to influence patient satisfaction and to give quality patient care because once you miss one important information then the hmmm . . . the quality given to patient is disrupted .” P13: “If we do not communicate very well there are lot of errors will happen .” P14: “ inability of the staff to speak up and not understood the orders of what was said to them and afraid or ashamed to ask or speak up to repeat instead that will the barrier in giving effective and quality care to the patients .” P15: “Communication with my colleagues does influence patient care because it needs one to receive the information properly and one to deliver the communication properly to deliver great total patient care because if one only receives the information without understanding the other person cannot understand what the person is implying then there will be problems with patient care.” P16: “ Pilipino speak very kindly to patients but the Indians they are speaking very harsh to patients . Therefore, the patients more comfortable with the people speaking kindly .” P17: “Sometimes patients try to express problem or feelings and we cannot understand .”
Language medium used in the workplace causes breakdown in communication that creates misunderstanding and conflict.	P1: “Arabic colleagues their English is poor, words are misinterpreted, and this can cause conflict .” P2: “Sometimes the word has different meaning to different cultures and can cause breakdown in communication that creates conflict and misunderstanding .” P3: “Although we all speak English, understanding English words sometimes is challenging .” P4: “Some words can be misinterpreted and talk very fast there is misunderstanding , and this affects the teamwork and work relationship in the unit and can affect our behaviours example get angry or conflict with each other.” P6: “Sometimes it’s difficult because the pronunciation for me when talking to other nurses form other countries , that’s one of the most difficult parts when I was new here in KSA and can cause conflict among the team members and colleagues.” P9: “We have to verify in case we do not understand each other what was the message because we are trying not to be misunderstood by each other. We have to verify and clarify that the information we receive is the correct one in order to give care to our patients.” P10: “language barriers because some of the nurses for example from different nationalities they cannot express well in English so some points may be missed. Some nurses having conflict personal , conflict and this affects communication.” P15: “Some but not all of other nationalities have difficulty explaining and communicating in English also like for example my doctor is only speaking in Arabic sometimes it is a struggle to comprehend what he is saying to the patient and sometimes we need to have translator available for such situations.” P17: “The barrier is the language and that is the big problem because I do not that much of Arabic and that is the big problem with communication.”
Subtheme 2.3: Behavioral barriers in a culturally diverse working environment
Non-verbal communication leads to misinterpretations causing others to feel offended.	P1: “peoples’ body language and gestures and words which can be interpreted differently. As I said earlier the tone of the voice sometimes seems to be aggressive and it’s their culture especially Indian to talk in loud voice , but they have freedom of expression.” P4: “Their ideas, words and gestures also different but eventually the idea gets across to them the way I want it to. Not all the time this is possible but mostly it is. Some words have different meanings and sometimes may offend them .” P6: “ Attitude, behaviour and body language or gestures also creates barriers to communication.” P8: “Maybe sometimes I feel that different nationality means different way of talking example in our country India we talk in loud voices and others talk in low level voices then they thought we shouting but we not shouting our voice as Indians are just loud then mistakenly, they think we shouting.” P13: “How they speak was too fast for me and too slow for me so had to learn to adapt and need the job so had to learn and understand especially some words .” P16: “Indians a bit rude they speak without smiling. Sometimes I am speaking in low voice and other speaking loud can be barrier to me.”
Theme 3: Facilitators of effective communication in a culturally diverse workforce
Subtheme 3.1: Knowledge regarding different cultures and religion in a culturally diverse working environment
To learn about other nationalities, religions, cultures, beliefs, and customs.	P1: “We also learn from other nationalities from their religion and their beliefs .” P2: “Through interpreter, speak slowly and clearly to make understanding more effective.” P4: “To avoid talking fast. Pronounce words slowly and clearly ”. P5: “To understand each other and to speak simple clear and slowly to follow the tone.” P7: “have lectures, training different cultures and different nationality .”
To learn other nationalities language.	P2: “Give more orientation to foreign nationals on language especially on basic terms of Arabic language.” P3: “We as foreign national must learn the basic Arabic language to follow orders accurately and to ensure patient satisfaction.” P4: “We must learn the language as most patients speak no English. To learn different languages and socialisation process.” P5: “for effective communication to use interpreters and to learn the language .” P6: “learn the basic languages of the different nationalities.” P7: “We train our staff to speak Arabic to speak to our patients and at the same time they can render better patient care.” P13: “During orientation we are teaching languages and we learning .” P15: “We just do not listen we need to listen and then we understand what the other person is speaking about.” P16: “I am able to communicate and now I am able to learn different language .”
Subtheme 3.2: Collaboration between different cultures and religion in a culturally diverse working environment
Collaboration to improve teamwork among professionals and patient care.	P1: “Collaboration improves our teamwork .” P4: “Form a good working relationship and improve on our teamwork with the patients care.” P5: “Use proper handover to avoid miscommunication or errors in the care of the patients .” P12: “ To improve communication should be easy with staff and discuss with staff and there should be teamwork and no difference between staff.” P13: “In the profession it is important to have good communication because the patient care and teamwork can be affected if communication not good.” P16: “We have to learn different cultures different languages and we have to understand them so that we can improve our communication with each other .”
Subtheme 3.3: Shared values in different cultures and religion in a culturally diverse working environment
Shared values to improve communication.	P1: “To facilitate effective communication I will say tolerance, patience and understanding and respecting the various cultures.” P3: “We must at least know the basic Arabic language on how to greet and to be polite and say thank you or can I help you .” P5: “Most important respect the various diverse cultures and this will improve communication.” P6: “to greet and say thank you and always be open minded and not criticise any person of nationality.” P10: “They need to listen first before they speak up like social media you have to re-read the message before clicking the send.”

Table 3.

Themes and Sub-themes.

THEMES	SUB-THEMES
THEME 1 Nurses’ perceptions of communication in a culturally diverse workforce	Sub-theme 1.1: Nurses’ understanding of communication • Communication is a two-way process of sending and receiving messages, which can be verbal or non-verbal. • Communication is required for optimal patient care and daily nursing activities
THEME 2 Barriers to communication in a culturally diverse workforce	Sub-theme 2.1: Cultural barriers • Lack of knowledge regarding different nationalities, cultures, and religions leads to misunderstanding.
	Sub-theme 2.2: Language barriers • Language barrier contributes to patient dissatisfaction and affects patient care. • The language medium used causes a breakdown in communication that creates conflict and misunderstanding.
	Sub-theme 2.3: Behavioral barriers • Non-verbal communication leads to misinterpretations, causing others to feel offended.
THEME 3 Facilitators of effective communication in a culturally diverse workforce	Sub-theme 3.1: Knowledge about different cultures and religion • To learn about other nationalities, religions, beliefs, and customs. • To learn other nationalities language.
	Sub-theme 3.2: Collaboration between different cultures and religions • Collaboration to improve teamwork among professionals and patient care.
	Sub-theme 3.3: Shared values in different cultures and religion • Shared values to improve communication.

THEME 1: Nurses’ Perceptions of Communication in a Culturally Diverse Workforce

Perceptions of communication in a culturally diverse workforce among nurses can have a variety of different elements. They can vary based on individual experiences, backgrounds, and contexts, as evidenced by the quotes in the next section of the themes derived from the data analysis. Nurses working in a multicultural environment need to understand the communication process and be aware of the challenges they may encounter in comprehending messages due to differences in culture, languages, and communication styles to ensure quality patient care and effective teamwork. The sub-theme that came up is the nurses’ understanding of communication, as discussed below.

Sub-theme 1.1: Nurses’ Understanding of Communication

Participants viewed communication as a two-way process of sending and receiving messages, which can be verbal or non-verbal. The following participant quotes support this sub-theme:

“Communication is a two-way process sending and receiving messages and understanding or being understood by receiving messages.” [P1, age 38, male, Nursing Education]

“Communication is very important in the nursing profession because it’s the way of expressing the feelings the thoughts, sharing ideas, and passing of information from one nurse to another.” [P10, age 54, female, Paediatric Ward]

Participants felt strongly that communication is required for optimal patient care and our daily nursing activities, as evidenced by the following quotes.

“Communication is important because it improves our work as a nurse educator . We are dependent on communication to provide quality service to our staff and our patients, which, in my opinion, is essential.” [P1, age 38, male, Nursing Education]

“Communication is important to give proper patient care and our daily activities. When doing tasks, we must communicate properly to give the care the patient needs.” [P4, age 48, female, Outpatient Department]

THEME 2: Barriers to Communication in a Culturally Diverse Workforce

Communication in a culturally diverse workforce can encounter various barriers due to differences in language, communication styles, cultural norms, and values. In theme 2, three sub-themes emerged, namely (1) cultural, (2) language, and (3) behavioral barriers in a culturally diverse working environment, as discussed below.

Sub-theme 2.1: Cultural Barriers

The study revealed that a lack of knowledge regarding different nationalities, cultures, and religions leads to misunderstanding, as is evident in the following quotes.

“We have different nationalities, such as Saudi, Indian, Filipino, and South African. In the beginning, when I started working in this hospital, I had some challenges with understanding my colleagues .” [P1, age 38, male, Nursing Education]

“The culture because people, in females, people they cover their face, they cannot speak to males. They have to be examined only by the same gender.” [P7, age 48, female, Family & Community Centre]

Sub-theme 2.2: Language Barriers

Participants reported that the language barrier contributes to patient dissatisfaction and affects patient care. This sub-theme also highlights the negative impact of the language barrier, which is the impact on patient care.

“All our patients are Arabic speaking and not literate or cannot speak English. This does cause patient experience and dissatisfaction with his care process and outcomes .” [P1, age 38, male, Nursing Education]

“Challenges such as language and the English is poor, difficult to understand, and this results in miscommunication or doubt example the Saudis cannot speak good English, and this is difficult for us as foreign nationals to understand them .” [P2, age 55, female, Nursing Administration]

Participants also emphasized that the language medium used in the workplace causes a communication breakdown that creates misunderstanding and conflict. The following quotes support this:

“Some words can be misinterpreted and talk very fast there is a misunderstanding , and this affects the teamwork and work relationship in the unit and can affect our behaviors, for example, getting angry or conflict with each other.” [P4, age 48, female, Outpatient Department]

“Sometimes it’s difficult because the pronunciation for me when talking to other nurses from other countries , that’s one of the most difficult parts when I was new here in KSA and can cause conflict among the team members and colleagues.” [P6, age 38, female, Nursing Education & Labour & Delivery]

Sub-theme 2.3: Behavioral Barriers

Participants also reported that non-verbal communication leads to misinterpretations, causing others to feel offended, as evidenced by the following quotes:

“People’s body language and gestures and words can be interpreted differently. As I said earlier, the tone of the voice sometimes seems to be aggressive, and it’s their culture, especially Indian, to talk in a loud voice , but they have freedom of expression.” [P1, age 38, male, Nursing Education]

“Maybe sometimes I feel that different nationalities mean different ways of talking. For example, in our country, India, we talk in loud voices, and others talk in low-level voices . Then they think we are shouting, but we are not shouting our voice as Indians are just loud, then mistakenly, they think we are shouting.” [P8, age 44, female, Obstetrics & Gynaecology Ward]

THEME 3: Facilitators of Effective Communication in a Culturally Diverse Workforce

Facilitators of effective communication in a culturally diverse nursing workforce are fundamental to supporting interprofessional collaboration, improving patient care, and promoting a supportive work environment. Three sub-themes emerged, as discussed below.

Sub-theme 3.1: Knowledge Regarding Different Cultures and Religion

Participants stated that a facilitator will include learning about other nationalities, religions, cultures, beliefs, and customs. The following participant’s quotes support this:

“We have to learn to adapt and work as a team. Collaboration improves our teamwork, and through this diverse culture, we also learn from other nationalities from their religion and their beliefs ”. [P1, age 38, male, Nursing Education]

“So, for me, so we have lectures, training different cultures and different nationality ”. . . will sit in one place and we will understand each other, and at the same time we will give that one to patients and good patient care”. [P7, age 48, female, Family & Community Centre]

Another facilitator reported by participants includes learning other nationalities’ languages, as evidenced by the following quotes:

“Facilitators . . . ways to improve these barriers for me maybe being open-minded and can be firstly to learn basic languages of the different nationalities especially to greet and say thank you and always be open-minded and not criticise any person of nationality.” [P6, age 38, female, Nursing Education & Labour & Delivery Ward]

“We must learn the language as most patients speak no English. The working environment is full of Arabic, and we must learn the language as most patients speak no English, and staff are from different countries and do not speak English well. To learn different languages and socialisation process.” [P4, age 48, female, Outpatients Department]

Sub-theme 3.2: Collaboration between Different Cultures and Religions

The participants in the interviews claimed that collaboration between different cultures and religions improves teamwork, facilitates effective communication, and enhances patient care, as evidenced by the following quotes:

“We have to learn to adapt and work as a team . Collaboration improves our teamwork, and through this diverse culture, we also learn from other nationalities, including their religion and beliefs”. [P1, age 38, male, Nursing Education]

“ To improve communication should be easy with staff and discuss with staff and there should be teamwork and no difference between staff”. [P12, age 29, male, Emergency Room]

Sub-theme 3.3: Shared Values in Different Cultures and Religion

The participants report that acknowledging and respecting shared values while also being sensitive to cultural and religious differences is essential for fostering effective communication, promoting inclusivity, and building strong relationships among team members. The following participant’s quote supports this:

“To facilitate effective communication, I will say tolerance, patience, and understanding and respecting the various cultures.” [P1, age 38, male, Nursing Education]

“We must at least know the basic Arabic language on how to greet and to be polite and say thank you or can I help you .” [P3, age 32, male, Emergency Room]

Discussion

This study contributes to a more comprehensive understanding of nurses’ perceptions of communication in a culturally diverse nursing workforce and informs future research and practice in healthcare communication worldwide.

The first theme found that nurses’ understanding of communication in a culturally diverse nursing team is central and critical to patient care. This finding is similar to studies confirming that communication in a culturally diverse team is essential for high-quality, patient-centered care (Kourkouta & Papathanasiou, 2014; Noviyanti et al., 2021). Noviyanti et al. (2021) stated that by practicing practical communication skills in culturally diverse care teams, nurses can promote positive outcomes, improve patient experiences, and uphold the core principles of compassionate care. All participants in this study clearly understood that human communication is a two-way transactional process in which people create shared meanings during interactions through verbal or nonverbal communication, as Santos et al. (2012) suggested. In a multicultural work environment, nurses perceive communication differently due to cultural incompatibility; the communication process becomes challenging and leads to adverse incidents with patients (Alsufyani et al., 2021).

Furthermore, Ashipala and Matundu (2023) state that effective communication is important to ensure optimal patient care in a culturally diverse nursing workforce, which is evident in this study. Clear communication helps nurses to build trust and relationships within the care team. Nurses are more likely to feel comfortable sharing important information about the patient’s health when they feel understood and respected by their colleagues (Isakov et al., 2023). Effective communication between nurses in a culturally diverse nursing workforce promotes teamwork and adherence to patient care plans (Horvath & Molnar, 2021).

According to Hartung and Miller (2013), communication in a multicultural nursing team is essential to ensure quality patient care, collaboration, and team cohesion. However, various barriers can hinder communication in such culturally diverse care teams. The results showed that various behavioral and language differences as well as a lack of knowledge about different cultures, communication styles, and shared values, such as respect and hierarchy, affected communication among the nurses in the study. These barriers can lead to misunderstandings and misinterpretations, affecting team performance and ultimately jeopardizing patient safety and care outcomes (Aboshaiqah & Alharb, 2020; Al Shamsi et al, 2020; Thomas et al, 2021; Xiao et al, 2013). Most participants in the current study indicated that some communication practices rely on nonverbal methods because they do not speak a common language, which often results in a need to better understand the meaning of the communication. In some cultures, direct eye contact is a sign of trust and honesty, while in others it is perceived as disrespectful or confrontational. Some nurses may unintentionally make offensive or inappropriate remarks or gestures in another culture (Xiao et al., 2013). This can hurt feelings, cause tension and disrupt communication (Hilel et al., 2023). The participants in the current study confirmed that their lack of knowledge about the differences in language and culture was a factor that led to misinterpretations and misunderstandings and thus to disruptions in communication within the care team. Poor communication can affect care coordination, handovers and teamwork (Thomas et al., 2021).

Furthermore, Lin et al.’s (2021) findings relate to the factors that facilitate effective communication in a culturally diverse workforce, which can create an inclusive and culturally competent nursing workforce capable of providing patient-centered care. As the study participants noted, cultural awareness and sensitivity can equip nurses with the knowledge, skills, and attitudes necessary for effective communication and collaboration in the care setting. The literature emphasizes that cultural awareness helps to avoid misunderstandings, promote active listening and adaptability, and create close relationships and an inclusive work environment (Caldwell, 2015; Henderson & Kendell, 2011). Subramanian (2016) found that learning different languages ensures that all nurses can effectively communicate and understand important information, reducing the risk of misunderstandings and errors in patient care. According to Almutairi et al (2017), understanding different cultural norms, customs, religions, and traditions enables nurses to communicate with sensitivity and respect and to apply communication strategies when interacting with other nurses from different cultures. To build a trusting relationship, one must understand the nurses’ language skills, the meaning of the words they speak and their behavior, as stated by some of the participants. (Subramanian, 2016). One participant pointed out that shared values are essential in shaping cross-cultural and cross-religious communication in nursing. This statement aligns with Scotta’s (2018) assertion that shared values create mutual understanding and respect between caregivers from different cultural or religious backgrounds. Sharing values between nurses facilitates communication; it provides a framework to clarify messages and behaviors and enables an open approach to communication and a willingness to understand each other’s perspectives (Albalawi et al., 2020).

Limitations

The study sample represents only a portion of the culturally diverse nursing staff in KSA, as the study was conducted in only one hospital in KSA, which limits the generalizability of the results. The language barriers in this study hindered effective communication between the researchers and the participants as the hospital is culturally diverse. Most nurses do not speak English as a first language and are not fluent in English. The Arabic staff needed help in understanding the questions; the interviewer had to rephrase the questions so that they were better understood. The above factors could limit the depth of the data collected or lead to misunderstandings in interpretation. Finally, despite efforts to include a culturally diverse sample, certain cultural groups or perspectives may be underrepresented in the study, as there were only two Arab participants. The comprehensiveness of the findings in relation to some aspects of communication could be overlooked.

Conclusion

The barriers, challenges, and facilitators that influence communication dynamics in a culturally diverse nursing team were identified by exploring nurses’ perspectives, as the Saudi Arabian regional hospital employs predominantly foreign nurses. Prioritizing communication in culturally diverse nursing teams improves patient outcomes, strengthens teamwork, increases job satisfaction, and advances healthcare in Saudi Arabia. Addressing these areas, the research can significantly contribute to the nursing literature, particularly in the context of culturally diverse hospitals. It provides practical insights and recommendations grounded in nurses’ lived experiences, thereby helping to improve communication, teamwork, and patient care in culturally diverse healthcare environments and making all stakeholders feel included and part of the solution.

Implications for Practice

The implications for nursing practice, the hospital should prioritize training nurses in cultural competence to improve their understanding of different cultural backgrounds and communication styles (Almutairi et al., 2017). This training should promote cultural sensitivity, reduce prejudice, and support effective communication in cross-cultural interactions. The healthcare organization will invest in language access services, such as interpreters and language classes, to facilitate communication between caregivers with limited English proficiency (Ashipala & Matundu, 2023). Ensuring language access improves communication between staff and patients to ensure patient safety, team collaboration, and overall quality of care. The nursing department will demonstrate its commitment to diversity, equity, and inclusion by implementing team-building activities and initiatives to improve nurses’ knowledge and awareness of the differences between various cultures through team collaboration (Reinisch & Karimi, 2020).

Footnotes

Acknowledgements

The authors acknowledge the participants who took part in the study, as well as the co-coder, Dr. K. Froneman, and the fieldworker, Dr. K. Chetty who assisted with data collection.

Author contributions

All authors contributed to the manuscript to merit authorship. The submitted manuscript is approved by all authors. LT, KDS, and ON conceived and planned the study. LT was a Masters’ student and collected the data. KDS and ON were the study supervisors and ensured that the study was of good quality and was conducted ethically. LT and KF analyzed the data. LT, KDS, and OG interpreted the data. LT, KDS, and OG drafted and revised the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript.

Data availability

All analyzed data supporting the findings of this research are included in the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study was self-funded, and no sponsor or additional source of financial assistance was received.

Disclaimer

The views and opinions expressed in this manuscript are those of the authors and they do not necessarily reflect the official policy or position of any affiliated agency of the authors.

ORCID iDs

Liesel Theron

Khumoetsile Daphney Shopo

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Exploring Perceptions of Communication among Culturally Diverse Nurses in Saudi Arabia

Abstract

Introduction:

Methodology:

Results:

Discussion:

Keywords

Introduction

Materials and Method

Results

Demographic Data of the Participants

THEME 1: Nurses’ Perceptions of Communication in a Culturally Diverse Workforce

Sub-theme 1.1: Nurses’ Understanding of Communication

THEME 2: Barriers to Communication in a Culturally Diverse Workforce

Sub-theme 2.1: Cultural Barriers

Sub-theme 2.2: Language Barriers

Sub-theme 2.3: Behavioral Barriers

THEME 3: Facilitators of Effective Communication in a Culturally Diverse Workforce

Sub-theme 3.1: Knowledge Regarding Different Cultures and Religion

Sub-theme 3.2: Collaboration between Different Cultures and Religions

Sub-theme 3.3: Shared Values in Different Cultures and Religion

Discussion

Limitations

Conclusion

Implications for Practice

Footnotes

Acknowledgements

Author contributions

Data availability

Declaration of Conflicting Interests

Funding

Disclaimer

ORCID iDs

References