i

NURSE CULTURAL COMPETENCE AND PATIENT-CENTERED CARE IN A

TERTIARY HOSPITAL IN SAUDI ARABIA

Joyce Lynn Rivera Opinga

Faculty of Management and Development Studies

University Of The Philippines
OPEN UNIVERSITY
Los Baños, Laguna
Philippines
2020
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Acknowledgment

Above all, I want to express my gratitude to our All-Powerful God for providing me
with the wisdom, fortitude, and capacity to finish this research. I could not have achieved this
without his guidance.
Boundless gratitude and appreciation for the help and support are extended to the
following persons for all their significant contributions in making this study feasible.
Prof Queenie Roxas Ridulme, RN, PHD, MAN Faculty-in-charge for her support,
encouragement, and endless consideration to fulfill this manuscript.
The thesis panel of critics is as follows, Ma. Elma L. Mirandilla, Ms. Grace Riego de
Dios, Mr. Fritz Gerald Jabonete, and Ms. Maria Rita V. Tamse, for their skillful critical
judgment and expertise in making this study more meaningful and valuable.
Editor for lending me a hand in checking and editing this study to make it more organize
and presentable.
Lastly, to my loved ones, for their never-ending love and support, which inspired me
while working on this research.
Many thanks and appreciation to all of you and may our Almighty God bless you.
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Abstract

Introduction:
Cultural competence is increasingly recognized as essential in nursing to ensure patient-
centered care in diverse healthcare settings. This study examines the relationship between
cultural competence and perceptions of patient-centered care among nurses in a Saudi tertiary
hospital, where expatriates constitute 80% of the nursing workforce.
Methods:
A descriptive correlational study examined nurses' cultural competency and patient-centered
care perspectives. 166 nurses were assessed using the NCCS, which measures nurses' cultural
competence towards culturally diverse patients, and the ICS-Nurse, which measures nurses’
perceptions of individualized care. Cultural competency was correlated with patient-centered
care scores using Pearson's correlation coefficient.
Results:
Findings revealed that nurses exhibited moderate levels of cultural competence (mean = 2.85,
SD = 1.09) and high perception on patient-centered care: (mean=3.96, SD=0.86). Also, the
study revealed a weak positive correlation between cultural competence and patient-centered
care (r = 0.1285, p = 0.098954). The cultural competence of nurses (x2=64.750, p=<0.001) and
views on patient-centered care (x2= 69.935, p=<0.001) are influenced by their nationality.
However, sex, educational attainment, and years of expertise did not have significant
relationship with the nurses’ cultural competence and perceptions on patient-centered care.
Discussion:
The results underscore the necessity for ongoing training programs focusing on cultural
competence and effective communication to enhance care quality. This suggests that although
nurses with greater cultural competency may have a slightly positive opinion of patient-
centered care, these opinions may be influence by other factors.
Conclusion:
The study suggests more research to better understand and improve nursing practice's
integration of cultural competency into patient-centered care. Future research should also aim
in determining proactive strategies, including education and policy reform, which are vital for
fostering an inclusive healthcare environment.
Keywords: cultural competence, patient-centered care, nursing, Saudi Arabia, healthcare
diversity
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Table of Contents

Acknowledgment ......................................................................................................................ii
Abstract ....................................................................................................................................iii
Chapter I: The Research Problem ......................................................................................... 3
Introduction .............................................................................................................................. 3
Background of the Study ......................................................................................................... 7
Statement of the Problem ...................................................................................................... 10
Objectives of the Study .......................................................................................................... 10
Significance of the Study ....................................................................................................... 12
Scope and Limitations of the Study ...................................................................................... 13
Chapter 2: Theoretical Background .................................................................................... 14
Synthesis.................................................................................................................................. 35
Theoretical Framework ......................................................................................................... 37
Conceptual Framework ......................................................................................................... 38
Operational Definition of Terms .......................................................................................... 41
Hypothesis and Assumptions ................................................................................................ 45
Chapter 3: Research Methodology ....................................................................................... 46
Research Design ..................................................................................................................... 46
Sampling Technique .............................................................................................................. 47
Setting...................................................................................................................................... 47
Data Collection Procedure .................................................................................................... 49
Research Instrument ............................................................................................................. 50
Procedure of Data Collection ................................................................................................ 53
Plan for Data Analysis ........................................................................................................... 53
Data Management .................................................................................................................. 56
Ethical Considerations........................................................................................................... 57
Chapter 4: Results and Discussion ....................................................................................... 58
Chapter 5: Summary of Findings, Conclusion and Recommendation ............................. 79
Recommendation.................................................................................................................... 81
References ............................................................................................................................... 83
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Chapter I: The Research Problem

Introduction

More and more research shows the importance to teach and practice cultural

competency in nursing, however reports of cultural insensitivity continue to emerge on a

worldwide scale. Because the patient population is becoming more diverse in terms of society

and way of life, nurse educators need to incorporate cultural competence as a required graduate

skill. According to Matsumoto (2007), humans must satisfy biological and social needs to

survive, and nature has provided humans with a fundamental toolkit of abilities, dispositions,

and preferences known as culture. In a nutshell, culture is an individual's method of coping

with the day-to-day challenges of survival, which is learned through generational transmission.

In my opinion, the distinctiveness of an individual or group's culture is shaped by life

experiences; it is a behavior acquired through exposure to the ambiguity of life's phenomena.

The complexity of the environment creates various types of problems and situations that

necessitate different types of responses to survive.

This study pays more attention to the influence of culture on healthcare providers'

ability to be competent culturally towards others in the provision of quality nursing care

ensuring safety and patient-centeredness amid cultural diversity. Nursing profession along with

midwives’ accounts nearly 50% of the global health workforce (WHO, 2020) that represents a

powerful aspect for addressing and meeting the demand of health for all. Currently, 80% of the

nursing workforce needed to support Saudi Arabia's increasing population is supplied by

foreign workers from more than 40 countries (Alhusni et al., 2017).

Becoming culturally competent is a difficult process that nurses in the 21st century need

to go through to improve community health care, eliminate inequities, and break down cultural

barriers (Dean, 2010). Furthermore, possessing cultural desire necessitates that the nurse be

open, adaptable, accepting of diversity, and eager to learn from others which are necessary to
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develop cultural competency (Campinha-Bacote, 2003). Most patients and their families are

Saudi nationals who speak Arabic as their native language, according to several literature

reviews, including one that was mostly carried out in Saudi Arabia and in contrast, the most of

healthcare professionals, including nurses, speak English. This language barrier complicates

their access to necessary care (Lamadah & Sayed, 2014). Generally, cultural competency is an

essential foundation for reducing differences in care quality that is culturally sensitive and fair

(Butler, et. at., 2016). In their study, Butler and other researchers explored cultural competence

but pointed a common misconception: it is often seen as focusing only on racial and ethnic

differences narrowing the view excludes other marginalized groups who, despite being

ethnically and racially like the provider, unequal treatment, or have unique healthcare needs

that lead to disparities and mistreatment.

In order to facilitate patient-nurse interactions, nurses who possess cultural competence

can establish a deeper connection with their patients. According to Campinha-Bacote (2011),

these improved nurse-patient relationships usually lead to better health and organizational

outcomes as well as higher patient compliance. The first element of being culturally competent

in nursing is being aware of other cultures. This phase necessities you to think about your own

views and ideals. Being culturally aware means being able to put aside your biases against

other cultures and being open-minded toward all of your patients and coworkers (Jeffreys,

2016). Developing cultural competence requires a continuous commitment to education.

Nurses must be willing to develop self-awareness, behaviors, and social skills pertinent people

from different cultures, and as well as how to advocate for others (Purnell, 2000).

In a tertiary hospital located in Saudi Arabia, cultural diversity is evident in various

forms, largely due to the presence of expatriate workers alongside a locally rich cultural

heritage. Nurses often work with patients from many different cultures, such as Middle Eastern,

South Asian, and Western. Each of these cultures has its own health beliefs, ways of
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communicating, and practices. Dietary limitations based on religious beliefs, for example, can

have a big impact on patient care. Because of this, nurses need to keep these things in mind

when arranging meals or talking about treatment options. Cultural competence is something

that more nurses are learning because they know how important it is to meet patients' medical

needs while also respecting and knowing their cultural beliefs and values. It is important to

understand the mindset of different types of patients so that you can deal with their unique

problems and provide care that is both effective and compassionate because if nurses know

about their patients' cultural preference, they can get to know them better. This is a very

important thing to do if you want to build trust, which is a big part of giving good care. It does

more than just let people know you hear them and care about what they have to say. There is a

stronger therapeutic connection when people trust each other.

By making rules, allocating resources, and encouraging an open environment,

administration is a key part of connecting cultural knowledge and patient-centered care. They

set clear rules and guidelines making sure cultural understanding is incorporated in all ways

patients are cared for. Administrators are responsible for ensuring that healthcare services are

adapted to patients' cultural needs. For example, they should help patients with their language

needs and accept their cultural beliefs. They also keep an eye on and review how cultural

competence is used in care, making sure that patient feedback is considered. Administrators

help make sure that care is culturally sensitive and patient-centered by pushing patients to get

involved and working together with community partners. Another good example is setting up

a mentorship program that links experienced nurses with novice nurses from a variety of

cultural backgrounds. This would help them learn from each other and teach each other about

their cultures. Also, patient-centered care rules tell nurses to talk to patients about their cultural

needs so that treatment plans can be made to fit each person's needs. These programs not only
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improve patient outcomes, but they also boost team morale and collaboration. This shows how

important cultural diversity is in a healthcare setting.

Since every patient is different, patient-centered care involves considering healthcare

from the patient's perspective and personalizing treatment to suit their needs and preferences

(Beach et al., 2006). Communication skills, understanding of cultural and social problems, and

universal health beliefs are the main focuses of a new multicultural approach to culturally

competent clinical practice. According to Epner et al. (2012), this strategy is regarded as

patient-centered. Leininger (2002) said that healthcare workers should do a full culturological

assessment in key cultural areas and that it would be helpful to include parts of the patient's

cultural background in the patient-centered plan. Both cultural literacy and patient-centered

care are good for health, but they do so in different ways. Both, for instance, mandate that

medical personnel treat every patient as a person, provide unconditional positive regard, foster

positive relationships, apply the bio-psychosocial model, understand the patient's values,

beliefs, and viewpoint on illness, and reach consensus regarding treatment plans (Saha et al.,

2008). To deliver patient-centered, culturally competent care, healthcare providers must be

adaptable and open-minded. This is because patients' needs and wants might be very different

depending on their cultural background and personal experiences. These methods also stress

how important it is for patients and providers to work together so that care plans are made to

fit each person's specific requirements and wants.

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Background of the Study

The Ministry of Health of Saudi Arabia's annual statistics report for 2017 says that there

were 185,693 nurses in total, and 63.3% of them were non-saudi. There is a shortage of nurses

in Saudi Arabia right now since locals are reluctant to work in the field. This has led to an

increase in the number of foreign nurses, mostly from India, Malaysia, South Africa, the

Philippines, and other countries (Alluhidan et al., 2019). Ranking 26th among 191 countries,

Saudi Arabia have improved greatly over decades in terms of overall healthcare efficiency. The

country is greatly empowered by values, beliefs, and virtues in accordance to the Islamic way

of life. The problem of providing culturally competent care comes up since numerous workers

come from all over the world (Almutairi and McCarthy, 2012). As healthcare personnel

migrated, it became harder for nurses to keep their organizations culturally competent. Even if

there are strong efforts to boost Saudi nationals to enter nursing profession, the government

will continue to hire health care workers from other countries until they can deliver enough

qualified nurses on their own (Tumulty, 2004). Because of multiculturalism in health care, it is

challenging to provide quality, patient-centered treatment because of changes and differences

in how health and illness are conceptualized (Paternotte et al., 2014). As committed nurses of

health care, we are obliged to be culturally competent and are responsible for understanding

differences aimed to be unified to achieve optimum health. As nursing leaders, we are bound

to create an environment that provides culturally proficient care to anyone regardless of their

culture, race, or generation.

In a literature review, effective nurse- patient communication is important and highly

given priority in improving quality of health care (Alshammari, Duff, & Guilhermino, 2019)

and found that the present methods are ineffective for Saudi patients because of disparities in

culture, religion, and language between patients, nurses, and the whole interdisciplinary team.

Sharing language of patients often results in miscommunication with foreign non-Arabic

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speaking nurses that imposes an extremely valuable aspect of therapeutic relationship between

the patient and the entire interdisciplinary team (Alsayed, & West, 2019). If people speak

different languages, they cannot communicate well. Even non-verbal communication such as

body language might mean something else in different cultures (Norouzinia et al., 2015).

Despite a significant benefit of therapeutic communication, heath care providers still identify

barriers that decreases its efficiency such as time limitations, barriers in information domain

not checking on patient’s level of understanding lessening education, preoccupation with

medical records and the inability to establish rapport (Albahri, Abushibs, & Abushibs, 2018).

Worldwide motion of individuals heightens cultural interaction resulting in inability to create

a uniform and standardized way of living thus increasing cultural conflict. Such barriers to

health care services were noted not only in language and information, but also in sociocultural

and economic aspect (Kuan AS, et. Al., 2020). As a result, nurses might neglect patients that

are not culturally inclined with them that has a very big impact in the provision of nursing care

(Ian, 2020). This proves that culturally competent nurses are vital in providing quality care for

all, resulting to better patient outcome (Sharifi, Adib-Hajbaghery & Najafi, 2019). However,

despite great efforts to improve cultural competency, there are still noted barriers on achieving

culturally congruent care such as lack or less of self-assessment or to be self-aware, assumption

of patient’s knowledge and lastly lack of experience or opportunities to experience other

cultures (randpierre, Koneru, Swartzman, & Lai, 2018). Moreso, there are still nurses that are

not culturally competent that needs to be addressed urgently.

Effective communication with patients from different cultures is necessary for

understanding and giving the best possible care, and intercultural nursing demands nurses to

treat patients as distinct persons while taking into consideration their cultural needs (Tuohy,

2019). Culturally competent care is defined by the National Quality Forum as any healthcare

organization's ability to render safe, high-quality, patient- and family-centered (National

 9

Quality Forum, 2009). By reducing inequities and enhancing patient outcomes, cultural

competency helps nurses and the entire healthcare team provide patient-centered care

(Betancourt, 2003). To make sure that care is really focused on the patient and culturally

competent, we need to work on measuring cultural competence that will help create a standard

set of practices for patient-centered care (Ahmed, et al., 2018). Clinicians with high level of

cultural competence will continue to be essential to health care because the patient population

is becoming increasingly diverse. To do this, they need to comprehend how complicated culture

is (Brommelsiek, Peterson, & Amelung, 2018). This is why this study wants to find out how

expatriate nurses' ideas of cultural competency and individualized care are related. The results

of the study could help improve the quality of care in the community.
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Statement of the Problem

The main objective of this research is to find out how cultural competency and the

perspective of patient-centered care are related among nurses in a tertiary hospital in Riyadh,

where they must deal with a lot of different cultures in health care. As a result of cultural

diversity, cultural conflict arises diminishing patient-centered care. As a requirement, cultural

competence becomes an essential element of any healthcare system’s ability to respond to

diversity. As nurses, we are bound and obliged to be an efficient and effective role model to

promote an environment where patient safety is always the most important thing. Even though

a lot of work has been put into making culturally competent care more important, there is still

no framework that everyone agrees on. It is very important for Saudi hospitals to do cultural

competence assessments when giving patient-centered care to support the country's efforts to

change their current strategies, improve health care delivery, and make sure patients have good

results. The study aimed at determining if there is a link between nurses' cultural competence

and provision of patient-centered care giving importance to identified core competencies in the

literature when dealing with a multicultural team providing care to immigrants of diverse

cultures. The researcher intends to provide a study that can be used by the present

administration as a reference to find out how culturally competent the nurses are and how well

they provide patient-centered care.

Objectives of the Study

This research assesses the cultural competence and patient-centered care approaches of

nurses at the largest tertiary hospital in Saudi Arabia, with particular emphasis on the

difficulties encountered by foreign personnel in addressing the varied needs of patients. By

pinpointing deficiencies and opportunities for enhancement in these domains, the study seeks

to improve the standard of nursing care and foster better health outcomes.
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The specific objectives of the study are:

1. To determine the respondents demographic profile in terms of:

1.1. Sex

1.2. Nationality

1.3. Educational attainment

1.4. Years of expertise

2. To describe the nurse’s cultural competence level in a tertiary hospital in Saudi Arabia in

terms of:

2.1. Cultural awareness ability

2.2. Cultural action ability

2.3. Cultural resources application

2.4. Self-learning cultural ability

3. To describe the perception on patient-centered care provided among nurses in a tertiary

hospital in Saudi Arabia in terms of:

3.1. Clinical situation

3.2. Personal life situation

3.3. Decisional control

4. To determine the relationship between cultural competence level and their perception on

patient-centered care provided by nurses in a tertiary hospital in Saudi Arabia.

5. To determine the relationship between cultural competence and perceived perception of

patient-centered care provided with the demographic profiles in terms of:

5.1. Sex

5.2. Nationality

5.3. Educational Attainment

5.4. Years of expertise

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Significance of the Study

The present study aims to the following groups and individuals, namely:

Nurse. Healthcare workers from both abroad and locally will learn more about being

culturally competent and how they view patient-centered care. This help them improve their

abilities and interactions with the patients they care for.

Health care provider. This will also be beneficial to the organization in building a

culturally competence patient-centered care organization working together aiming to a

common goal and objective. By integrating the concepts of cultural competency and patient-

centeredness together, services are aligned to fulfill the requirements of every patient, ensuring

that the community receives high-quality care. The results can be used by hospital

administrators and leaders to create focused training initiatives and regulations that foster

cultural competency and raise the standard of patient care generally.

Patients. Patients will benefit from improved nursing practices that are responsive to

their cultural needs, leading to improved health and greater satisfaction, as patients receive

more personalized and culturally sensitive care, fostering increased trust in healthcare

providers and a more positive overall healthcare experience.

Health care sector of Saudi Arabia. This study can help the health care system in Saudi

Arabia provide better care to patients from many other countries, especially Saudi patients.

Saudi Ministry of Health. The study can also serve as a reference to the Saudi Ministry

of Health in developing strategies that promotes culturally sensitive patient-centered care. This

study will be a significant effort in the promotion of a good and healthy environment within a

culturally diverse workplace. Ensuring a working environment that is welcoming not just to

patients but also to the health care provider decreases schism, resulting in a highly productive

quality work and satisfaction.

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Researchers. The study will also be beneficial for researchers providing an expanded

range of knowledge promoting transcultural nursing and patient centeredness. Furthermore, the

manuscript will also serve as a future reference for researchers and students about transcultural

nursing.

Future Researchers. This will also allow the future researcher the opportunity to fulfill

her responsibility to the entire community promoting peace and harmony.

Scope and Limitations of the Study

The goal of this study was to find out how culturally competent and patient-centered

the nurses were in a tertiary hospital in Saudi Arabia. Data collection includes nurses at all

levels. This study was limited to those working in tertiary hospital in Riyadh, Saudi Arabia.

The study assessed the cultural competency of nurses who worked in the same hospital for a

year in the same unit. Because only one Saudi Arabian hospital was used for the study, the

results' applicability was limited. Time constraints due to an ongoing pandemic may have

affected the researchers' ability to reach all eligible participants. The survey was conducted by

disseminating a questionnaire available only in English. The study focused solely on nurses'

cultural competence and patient-centered care, excluding other healthcare challenges. The

findings help to better understand cultural competency in nursing practice in Saudi Arabia.

More study is suggested to investigate these issues in various healthcare settings and expertise

levels.
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Chapter 2: Theoretical Background

This chapter examined various literature, studies, and theoretical frameworks to

emphasize the importance of the present research. It employed databases such as PubMed,

CINAHL, and Scopus. Essential search terms included "cultural competency," "patient-

centered care," "nursing in Saudi Arabia," "expatriate nurses," and "healthcare quality," which

led to a complete understanding of the current research environment and emphasized the need

for additional research within the context of Saudi tertiary hospitals.

Review of Related Literature

This chapter critically examines at several pieces of literature, studies, and theories to

show how important this investigation is. The study is going to investigate at how culturally

competent nurses are in a tertiary hospital, how they see patient-centered care, and how cultural

competence and perceptions of patient-centered care are related among nurses in a tertiary

hospital.

Cultural Competence Level among Nurses

Systems that offer culturally competent care consider the various values, beliefs, and

behaviors of their patients. Stated differently, healthcare is customized to accommodate

individuals from diverse social, ethnic, and linguistic backgrounds (AHA, 2019). According to

the same study, a culturally competent organization understands how individuals from various

cultures interact with one another, how cultural differences can impact people, how to learn

more about other cultures, and how to adapt services to accommodate cultural differences

(AHA, 2019).

Cultural competence is highly individual. While some studies suggest certain groups

may demonstrate higher levels of cultural competence (Maryunani et al., 2021), this does not

mean that all individuals within those groups do, or that individuals in other groups are

necessarily less competent. Additionally, there is a recognized need for further cultural
 15

knowledge enhancement among expatriate nurses, particularly those from India and the

Philippines (Inocian et al., 2015). Park et al. (2012) found that individual personality traits play

a bigger role than culture in shaping how directly people communicate. While culture

influences communication, it does not fully determine it—there is wide variation even within

the same culture. As a result, although demographic factors can provide a foundation for

grasping cultural differences, they should not be relied upon to forecast a person's cultural

competence. Instead, experience, communication abilities, self-awareness, and a readiness to

learn serve as more dependable indicators (dе Guzman et al., 2016).

The National Center for Cultural Competence defines "cultural awareness" as being

aware of what is common and different between cultural groups (Goode & Dunne, 2004).

"Cultural action ability" means that nurses are capable of adapting their services to respond to

the cultural needs of their patients (Lin et al., 2019), while "cultural resources application"

involves utilizing significant cultural sites and artifacts that resonate with specific groups

(Carter, Helms, & Juby, 2002). "Self-awareness" is being able to think about who you are and

what your personal beliefs are (Silvia & O'Brien, 2004).

I cannot stress enough how important it is for healthcare workers to be culturally

competent. The European Commission's Expert Panel has made it clear how important it is for

healthcare to be aware of cultural variations so that everyone can get the care they need (Saso

et al., 2008). Ignoring these disparities is not simply a mistake; it can also contribute to bad

consequences for patients. We are talking about wrong diagnoses, adjusting treatment that are

not necessary, and patients being less inclined to follow their doctor's advice (Brach et al.,

2002). It is not enough to know the facts and therapies; you also need to know the person, their

background, and what they need to feel really supported. If physicians and patients do not know

how to communicate with people from different cultures, it can be very hard to do so and this

can lead to reduced satisfaction and trust (Tang et al., 2018). Not understanding someone's
 16

cultural background might cause problems and make it hard for them to get the best care. And

in nursing, the effects can be much more direct: wasted time, frustration, and

miscommunication—problems that could be avoided with the right training (Albagawi,

2019). This is why I think it is not only important but also significant to make healthcare

systems more culturally competent. It is a means to improve the quality of care, get better

patient outcomes, and, most significantly, fix the obvious racial and cultural health gaps we

observe around the world (Narula & Prakash, 2022). The American Association of Colleges of

Nursing has been pushing for nurses to learn about cultural competency since the 1990s

(Almutairi et al., 2017) and this should be a focus which is very important for the future of

healthcare.

Cultural competence is more important than ever in Saudi Arabia because the country

is becoming more diverse which is especially true in healthcare. There may not be a lot of new

studies from 2022 to 2024, but the ones that have already been done make it obvious how vital

cultural competence is for providing good care in this increasingly diverse environment

(Hashish et al., 2020). This is a natural step for the Kingdom when more people from different

cultures are coming together, and we need to know how to care for patients whose origins may

be very different from ours. Hashish et al. (2020) say that nurse teachers need to be culturally

competent so they can teach their students how to care for patients from different cultural

origin. It is not just about learning from books and practicing clinical skills; it is also about

learning about cultural differences and how they affect healthcare. It also makes a lot of sense

that nurses in Saudi Arabia should take cultural competency and foreign language lessons as

part of their ongoing education (Cruz et al., 2017). It is not enough to only cure sickness; you

also need to know how a patient's culture, religion, and social life affect their experience and

care choices. This step seems like a vital investment for the long-term success of healthcare in
 17

the Kingdom. We can get past possible problems with language and culture by doing these

things, which will help both patients and healthcare providers (Hashish et al., 2020).

Cultural Awareness Ability

Nurses need to be culturally competent, especially when they work with a wide group

of patients, how it helps nurses give care that is not only a professional kind but also kind,

flexible, and sensitive to each patient's cultural needs (Sharifi et al., 2019). On the other hand,

it is not enough to just understand other cultures; we also need to be aware of how our own

cultures affect how we think, act, and relate to others and it is called cultural awareness which

is a big aspect of cultural competency. It is more than just acknowledging differences, it is also

about being aware of how my own culture affects how I interact to people. It is not enough to

just learn about different cultures; you also need to understand why people from those cultures

believe and act the way they do. As a nurse, you should also accept the thoughts, beliefs,

traditions, and choices of patients from all walks of life. For example, some patients had special

dietary needs because of their religion or culture. It is not enough to just change the treatment

to fit the person's physical needs; you also need to know what their overall needs are.

When nurses know more about different cultures, they can better identify and deal with

any biases or mistakes that may happen with patients. People who are more culturally aware

are more sensitive and loving when they care for patients, which is helpful for getting along

with people from other cultures (NurseJournal, 2019). A study by Campinha-Bacote (2002)

says that knowing other cultures is a basic and very important part of cultural competence.

Effective communication, respectful behavior, and planning care based on national views are

all examples of culturally competent care practices. This is more likely to be done by nurses

who are culturally aware. People who get treatment in this way may have better outcomes, be

happier, and be more likely to stick to their goals.

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Another study by Govere and Govere (2016) found that nurses who knew more about

different cultures were better at setting the needs of their patients first. Patient-centered care is

a way of providing care that takes into account the patients' cultural beliefs, attitudes, and

desires. People think that being culturally competent as a nurse is an important part of taking

good care of patients, especially in a lot of different health situations. With this appreciation

and respect in mind, the ability nurses have for cultural differences is going to have a direct

impact on patient satisfaction in terms of health outcome, prevention of healthcare disparities.

Saha et al. (2018) assert that cultural competence is what would make it feasible for people

from diverse cultures to communicate better, build trust, and eventually give better care to

patients. To become culturally competent, you need to learn new things and improve your skills

in areas that can be measured with tools like the CCAT and IAPCC. But in this scenario, it is

important for health providers (Betancourt, 2006).

A long list of barriers hampers the building of culture competence in nurses. As

explained earlier, some of the above barriers also include training and have a few who complain

they rarely have spare time, yet others, having poor linguistic skills and language ability or

proficiency do not aid one in improving the cultural communication relationship. Altogether,

the above listed all constitute difficult challenges across different cultures within effective

practice (Hart & Mareno, 2013). There is agreement among most nurses that, indeed most do

not experience preparedness of cultural care mainly due to minimal nursing education curricula

emphases on cultural competencies within their learning practice (Alexander, BeLue, Kuzmik,

& Boltz, 2020). This is further compounded by the institutional barriers such as lack of support

in organizations, low representation of diversity in the nursing workforce, and this tends to

hinder the full realization of cultural competence (Fekadu, Andualem, & Gebresilassie, 2021).

Hence, at the core of the nursing education provision is education and training on

cultural competence. Roberts, Warda, Garbutt, and Curry (2014) contended that simulation-
 19

based learning for training cultural competence increase cultural awareness among nurses. It

is, therefore, likely that such training, if designed with case scenarios that are practical,

culturally diverse, will ensure that nurses are better prepared to understand the diverse needs

of different patient populations. (Farokhzadian et al., 2022). This developed as a more fluid

process, such as the cultural humility process where one must constantly reflect on themselves

and learn from the patient instead of assuming that they know (Foronda et al., 2020). In the

same way, Burden et al. (2012) stress that education should help future educators understand

and accept different cultures by encouraging them to appreciate, adjust to, and include diverse

backgrounds. This helps build their cultural awareness and skills.

It is also clear that cultural competency is becoming more important in nursing practice.

A lot of countries, like the US, UK, and Australia, have programs to help nurses understand

other cultures. However, success is dependent on health policies, diversity of the workforce,

and attitudes toward immigrants (Hashish et al., 2020). As nurses' roles change in diversified

health care systems, they need to keep learning and growing so they can provide excellent

cross-cultural care. This would improve patient care and lower health inequalities (Butler et

al., 2016).

Cultural Action Ability

Cultural action ability represents a critical dimension of cultural competency in nursing,

emphasizing the practical application of cultural knowledge and understanding in patient care.

This skill goes beyond just being aware of cultural differences; it means that nurses must

actively change the communication approach and care for patients to meet their specific

cultural needs. Cultural competence starts with being able to communicate well. Nurses who

are good at cross-cultural communication are better at building relationships, getting the right

information, and making sure patients understand what they are saying. Squires et al. (2017)

said that nurses who are good at this kind of communication are more likely to give care that
 20

is culturally appropriate. Also, cultural action ability includes putting the patient's cultural

values, traditions, as well as preferences to their care plan. This could mean changing how

treatment is given to respect cultural preferences, such food restrictions, or the use of alternative

remedies. Leininger (2002) stressed the necessity of incorporating cultural values into

healthcare practices. He said that nurses should actively try to learn about and respect the

customs and practices of their patients.

In short, nurses who want to give care that is culturally competent need to take cultural

action. They need to work hard all the time to learn about their patients' varied cultures and be

able to adapt how they care for them based on what they learn (Covington, 2001; De &

Richardson, 2008). This way of doing things not only makes care better, but it also makes the

healthcare system more equitable and open to everyone. This makes patients happier and

healthier (Nashwan, 2023). Nurses may effectively connect different patient groups with the

healthcare system by improving their cultural action skills making sure that care is both

relevant and courteous.

Cultural competence has been described as the understanding, respect, and

effectiveness of the nurse in patient-culture interaction (Thomas, 2013). The case is even much

more important as most of the patients and health providers are from a different ethnic

background and backgrounds linguistically and religiously both. Nurses’ ought to understand

and appreciate various cultural differences which could impact health care beliefs and practice

and means of communication. Culturally sensitive nurses will be an advocate between a patient

and a healthcare system for the kind of care offered in the care delivery to not only be clinically

right but respectful of and responsive to the need of a patient (Cultural Care in Nursing:

Challenges & Strategies, 2024). This helps to establish trust between the health providers and

the patients, contributes to high patient satisfaction, and brings about positive health results
 21

since it makes medical practice fit the values and choices of patients' cultures (Tang et al.,

2019).

Nursing requires cultural competence, especially in patient-centered care that addresses

each person's needs, preferences, and values (Epner & Baile, 2012) which is crucial in varied

countries like Saudi Arabia with traditional and modern healthcare systems. Nurses must be

aware of cultural differences in their daily work. Simple actions, such as respecting a patient’s

cultural background when making decisions or providing emotional support, are essential

(Abalos-Fabia et al., 2019). Culturally competent nurses communicate better, help reduce

healthcare disparities, and improve patient outcomes (Alsharari et al., 2024). They develop

trust and a good relationship, which are important for good care and happy patients. This

method not only helps nurses and patients communicate better, but it also encourages patients

to tell nurses important things about their health and worries. Also, culturally competent

treatment considers a person's physical, emotional, and social requirements. Seeing patients as

a whole helps nurses serve them better (Jasemi et al., 2017). In the end, putting more emphasis

on cultural competency in nursing leads to a fairer and more just healthcare system that helps

both patients and healthcare providers.

Cultural Resources Application

Cultural resources application involves using translators, cultural consultants, and

community organizations to bridge the cultural and language gap between healthcare personnel

and diverse patients (Douglas et al., 2014). Cultural competence in healthcare, communication,

and care delivery require this process (Swihart, Harding, & Riekert, 2019; Smith, 2021).

Interpreters enhance patient understanding and satisfaction, particularly for non-English

speakers, which can lead to better compliance with treatment plans (Betancourt et al., 2003;

Flores, 2005). Cultural consultants offer important insights into patients’ cultural beliefs, which

helps providers give culturally sensitive care (Coronado, 2013; Kleinman & Benson, 2006).
 22

Community resources play a key role by linking providers and patients to relevant social

services and culturally appropriate support (Swihart et al., 2019; Foti, 2014). These resources

increase patient satisfaction and health outcomes (Lavizzo-Mourey, 1996). Educational

materials and workshops also enhance nurses’ understanding of various cultural values and

communication styles, allowing for more personalized care (Harkess & Kaddoura, 2015;

Sperry, 2010). These materials help healthcare staff create an environment where all patients

feel understood and appreciated. Culturally competent clinicians must also understand that

gestures, facial expressions, eye contact, touch, and proximity affect communication across

cultures (Long, 2011). They should be mindful of their own nonverbal cues as well as their

patients' body language to better understand their needs. This awareness helps build trust and

enables providers to offer courteous, compassionate, and culturally appropriate care.

Self-Learning Cultural Ability

Self-directed cultural ability is an important part of cultural competence for nurses. As

a nurse, you should always be trying to learn about and understand the different cultures of the

people you care for so you can give them better, more personalized care (Seomun et al., 2021).

This also shows that nurses are in charge of their own growth and development in terms of

cultural competency. Nurses can better serve a culturally diverse patients by actively searching

information and learning about diverse cultures. For instance, nurses can improve their cultural

competency by reading about different cultures, attending job-related training, and attending

cultural awareness and sensitivity courses. These activities assist nurses understand how their

experiences and culture effect patient communication. Researchers found that nurses who learn

about other cultures can better recognize and manage cultural differences. This allows them to

provide better, culturally relevant care (Hern et al., 2005; Papadopoulos, 2004). This

continuous training helps nurses understand and satisfy the needs of people from diverse

cultures to make healthcare more welcoming and enhance patient outcomes. Self-learning is
 23

important because it lets nurses give patients care that meets all of their needs—physical,

emotional, social, and spiritual—within the context of their culture (Seomun et al., 2021).

Purnell (2013) emphasizes the need for constant self-learning in nursing, urging nurses

to actively pursue opportunities to enhance their cultural competence. In summary, self-

directed cultural ability is an important and ongoing journey that helps nurses give care that is

effective, respectful, and culturally sensitive. It is important for nursing education and practice

to focus on self-learning to improve healthcare outcomes for different groups of patients.

Perception of Patient-Centered Care among Nurses

The Institute of Medicine Committee identified patient-centeredness as one of the goals

for making the healthcare system better in their book Crossing the Quality Chasm. According

to the committee, all clinical decisions should be based on the patient's values, and each

patient's needs, preferences, and values should be respected and taken into consideration when

providing care (IOM, 2001). The IOM Reports also discussed the importance of education for

healthcare professionals in another report. This is important to lower health care disparities and

help healthcare workers understand how social and cultural factors affect individualized care

(IOM, 2003). The IOM also said that healthcare providers could improve communication and

trust by understanding different values, beliefs, and requirements of their patients. This leads

to better health outcomes. Adding these things to care delivery can also assist make sure that

all patients get tailored, effective, and courteous care, no matter where they come from.

To elaborate, nurses can support patient individuality by actively listening to patients,

understanding their preferences, and adapting their interventions accordingly (Chen et al.,

2021). This includes promoting patient autonomy by involving them in decision-making and

showing empathy to build trust (Charalambous et al., 2010). Furthermore, nurses evaluate the

maintenance of individuality through reflection, patient feedback, and collaboration with other

healthcare professionals (Chen et al., 2021; Uno, 2019). Challenges in providing individualized
 24

care may arise from factors such as the work environment or staff shortages (López‐Domingo

& Rodríguez‐Martín, 2020). Other researchers found that the key components of patient-

centered, culturally competent care involve treating patients the way we would like to be treated

in times of vulnerability and fear. They concentrated on patient-centeredness, founded on

respect, sensitivity, composure, collaboration, honesty, discernment, curiosity, and tolerance

(Epner & Baile, 2012). Researchers advocate for the formulation of metrics for patient-

centeredness and cultural competence, as these two healthcare concepts have received

significant attention and momentum over the past decade, both aiming to enhance healthcare

quality (Saha et al., 2008).

Focusing on the nurse’s view about individualized care, literature review discusses 3

important domains; (1) clinical condition, (2) personal life, and (3) sense on control over care

related decisions (Radwin, 1995; Happ, et al., 1996; Suhonen et al., 2004, 2005). The first

dimension focuses on the progression of disease and how individuals react differently based

on their sensitivities and predisposing factors. These factors include personal health

management, vaccination status, lifestyle choices, and other characteristics that impact how a

patient responds to treatment (Fierz, 2004). Additionally, everyone’s lifestyle and personal

experiences play a significant role in their care since the patient possesses unique insights into

their disease and coping mechanisms that others may not fully understand (Shepherd et al.,

2018). Furthermore, even in similar circumstances, each patient is unique because their mood

and level of commitment to the treatment plan affect their willingness to take part in their own

care and decision-making. To improve their ability to make decisions and provide support,

nurses must thus give patients and their families thorough information (Molina-Mula et al.,

2020). Unfamiliarity with the country’s specific cultural characteristics, particularly the health

care system, results in nurses having difficulties in adjusting to Saudi culture and worst is that

they may experience culture shock (Lamadah, 2014). Creation of quality indicators that
 25

measure cultural competence is necessary to assess that care is genuinely patient-centered and

culturally competent. Without indicators, it is challenging to track whether improvements in

healthcare delivery are occurring (Ahmed et al., 2018).

The author of the article "Exploring the Impact of Patient Perceptions of Health Care

Provider Cultural Competence on Health-related Quality of Life among an Immigrant

Population" (Zghal, 2018) says that there is still huge gap in studies about the link between

culturally competence, patient-centered care and health-related quality of life. The author

looked at a number of tools that measure cultural competence from the patient's point of view.

The connection between cultural competency and patient-centered care is now inadequately

defined, potentially hindering the implementation of patient-centered techniques among Saudi

Arabians (Almutairi et al., 2014). Hall (2020) asserts that providing patient-centered, culturally

competent care is essential as it increases patient engagement, nurses' quality metrics, insurance

reimbursement, and patients' perceptions of treatment quality, hence enhancing adherence.

Nurses' perception is one of the key components that ensure the successful

implementation of patient centred care in the health care environment. Most studies that have

discussed the perception of nurses regarding patient centred care found a substantial awareness

of its importance in increasing patient satisfaction, health outcome, and general quality of care.

However, the willingness of nurses to provide that care is affected by educational background,

workload, and level of support from the hospital (Puntillo et al., 2019). Most of the nurses

know that the fulfilment of emotional, social, and cultural needs of patients is required in

different settings, but they complain about not practicing patient centred care daily because of

the number of patients, less time available for each patient, and less training on communication

skills (Joukar et al., 2021). For instance, Lee et al. (2020) showed that nurses have a good

understanding of the theoretical concepts of patient centred care but is still very challenging to
 26

put them into practice in the acute care environment where most of their time is absorbed in

clinical work.

Professional values and organizational culture also determine the nurses' perception of

patient centred care. In another study, Aghajani et al. (2021) found that nurses are more likely

to perceive patient centred care positively and enact it more effectively in practice if there is a

commitment of hospitals to patient-centred care and support leadership. Lack of institutional

support-for example, inadequate staffing and resources was identified as a barrier to the

effective delivery of patient-centred care (Ohr et al., 2022). Although the nurses said they

exerted efforts to establish therapeutic alliances with the patients, the rules in the institution

emphasized efficiency more than participation in an attempt to thwart the possibility of care

being customized. The studies clearly demand constant professional development and systemic

changes favourable to the holistic care-giving activities of the nurses.

Clinical Situation

The physical, emotional, and behavioral reactions of a patient to their illness and

treatment are all included in their clinical condition while they are in the hospital (Engel et al.,

2022). The framework of patient-centered care, which places an emphasis on each patient's

unique preferences, needs, and values, is helping to better understand this complex response

(Aboumatar & Cooper, 2013; Catalyst, 2017). These techniques document changes in the

patient's emotional health, physical health, and level of engagement in care activities (Austin

et al., 2020). Patients should be actively engaged in owns care, given timely and correct

information, and encouraged to make self judgement (Patient- and Family-Centered Care

Defined, 2023) are some of the most important concepts of patient-centeredness.

When nurses make individualized care plans for each patient, they need to be culturally

sensitive to make sure that the care they respect the patient's cultural beliefs, values, and

practices. With this approach, nurses need to know a lot about their patients' cultures and think
 27

about how those cultures might affect the decisions they make about their health care. There

are a lot of different kinds of people living in Saudi Arabia, both Saudis and foreigners from

many different religious, racial, and cultural groups making cultural competence even more

complicated. When working with patients in this setting, nurses need to be aware of the many

beliefs, practices, and beliefs that patients may have especially true when it comes to treatment

choices, attitudes towards healthcare, and beliefs about health in general (Rivera, 2020).

Cultural competence is also something that nurses do every day that helps build trust between

them and their patients. When patients feel like their culture are understood and accepted, they

are expected to feel at ease, supported, and in charge of their healthcare. By making sure that

cultural proficiency is a key part of planning individualized care, nurses not only make the

experience of patients better, but they also help healthcare be more effective and complete.

There is a lot of evidence that shows that personalized care plans are very helpful for

improving patient satisfaction and health results. Patients are more expected to follow through

with their care plans if they get care that is specifically tailored to their needs and tastes. This

will improve their health in the long run. For instance, Greene et al. (2015) discovered that

patients who were given personalized care plans were more likely to stick to their treatment

plans. It was this dedication to the recommended treatment that not only improved their health

but also made them happier with the care they received. These results show how important it

is to have an approach that is patient-centered, which means that the care plan is changed to fit

the patient's preferences and circumstances.

Patient-centered care, which puts the person at the center of the healthcare process,

depends on personalized care plans that is not generic is made possible by these plans (Karout

et al., 2013). Instead, care is tailored to each patient's unique tastes, values, and needs. This

one-on-one approach is very important for building a therapeutic connection based on trust,

respect, and understanding. As the people who care for patients the most, nurses are very
 28

important in making and carrying out these plans (Shubair, 2023) (Karout et al., 2013) (Salam,

2022). They can get a lot of information from patients because they talk to them directly. This

includes the patients' medical history, current health, and any important social or cultural

background. This helps nurses develop a care plan for the person, taking into account their

physical, mental, emotional, and social health. This is how nurses make sure that patients get

the care they need. This leads to improved treatment and a better overall healthcare experience

(Salam, 2022).

When patients think that their healthcare workers understand and value them, they are

more happy with their care. Patient satisfaction and cultural competency are closely linked to

patient-centered nursing care, as discussed in (Darnell & Hickson, 2014). Nurses working in

Saudi Arabia need to be prepared to handle the country's varied cultural environment. To

successfully deal with this diversity, nurses need to be aware of the small but significant

cultural differences that may affect how a patient makes decisions, interacts with family

members, and talks to others. In Saudi culture, for example, family is very important when it

comes to health care choices, especially when it comes to children or older people. As is

common in more traditional families, choices might not just be made by the patient. Instead,

they might be made by the patient's family or the male head of the household. Abalos-Fabia et

al. (2019) also looked at the behavior, awareness, and sensitivity of healthcare workers in

multicultural situations looking specifically looked at how these workers deal with cultural

differences when interacting with patients.

Self-care tools and support are important parts of patient-centered care because they

give patients an active role to make their own health decisions and improve their overall health.

If people have the right information, tools, and help, they can make smart decisions about their

health, which can improve their health. As the patient's main caretaker, nurses are in a unique

situation to help them take charge of their own health. They can help patients better understand
 29

their conditions and take care of their health by giving them useful tools, education, and

counselling (Smith, 2018). Looking into patients with long-term or chronic illnesses as an

example need this help the most because they must deal with their condition. Because they

know how to look after of themselves, these people are more likely to be able to deal with their

conditions well, lower their risk of complications, and keep their quality of life high. Nurses

can help patients deal with difficulties of chronic illnesses by giving them ongoing advice and

making sure they feel strong and ready to take care of their health every day. Being involved

in their own care not only makes them healthier, but it also gives them more confidence and a

sense that they are responsible for their treatment. In a study on the effects of self-care support

on patients with chronic conditions, Hwang et al. (2016) discovered that patients who had

access to sufficient resources and support for self-care experienced better health outcomes,

such as better quality of life and symptom management.

Being in the hospital can be stressful and cause symptoms and anxiety (Saxon, 2018).

Psychological distress (The Title Is Simply "Distress," 2024), anxiety (Nursing Care Plans For

Anxiety, 2009), and even post-traumatic stress disorder (Callus, 2022) might happen during

this time. Nursing care is very important for mental health since it helps people talk to each

other, understand their treatment, stay oriented, and feel safe (Pattison, 2005). It is important

to keep an eye on a patient's clinical condition, including how they feel and act, in order to give

them holistic and patient-centered care (Aboumatar & Cooper, 2013). Additionally, a key

element of nurse conceptions of individualized care is their capacity to offer resources and

support for self-care. Patients believe that the care they receive is customized to meet their

needs and preferences when nurses are able to assist them in their self-care endeavors. Better

patient outcomes and increased job satisfaction may follow from this (Ruel, 2020).

Patients can learn about their problems, treatment options, and possible risks from

nurses, which helps them make smart choices regarding their care. According to Zupa et al.
 30

(2021), dyadic therapies that include both patients and family supporters can help people with

type 2 diabetes manage their condition. This study shows how helpful it is for family members

to help patients control their own care. Also, Castro et al. (2016) talks about the ideas of patient

empowerment, participation, and patient-centeredness in hospital care, stressing how important

it is for patients to be actively involved in their own care. Nurses can also help people learn

how to manage their prescriptions, notice and respond to changes in their health, and find

community services. Chen et al. (2023) focuses on shared decision-making tools, but it also

makes the case for involving patients in healthcare decisions, which is in line with the concepts

of self-care support. Coulter (2012) goes into more detail about effective ways to get patients

involved in their care, giving examples of interventions that encourage patients to take an active

role in their care.

In a tertiary hospital setting, nurses often work with doctors, specialists, therapists, and

other medical professionals as part of a multidisciplinary team. This teamwork lets healthcare

professionals develop a full care plan that considers every aspect of the patient's health and

well-being. Using a team-based approach lets you look at all the patient's needs (Valseno,

2020). When care is coordinated, people get the appropriate care in a timely manner, which

improves their overall experience. If you work with other healthcare workers and make sure

that care plans are followed, this can lower the risk of medical mistakes, make patients happier,

and help with continuity of care. Patient-centered healthcare (Yakusheva et al., 2024) depends

on this coordinated approach that encourages multidisciplinary team to talk to each other and

work together to make sure that patients get full and smooth care. Nurses play a big role in

making sure that this coordinated process works for the entire team. They are in charge of

making a care plan for a patient that considers all their needs and protects their health and well-

being (Gloster et al., 2021). This team-based approach lets each healthcare worker use their

own special skills while working together. This helps patients get better care at a lower cost.
 31

Coordinated care is better for patients because they do not need to go to the hospital as often

and their general healthcare costs are lower than those who do not get it (Herrera et al., 2015;

Karam et al., 2021; Lee & Bae, 2018). In a major hospital like this one, nurses play a big part

in these good results and are an important part of the healthcare team (Herrera et al., 2015).

Personal Life Situation

A patient's personal life situation, encompassing their cultural background, habits,

beliefs, and previous experiences, significantly influences their response to a management plan

and their illness (Speck, 2016). This personal context shapes how individuals perceive their

health, adhere to treatment, and interact with healthcare providers.

There are a number of factors that make this effect happen. People's cultural views can

change how they look for health care, what kind of treatment they want, and how they talk to

each other (Harrison et al., 2019). Particularly with regard to the treatment and prevention of

chronic diseases, the complex relationship between everyday behaviors and health outcomes

has attracted a lot of attention (Michaelsen & Esch, 2022). Personal beliefs, such as spiritual or

religious ones, might help people deal with illness and make decisions about how to live their

last days (Speck, 2016). Additionally, past experiences with healthcare affect expectancies,

faith in the medical system, and following future treatment recommendations (Homa et al.,

2023). Healthcare workers need to know about these specific aspects in order to give care that

is tailored to each patient, effective, and focused on the patient (Aboumatar & Cooper, 2013).

Healthcare practitioners need to know these specific aspects in order to give individualized,

effective, and patient-centered care (Aboumatar & Cooper, 2013). Betancourt says that cultural

competency has changed to include abilities that put the ideas of patient-centered care into

action (Betancourt, 2006). This means going beyond just learning about a patient's past and

instead learning how to give good care, no matter what distinctions there may be (Betancourt,

2006).
 32

Decisional Control

How and what a patient knows about their condition have a big impact on how much

control they feel they have over choices about their care (Brach & Fraserirector, 2000). This

part of the measure is very important when talking about cultural competence and patient-

centered care because it acknowledges that the patient has the right to make their own choices

and that it's better to make choices together (Humbeeck et al., 2020). People should take part

in their own care, which has been proven over and over again. In this case, "patient activation"

means that the patient can do more and thinks that the standard of care is better. They have

trust in their own abilities and know how to take care of their own health (Alegría et al., 2009).

Alegría et al. (2009) say that people are more likely to talk to their doctors, say what they want,

and follow their treatment plans when they feel informed and in charge. Not being able to

understand or change things can make people anxious, alone, and unhappy with their care, on

the other hand. It's even more important to respect patients' views and ideals when making

decisions when you know about their culture (Aboumatar & Cooper, 2013). Some cultural

groups might like a family-centered approach, in which everyone in the family is involved in

decisions and talks (Brach & Fraserirector, 2000). Healthcare providers need to be aware of

these tastes and change how they talk to patients and make decisions based on them (2023).

Healthcare workers can improve patients' health and make them happier by making the

workplace a place where everyone works together and where patients feel valued, respected,

and in charge (Nápoles et al., 2009).

The main goal of patient-centered care is to improve general health and how important

it is to help patients stay healthy and avoid getting sick. Nurses are very important in this

because they teach, advise, and provide preventive care to their patients. Dow (2018) says that

nurses can greatly improve their patients' health and help keep them from getting sick by doing

these things. Teaching patients about their health helps them avoid illness. Nurses educate
 33

patients to make healthy choices such as teaching them how to diet, exercise, and manage

stress. Nurses can collaborate with patients to develop health care plans, reduce risks, and stay

healthy through counselling. This personalized treatment helps patients stay healthy and feel

encouraged in long-term healthy choices (Dow, 2018). Patients at risk for chronic diseases or

who require help managing them may benefit from counselling (OpenStax, 2024). By coaching

patients, nurses can assist them improve their health and lifestyle.

Because the country's population is growing so quickly there is a big need for healthcare

that is sensitive to an environment coming from different cultural origin. Big hospitals have

people from many countries and backgrounds, so the people who work there need to know how

to understand and accept those differences. This means that everyone who work in health care

need to know about their patients' cultural norms and interests, especially when it comes to

how they like to talk to others, involve their families, and get treatment (Albalawi et al., 2020;

Falatah et al., 2022). Hashish et al. (2020) and Halabi et al. (2020) both say that cultural

competence is important to make sure that patients feel valued and understood in healthcare

situations. It is hard to figure out how to provide health care in Saudi Arabia because there are

both Saudis and people from other countries living there. Because they come from different

religions, countries, social norms, and languages, nurses and patients may find it hard to talk

to each other (Hashish et al., 2020). One thing that is very important here is to ensure that

patients feel like they are in charge of their healthcare decisions. For example, in some Saudi

families, health care choices are made as a group. Remember that family is a big part of making

choices, and be open to the patient's culture. This can be helped by nurses and other health care

workers who use translators or other tools that are appropriate for different cultures to make

talking to each other easier. Abalos-Fabia et al. (2019) say that this helps people fully

understand their options and feel like they have the power to choose how they are cared for. A

second way for doctors and nurses to gain patients' trust is to show that they value and respect
 34

their patients' cultural beliefs and values. Their health and happiness may get better because of

this (Albalawi et al., 2020; Betancourt, 2006). As a general rule, patients will do better with

their care and stick to their treatment plans if they feel like their cultural points of view are

known and valued.

Relationship between cultural competence level and perception on patient-centered care

provided among nurses in a tertiary hospital in Saudi Arabia

Cultural competence and patient-centered care are both meaningful ideas in healthcare,

but there is not a lot of evidence to support the idea that they go hand in hand (Saha et al.,

2008). For cultural competence to work, you need to see each patient as distinctive person,

understand their doubts and flaws, and value the moral side of the professional contact (Epner

& Baile, 2012). It means that healthcare workers should learn more about and be more sensitive

to different ethnic backgrounds so that they can provide care that fits with the patients' values,

beliefs, and preferences. Still, it's not always easy to go from knowing about culture to treating

patients in a way that is focused on them. Patients should be at the heart of care and evidence-

based practice don't always agree, which can be problematic (Engle et al., 2019). Patient-

centered care is seen as an important part of health care systems by many (Shyu, 2024; Liberati

et al., 2015). Communication is important for getting the good health results because it is based

on long-standing nursing principles that stress personalized care based on the patient's health

worries, beliefs, and contextual elements (Kwame & Petrucka, 2021). Certain research

indicates that although healthcare personnel could demonstrate enhanced cultural awareness

post-training, this enhancement does not necessarily result in modifications to clinical practice

or improved patient care (Truong et al., 2014). This disconnection may arise from the

intricacies of human interactions, wherein cultural factors converge with various other

variables, including socioeconomic status, educational attainment, personal experiences, and

individual preferences, all of which shape a patient's healthcare needs and expectations (Racial
 35

et al., 2003). Healthcare workers may possess cultural knowledge yet still fail to provide

patient-centered care if they inadequately integrate this awareness into their clinical decision-

making and communication practices (Kwame & Petrucka, 2021).

One big problem with making a clear connection between cultural competence and

patient-centered care is that it's hard to define and measure both of them (Gwyer & Hack,

2014). Cultural competence is a broad term that includes many different behaviors, skills, and

pieces of information (Grinberg & Nissim, 2025; Sue et al., 2008). Self-assessment tools or

subjective evaluations are often used to measure cultural competence, but they may not truly

show how well someone can provide culturally sensitive care in real-life clinical settings. The

human parts of care are clearly not included in the term "patient-centered access."

Communication isn't the only part of patient-centered care; it also looks at other things, like

how convenient office hours are, how easy it is to make appointments, how timely

appointments are, and how close services are to where people live (Saha et al., 2008). Care that

is patient centered is also very complicated, as it includes things like making decisions together,

communicating clearly, giving mental support, and respecting the patient's choices. It is hard

to measure how well different cultural competence interventions work and see how they affect

patient-centered outcomes across a wide range of healthcare settings and populations. There

are also not many good studies, which makes it even harder to understand how cultural

competence and patient-centered care are related. A significant deficiency in the research is the

absence of comprehensive frameworks for integrating cultural competency into nursing

education. This is made more difficult by the fact that faculty and nurse leaders don't know

much about how nursing practice and cultural events are connected (Leffers et al., 2017). A lot

of research looks at how healthcare professionals' knowledge, attitudes, and views change after

they get cultural competence training (Clifford et al., 2017). Up to now, though, most of the

tests only check for information, skills, and abilities, not real clinical competence (Purnell,
 36

2016). Cultural competence is an essential skill for healthcare to have, but not be seen as the

only way to provide patient-centered care.

The ethical responsibility tied to cultural competence is another area of complexity.

Nurses' ability to respect patients' values, preferences, and dignity directly influences the

ethical delivery of care (Milton, 2015). Yet, connection between cultural competence and

ethical decision-making can be challenging, especially when nurses face conflicting values

from patients, colleagues, or society (Dean et al., 2020). These ethical dilemmas, compounded

by language and cultural barriers, can make it harder for nurses to balance cultural sensitivity

with other aspects of patient care, further complicating the relationship between cultural

competence and patient perceptions (Donnelly, 2000; Berestova et al., 2019).

 37

Synthesis

The research says a lot about how cultural competence in nursing affects patient-

centered care. Here are some of the most essential things it says. First, it highlights how

significant it is for healthcare staff, especially nurses, to know and recognize cultural

differences for them to effectively manage health disparities. This means that care must be

given fairly and without any discrimination. Making sure that healthcare systems understand

and respect the patient’s diverse backgrounds is an important part of being culturally competent

improving health outcomes and general well-being. Many people agree on how important it is

to be culturally competent, but there are not many ways to measure patient-centered care in this

setting. Once nurses understand cultural differences, they can better evaluate their patients and

make care plans that are more in line with their cultural backgrounds. In creating personalized

care plans, nurses can learn more about patients' health by encouraging open and respectful

communication and nurses depends on cultural competence. As healthcare becomes more

varied, nurses who learn about different cultures can communicate, accommodate cultural

preferences in care, and empower patients to be engaged in their treatment, which improves

overall nursing care. Regardless of ethnicity, culturally competent care reduces health

disparities by treating all patients similarly. It improves patient-nurse connections by fostering

respect and understanding. If nurses understand cultural variations, they can better fulfil the

varied demands of a variety of patients, improving treatment.

 38

Theoretical Framework

Based on Purnell's Model for Cultural Competence, this study shows how vital it is for

healthcare workers and patients from different cultures to build strong relationships. This

model is based on the idea that culturally competent healthcare workers helps provide more

patient-centered care by letting them treat each patient in a way that takes consideration their

unique cultural origin (Purnell, 2002). According to Purnell's model, cultural competence

includes a lot of important things, like knowing about a patient's cultural views, practices, and

values when it comes to health even considering things like their race, religion, language, and

personal healthcare habits (Purnell, 2002). Healthcare workers can give better care that fits

each patient's needs if they understand these different aspects. This leads to better health results

and greater patient satisfaction. The Purnell model is a helpful way for healthcare workers to

make sure that all their patients feel valued and understood while also providing medical

treatment effectively.

Figure 1. Purnell’s Model for Cultural Competence

 39

The Purnell Model takes this complexity into account by including many cultural areas

that are not always taken into account in other transcultural models, like biocultural ecology

and workforce problems (Purnell, 2000). There are twelve cultural domains that make up the

model: heritage, communication, family roles and organization, biocultural ecology, high-risk

behaviors, nutrition, pregnancy, death rituals, spirituality, health care practices, and health care

professionals (Odonel et al., 2019). Culture is not a fixed thing, and people from the same

culture can have different views, values, and behaviors. One's cultural identity and health-

related behaviors can be greatly affected by their socioeconomic position, education,

acculturation, and personal experiences. Also, cultural competence can be used in a lot of

different ways in the real world, depending on the cultural setting, the organization's culture,

and the relationships between people (Soekotjo et al., 2021).

It can be challenging to understand what the study implies (Lau & Rodgers, 2021) since

cultural competency programs don't always make ideas plain or give useful suggestions. The

Purnell Model remains instrumental in elucidating potential pathways and nuances regarding

the influence of cultural competence and patient centeredness, despite the absence of direct

correlations between overall cultural competence and specific healthcare outcomes. The model

is valuable for more than just looking at correlations; it gives us an organized way to understand

the problems that can happen when individuals from various cultural backgrounds work

together in healthcare (Purnell, 2002). The Purnell Model can help you identify and deal with

these specific areas of cultural influence, even if the overall link between cultural competency

and patient-centered care looks weak or not statistically significant. This could lead to focused

actions that make patients' experiences and outcomes better.

 40

Conceptual Framework

The research is based on Purnell's Model for Cultural Competence, which shows how

important it is for healthcare workers to understand and include patients' cultural beliefs,

practices, and values in their care. Moreover, cultural competence is not an extra that can be

added to healthcare but an essential part of providing better care that is more personalized,

inclusive, and effective. The framework says that cultural competence should be an ongoing

process in healthcare, with providers constantly learning about other cultures to improve the

health of their patients. By using cultural knowledge in their daily work, healthcare

professionals can make the workplace friendlier, more respectful, and more helpful, which

improves patient happiness and health. It focuses on how knowing different cultures directly

affects providing care that is tailored to each patient's unique background.

The conceptual framework suggests that a care that is centered on the patient, cultural

skills, and influencing factors should all work together and change over time. The goal is to

find actionable insights that can help healthcare institutions create environments that are more

culturally sensitive, responsive, and fair for all patients.

Figure 2. Conceptual Framework

Culturally Competence Patient-Centered Care

• Cultural awareness ability • Clinical situation
• Cultural action ability • Personal life situation
• Cultural resources application • Decisional control
• Self-learning cultural ability

Demographic Profile
• Sex
• Nationality
• Educational attainment
• Years of expertise
 41

Culturally Competent Patient-Centered Care

The goal of analyzing the framework is to clarify how the study's variables are

related to each other. Patients' cultural backgrounds have a significant impact on nurses'

cultural competency because they affect health inequalities, communication and relationships

between doctors and patients, the experience of disease, and health care outcomes (Chen,

2009). On the other hand, the demographic characteristics of nurses also affect their ability to

provide culturally appropriate, patient-centered care, as shown by a study done in almost the

same circumstances (Inocian, 2015). This new way of thinking has sparked a lot of interest

among doctors, policymakers, executives, researchers, and academics (Frampton et al., 2017)

because it shows how much better health and health care outcomes can be when patients and

families are truly involved in their care and in the redesign of health care systems and processes.

This study tries to find out how different variables are related by using a tool to find out how

culturally competent nurses are and how they feel about patient-centered care. Also, nurses

need to know about one of the new problems in health care: measuring how culturally

competent patients think their providers are and how it affects their health.
 42

Operational Definition of Terms

1. Cultural Background is defined as the unique characteristics of an individual as a result

of a day-to-day interaction that greatly affects his/ her way of life.

2. Demographic profile refers to the subjects sex, nationality, educational attainment and

years of expertise.

3. Sex will be self-reported. Answers will be coded "Male," "Female, defined as the

biological classification of individuals based on measurable characteristics such as

chromosomal patterns, gonadal structure, hormone levels, and external genitalia.

4. Nationality refers to the country to which a participant holds citizenship or permanent

residency. Categories would include "Saudi Arabian," "Expatriate (non-Saudi)," and

"Other" if those categories do not apply to the participant. This will allow for

understanding cultural or demographic differences in the sample.

5. Educational attainment is determined based on self-reported responses in a

questionnaire, asking participants to select their highest completed education level from

a predefined list.

6. Years of expertise is defined as the number of years a nurse participant has actively

worked in a professional nursing role. This experience must be documented through

employment records, certifications, or licensure.

7. Cultural Competence (CC) refers to the ability to successfully interact, understand and

communicate to people within a multicultural organization. An independent variable

that is going to be measured using a tool focusing on four domains.

8. Cultural awareness ability is defined as the nurse recognizing and appreciating cultural

differences in values, traditions, and norms, along with sensitivity and respect in

interactions with diverse individuals.

 43

9. Cultural action ability is the nurse expertise in adapting behaviors and communication

to respond effectively to cultural differences, utilizing cultural knowledge for decision-

making and fostering collaboration.

10. Cultural resources application refers to the nurses’ ability to use available resources that

helps reduce cultural conflict. The ability to effectively utilize culturally relevant tools,

materials, and community resources in patient care, assessed through the integration of

these resources in care plans and the frequency of their use during patient interactions.

11. Self-learning cultural ability is the willingness of the nurse to learn and be engage in

ongoing self-directed education and reflection about cultural diversity and its impact

on patient care, which is operationally measured through participation in cultural

competency training, completion of relevant educational courses, and self-reported

assessments of cultural knowledge and understanding gained through experiences with

diverse patient populations.

12. Culturally competent care means that nurses can give a patient care that is in line with

their cultural beliefs and values while still making sure the care is safe and of high

quality. Healthcare services that actively take into account patients' cultural

backgrounds, beliefs, and values when assessing, planning, carrying out, and evaluating

care, as measured by patient satisfaction surveys, participation in cultural awareness

training, and the inclusion of culturally appropriate practices in care plans.

13. Patient-centered care is a overall approach that emphasizes the development of

personalized care plans, supports self-care, ensures coordinated care, provides

convenient access to services, focuses on performance improvements, and promotes

wellness and disease prevention, all tailored to meet patient demands.

14. Clinical condition is defined as the physical, emotional, and behavioral response of each

patient that results from hospitalization. It is measurable physical, emotional, and

 44

behavioral responses of a patient during hospitalization, assessed through clinical

evaluations, psychological assessments, and behavioral observation tools that capture

changes in health status, emotional well-being, and engagement in care activities.

15. The patient's cultural background, habits, beliefs, and past experiences all play a role in

how they respond to the care plan and the illness itself. Personal life situation is defined

as the combination of a patient's cultural background, daily activities, personal beliefs,

and past healthcare experiences. This can be measured by organized interviews or

questionnaires.

16. Sense on control over care related decisions is the knowledge of the patient, the extent

of his perception to his own clinical situation that drives his decision-making process

expressing his own thoughts, opinions, and views about the course of plan.

Operationally, this means how much a patient thinks they know and understand about

their clinical situation, how much they think they can affect treatment decisions, and

how much they are involved in the decision-making process. This is measured through

self-reported measures of knowledge, perceived influence, and participation in

discussions with healthcare providers.

 45

Hypothesis and Assumptions

As part of this study, the researcher included hypothesis:

1. There is a significant relationship between cultural competence and perception of

patient-centered care provided among nurses in a tertiary hospital in Saudi Arabia.

2. There is a significant relationship between cultural competence level and demographic

profile as to sex, educational attainment, years of expertise and nationality among

nurses in a tertiary hospital in Saudi Arabia.

3. There is a significant relationship between the perception on patient-centered care

provided and demographic profile as to sex, educational attainment, years of expertise

and nationality among nurses in a tertiary hospital in Saudi Arabia.

 46

Chapter 3: Research Methodology

Research Design

This study used a descriptive correlational approach to look into the level

nurse’s cultural competence and how they think about patient-centered care I a tertiary hospital

in Saudi Arabia. This method helped find trends and links, which gave us a better idea of how

nurses' cultural competence might affect how they care for patients. Researchers were able to

figure out the strength and direction of the links between cultural competence and patient-

centered care by collecting data on both at the same time. This helped them learn more about

how cultural factors affect nursing practices and patient results. The study was especially

helpful because it looked at a diverse group of nurses in Saudi Arabia providing a great

opportunity to learn about the challenges of cultural skills in this type of healthcare settings.

Our research aimed to find out how culturally aware the nurses at a major hospital were and

how they felt about patient-centered care. Rivera spoke about descriptive correlational study,

which looks at how variables are related without proving cause and effect. It includes looking

at and measuring different factors to find links between them. To look into these connections

and answer the study question, a validated self-report survey was used. The results can be used

to create programs and training that will help nurses become more culturally competent, which

will improve their overall care for their patients.

 47

Sampling Technique

G Power software, which computed the required number of participants was used to

know the study's sample size. A 95% confidence level was established to guarantee a high level

of dependability in the findings and a power level of 80%. A moderate effect size—which is

commonly employed when a researcher anticipates a reasonable but not significant impact—

was assumed. The software calculated that a final sample size of 128 subjects was necessary

to attain the required statistical power and confidence in the results based on these parameters.

The target audience was nurses who worked at a major hospital in Riyadh, Saudi Arabia who

were ready to share their insights about their cultural experiences with clinical care and were

registered nurses working in a clinical unit for more than a year. Nurses of all educational

backgrounds were eligible to participate. Exclusion criteria included nurses in administrative

positions without direct patient care responsibilities and clinical resource nurses.

To address the potential for a low response rate impacting the desired confidence level,

a larger sample of 154 nurses was recruited. Random sampling method were used made sure

that each person in the target group had chance of being picked using an online random

sampling tool (Urbaniak & Plous, 2020). To keep things private, a participant code was given

to each qualifying answer. This method made sure that the demographic group was

representative while keeping the participants' identities secret. The study chose a group of

people that were typical of the whole community to look at how cultural competence and

patient-centered care work in hospitals in general. A bigger sample size improved statistical

power, which meant that fewer people dropped out and the results were more reliable.
 48

Setting

A second-largest hospital in Riyadh, Saudi Arabia, which is the biggest city in the

country, was the site of the study. A lot of the nurses who worked at the facility were from

other countries; about 75% of the staff were from other countries. Saudization policies that the

Saudi government put in place across the country were meant to increase the number of Saudis

working in healthcare and other fields. At the time of the study, about 80% of the hospital's

nurses had come from other countries to help meet the fast-growing need for health care. This

reliance on foreign nurses led to a diverse workforce with nurses from different cultures and

with different ideas about how to provide healthcare. This situation made it possible to look at

how cultural competence and patient-centered care work together in a mixed healthcare setting.

The study's results could also help with developing methods to be culturally sensitive to

patients from different cultures and improve patient outcomes in similar situations. We might

also learn something useful about the pros and cons of putting together a diverse group of

workers in a healthcare system that is quickly rising from the study.

 49

Data Collection Procedure

Ethical review boards from both the hospital and the University of the Philippines

gave their approval before any data collection started making sure that all ethical rules and

guidelines were followed. This process was very important for protecting the subjects' rights

and well-being and making sure that the study was done in the most honest and ethical way

possible. The participant selection method was meant to include people who met the criteria

to provide useful data for the study and make sure that the results could be applied to the

larger group being studied. We use Google Forms as the survey tool so that data collection

will more quickly and easily where participants could answer the poll online with this web-

based tool, so they did not have to use paper-based methods. In addition to talking about what

the results meant, this study also made suggestions based on the results.

Approval of the study proposal

Hospital Scientific Review Board Approval

UPOU Ethics Review Board Approval

Selection of Participants

Distribution of Data Collection Tool

Collection of Survey Responses

Data Analysis and Interpretation

Report Findings
 50

Research Instrument

The participants completed self-report questionnaires that included sex, nationality,

educational attainment, and years of clinical nursing experience. These demographic

variables served as independent variables in the analysis, used to explore potential

relationships with nurses' cultural competence and perceptions of patient-centered care. Sex

and country of citizenship were treated as categorical variables. Sex was categorized as male

or female, while country of citizenship represented nationality. Years of clinical nursing

experience were grouped into the following categories: 1-5 years, 6-10 years, 11-15 years,

and more than 16 years. These demographic variables provided background information

about the nurse participants and potentially influenced their responses to the main study

scales.

Nursing Cultural Competence Scale

The Nursing Cultural Competence Scale (NCCS) is a test with 19 questions that uses

a 5-point Likert scale (1 = Rarely, 2 = Occasionally, 3 = Neutral, 4 = Often, and 5 = Always)

to measure how culturally competent nurses are. A higher score means you are more

competent. This scale is divided into four key areas: the first is cultural awareness ability (7

items), which gauges a nurse’s capacity to appreciate different cultural perspectives and

recognize critical situations—such as opting out of treatments due to traditional beliefs about

discussing death—where cultural values play a significant role. The second area is cultural

action ability (6 items), focusing on the practical delivery of culturally appropriate nursing

care through effective communication and problem-solving skills. The third is cultural

resources application ability (3 items), which pertains to the nurse’s proficiency in identifying

and leveraging various resources, including professional networks and online platforms, to

understand cultural needs of patients. Lastly, self-learning cultural ability (3 items) reflects a

nurse's commitment to ongoing cultural education through reading and formal courses. An
 51

initial psychometric assessment conducted with nurses in Taiwan demonstrated a Cronbach’s

α of .88.

Table 1

Weighted Values (NCCS)

Point Range/Interval Verbal Interpretation

5 4.20-5.00 High Cultural Competence
4 3.40-4.19
3 2.60-3.39 Moderate Cultural
Competence
2 1.80-2.59 Low Cultural Competence
1 1.00-1.79
Note. The table displays the weighted values with corresponding mean ranges and their verbal

interpretations for the NCCS.

Individualized Care Scale

Suhonen et al. first came up with the ICS-Nurse in Finland. It is a self-administered

tool that nurses can use to rate their views on individualized treatment. This tool has a 5-point

Likert scale and is divided into 2 main parts: ICS-A-Nurse and the ICS-B-Nurse where each

part has 17 items. The ICS-A-Nurse subscale looks at how nurses let patients be themselves

through different nursing practices. The ICS-B-Nurse subscale, on other hand, looks at how

nurses feel about the individuality they keep in the care they give, based on their recent work

schedule. This two-dimensional framework captures the concept of individualized care as

both a lasting characteristic and a dynamic condition, which is a viewpoint also recognized in

other healthcare scenarios. Each dimension includes three subscales: clinical situation (items

1–7), personal life situation (items 8–11), and decision-making autonomy concerning care

(items 12–17), with responses from 1 (strongly disagree) to 5 (strongly agree)—with higher

scores indicating a stronger perception of patient centered care. The instrument has high
 52

psychometric qualities with Cronbach's alpha values of 0.88 (range from 0.72 to 0.83) for the

ICS-A-Nurse subscales and 0.90 (ranging from 0.73 to 0.84) for the ICS-B-Nurse subscales.

In addition, groups of experts evaluated its content validity.

Table 2

Weighted Values (ICS-Nurse)

Point Range/Interval Verbal Interpretation

5 4.20-5.00 High Perception
4 3.40-4.19
3 2.60-3.39 Moderate Perception
2 1.80-2.59 Low Perception
1 1.00-1.79
Note. The table displays the weighted values with corresponding rate mean and their verbal

interpretations for the ICS-Nurse.

 53

Procedure of Data Collection

Following final IRB approval, eligible nurses got an email with a link to a concise

research overview and online informed consent form. Upon completion of the overview,

potential participants indicated their acceptance or rejection of study participation via a

designated button. Participants who consented were directed to a dedicated online survey link

(Google Forms) containing the research tool. The survey link was optimized for accessibility

on any Android device, ensuring convenient and uninterrupted participation. To maintain

anonymity, respondents were assigned unique participant numbers during the sampling

process, eliminating the need for personal identification. Automated response receipts were

generated for both researchers and respondents upon survey completion. The researcher, as the

form owner, actively monitored response progress throughout the time when data was being

collected. This streamlined process facilitated a high response rate and ensured data integrity.

After that, the obtained data was analyzed to answer the research questions.

Data Analysis

This study used descriptive statistics to investigate how nurses' cultural competency,

their views on patient-centered care, and their demographic information were related. The goal

was to get an entire understanding of how these things work together, with a focus on patient-

centered care as an independent variable that affects cultural competency. The study used the

Nursing Cultural Competence Scale to find out how culturally competent nurses are. This scale

gave a measurable way to see how culturally competent nurses were. To summarize the

answers from the NCCS, weighted means were used. The NCCS is a 5-point Likert scale, which

gives ordinal data, however the weighted mean showed the central tendency of the sample's

replies. This mean score showed how culturally competent the nurses in the study were on

average.
 54

The Individualized Care Scale for Nurses was adopted to measure nurses' perceptions

of patient-centered care, treated as a dependent variable in this analysis. This scale captured

nurses' perspectives on how patient-centered their care practices were. Like the NCCS analysis,

weighted means were computed for the ICS-Nurse to gauge the general perception among

nurses regarding patient-centered care. Both the NCCS and ICS-Nurse are Likert-scale

measurement tools, inherently yielding ordinal data. But for this study, the results were

analyzed as continuous data so that we could better evaluate how nurses in the sample

understood and practiced patient-centered care. The Pearson Correlation Coefficient was used

in the study to find out how cultural competency (independent variable) and patient-centered

care (dependent variable) were related. This statistical method is appropriate for examining the

effects of independent variables on dependent variables. Given that both measures were treated

as interval-level data, the Pearson correlation provided insights on both the direction and

strength of relationship. The purpose of this study was to ascertain whether nurses' attitudes

and behaviors regarding patient-centered care were significantly predicted by their cultural

competency scores. The research examined the nurse’s demographic characteristics, including

sex, educational achievement, nationality, and years of experience, as independent variables

with nominal measurement levels. Chi-Square Test was used to look at demographic traits,

cultural competence, and patient-centered care.

 55

Independent Dependent Level of Statistical

Research Questions
Variable (IV) Variable (DV) Measurement Treatment

What is the level of

cultural competence
Cultural
among nurses in a - Interval Mean
Competence
tertiary hospital in Saudi
Arabia?
What are the perceptions
of patient-centered care
Patient
provided by nurses in a - Interval Mean
Centered Care
tertiary hospital in Saudi
Arabia?
What is the relationship
between the level of
cultural competence and Pearson
Cultural Patient
perceptions of patient- Interval Correlation
Competence Centered Care
centered care among Coefficient
nurses in a tertiary
hospital in Saudi Arabia?
What is the relationship
Nominal,
between cultural and
Demographic Cultural Ordinal, and Chi-Square
demographic profiles of
Profile Competence Interval Test
nurses in a tertiary
(Moderating)
hospital in Saudi Arabia?
What is the relationship
between perceived Nominal,
patient-centered care and Demographic Patient- Ordinal, and Chi-Square
demographic profiles of Profile Centered Care Interval Test
nurses in a tertiary (Moderating)
hospital in Saudi Arabia?
 56

Data Management
Responses were gathered through a web-based survey administered via Google

Forms. Once participants submitted their responses, the platform automatically generated an

Excel spreadsheet that organized the data based on the specified variables. This Excel file

was securely saved in the researcher’s Google Drive. Upon reaching the target number of

responses, the researcher extracted the data from this file for further analysis.

To maintain things confidential, each participant's response was labeled according to

the corresponding variable being measured, and each person who answered was given a

different subject code. This coding system helped maintain anonymity while allowing for

organized data categorization.

Additionally, all the information that was gathered was securely stored on a computer

that was available only to the researcher by means of a password. Due to the importance of

maintaining the accuracy of the research process, this is done to ensure that the participants'

confidentiality was protected. Data that had been encoded with great care was included in the

final submission of the study. This was done to ensure that any significant qualitative insights

were collected and examined in conjunction with the survey results.

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Ethical Considerations

The hospital's Research Ethics Committee gave official approval for the on-site study

before any data collection began to make sure everyone knew what was the research all about,

they were all given a full explanation of the study's purpose, its goals, and the possible good

effects it could have on healthcare practices. An online informed consent process was used,

and the users' basic rights to privacy, self-determination, and anonymity were emphasized to

make sure that everyone who took part in the study fully understood both the possible risks and

benefits of taking part. Participants were given a clear description of the study's goals and their

rights, with a focus on making sure they could stay independent during the whole process. They

could electronically prove that they agreed by acknowledging that they had received the

acceptance. This online tool made the consent process clear and easy to access for participants,

and it also let them know that their participation was completely voluntary.

Each person received a unique identification number without names to ensure privacy.

Participants were assured they could stop participating the study at any time of the survey

process. All data was kept secure and private according to study ethics. The data was solely

accessible to the researcher, saved and managed according to data protection and ethical

research guidelines. Throughout the study, there was regular oversight and tracking to make

sure that ethical standards were always followed showing a strong commitment to responsible

and respectful research behavior. This method not only made sure that ethical rules were

followed, but it also showed that the study was serious about protecting the rights, welfare, and

respect of every participant.

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Chapter 4: Results and Discussion

The information in this chapter is about data interpretation that was gathered from 166

people using certain tools. The results are organized in a way that makes sense given the order

of the problems, and they are explained in a number of different ways by using test results as

metaphors.

Table 3

Demographic Profile of the Respondents

Profile Variables Frequency Percentage

Sex
Male 119 72%
Female 47 28%
Nationality
Saudi 15 9.2%
Filipino 129 79.1%
Indian 17 10.4%
Slovak 1 0.6%
Serbian 1 0.6%
Educational Attainment
Diploma 2 1.3%
Bachelors’ Degree 148 91.1%
Master’s Degree 8 7.6%
Years of Expertise (in the unit)
1-5 years 69 42%
6-10 years 18 11%
11-15 years 73 45%
16 years or more 4 2%
Note. Not all participants responded to every demographic profile question. Percentages reflect

the proportion of responses within each category.

The study aims to investigate the demographics of a group of people who filled out a

poll. This information is very important for knowing the nursing staff at the chosen tertiary

healthcare institution in Saudi Arabia and how that might change the way care is given.
 59

As shown in Table 3, the sample comprised 72% females and 28% males (n=166). This

finding aligns with global trends in the predominantly female nursing profession. The

respondents' nationalities reveal a predominantly Filipino nursing workforce, comprising

79.1% of the sample. Other nationalities include Saudi (9.2%), Indian (10.4%), Slovak (0.6%),

and Serbian (0.6%). The educational attainment data indicate that 91.1% of respondents hold

a bachelor's degree, 7.6% have master's degree, and 1.3% have diploma. Respondents have

between 1 and 5 years of experience (42%), followed by 11 to 15 years (45%), 6 to 10 years

(11%), and 16 years or more (2%).

As with other studies, including Aiken et al. (2015), the breakdown of nursing

demonstrates that there are many more female nurses than male nurses. Studies have

demonstrated time and time again that more than 85% of nurses are women in the US, UK,

Canada, and Germany. It is true that there is a big need for Filipino nurses around the world.

These nurses are known for being skilled and dedicated (Al-Mahroos et al., 2019; McNeely,

2020). People from Saudi Arabia, India, Slovakia, and Serbia are part of the international

group. They improve healthcare by encouraging different points of view and caring for patients

as a whole person. A lot of people who answered had gone to school and learned a lot to make

sure they could do their jobs well as nurses, which shows that the nursing field is pretty

educated. The results also support Saudi Arabia's efforts to uplift the quality of nursing

education and bring them in line with global standards. Also, nurses who have a postgraduate

degree are more likely to be content with their professions and stay with them. Experienced

nurses make a big difference in the healthcare system by using their substantial knowledge

improving patient outcomes and the quality of service. Longer tenure is also connected to

higher job satisfaction and retention, which means that the hospital has a stable and skilled

nursing staff.
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Table 4

Cultural Competence Level among Nurses per Subscale

Subscale Mean Standard Deviation

Cultural Awareness Ability 2.68 0.99
Cultural Action Ability 3.00 1.10
Cultural Resource Application 3.05 1.17
Self-Learning Cultural Ability 2.66 1.11
Cultural Competence Level 2.85 1.09
Note: Cultural competence level is the overall mean score derived from the subscales. Higher

scores indicate greater cultural competence.

Nurses’ cultural competence was interpreted having “moderate cultural competence”

(M-2.85, SD-1.09). Notably, all four subscales were also interpreted as “moderate cultural

competence”: a) Cultural awareness ability (M-2.68, SD-0.99), b) Cultural action ability (M-

3.00, SD-1.10), c) Cultural resource application (M-3.05, SD-1.17), and d) Self-learning

cultural ability (M-2.66, SD-1.11).

The finding that nurses' cultural competence is at a moderate level in all subscales.

More specifically, the study showed that nurses understand the cultural dimension that

influence patient care, but there is still opportunity for progress in this area to reach higher

levels of competence. Results also illustrate the moderate level of cultural competence

pertaining to cultural action ability, emphasizing nurses' capacity to implement culturally

informed actions during patient care, as well as in cultural resources application, highlighting

their ability to employ various resources when providing care to patients from other cultures.

Furthermore, the findings highlight the moderate level of competence relative to self-learning

cultural ability, suggesting that nurses can further engage in self-directed learning to improve

their cultural competence.

These results support the concept that cultural competence is an important, as it affects

both the nurse-patient relationship (Covington, 2001) and the general quality of care (Hashish
 61

et al., 2020). Cai et al. (2021) say that cultural competence can be affected by age, work

experience, schooling, and being exposed to different cultures. Ličen and Prosen (2023) say

that healthcare workers should try to understand patients based on their cultural background to

improve their competence culturally. This is done with the help of professional programs that

focus on meeting and interacting with people from diverse origin (Hashish et al., 2020).

Table 5

Cultural Competence Level among Nurses per Item

Standard
Item Mean
Deviation
Cultural Awareness Ability
I know clinically, individual cases or patients will
2.57 1.32
reject treatment due to folk taboo.
I know clinically, individual cases or patients will mind
2.69 1.13
homophonic (same thinking).
I know clinically, individual cases or patients will
2.85 1.33
affect treatment due to special cultural events.
I know clinically, individual cases or patients will think
2.93 1.31
that the perineum is dirty
I know clinically, individual cases or patients will
2.59 1.25
believe folk treatment is better than medical treatment
I know clinically, individual cases or patients will think
2.48 1.15
of death as a taboo topic
I know clinically, individual cases or patients will
2.65 1.27
cause conflict in treatment due to different beliefs.
Cultural Action Ability
When taking care of a case, I can handle 2.95 1.25
misunderstandings due to language barrier.
When taking care of a case, I can handle the difficulty 3.16 1.31
when building nurse-patient relationship.
When taking care of a case, I can handle spending 2.78 1.26
more time communicating
When taking care of a case, I can handle using different 2.98 1.12
degrees of treatment guidelines due to cultural
differences.
When taking care of a case, I can handle the degree of 2.98 1.12
fear in individual cases or patients.
When taking care of a case, I can handle different 3.17 1.20
levels of nursing care due to differences in patients’
religious rituals or living habits.
 62

Cultural Resource Application

When taking care of patients of a different culture, I
will look for help from social workers, religious 3.14 1.31
personnel or colleagues
When taking care of patients of a different culture, I
will look for assistance from helpers or foreign 3.10 1.34
workers.
When taking care of patients of a different culture, I
will look for internet resources such as mobile phone 2.90 1.28
applications or computer translation.
Self-Learning Cultural Ability
When taking care of patients of a different culture, I 3.14 1.31
will look for help from social workers, religious
personnel or colleagues
When taking care of patients of a different culture, I 3.10 1.34
will look for assistance from helpers or foreign
workers.
When taking care of patients of a different culture, I 2.90 1.28
will look for internet resources such as mobile phone
applications or computer translation.

The mean and standard deviation of responses to the NCCS questions were used to

assess each subscale of nurse cultural competence. According to the NCCS Weighted Values,

the mean scores across all categories range from 2.48 to 3.17, signifying a Moderate Level of

Cultural Competence (2.60–3.39).

Cultural Awareness Ability

The Cultural Awareness Ability subscale items were all described as “moderate”, with

mean scores ranging between 2.48 – 2.93: a) Patients considering death a taboo topic (M-2.48,

SD-1.15), b) Patients rejecting treatment due to folk taboos (M-2.57, SD-1.32), c) Patients

belief on folk treatment is better than medical treatment (M-2.59, SD-1.25), d) Patients causing

conflict in care plan due to different beliefs (M-2.65, SD-1.27), e) Patients minding

homophonic (same thinking) (M-2.69, SD-1.13), f) Patients being affected by special cultural

events (M-2.85, SD-1.33), g) Patients perceiving the perineum as dirty (M-2.93, SD-1.31), with

the highest mean score shown by the item, “Patients perceiving the perineum as dirty” (M-
 63

2.93, SD-1.31), and the lowest mean score shown by the item, “Patients considering death a

taboo topic” (M-2.48, SD-1.15).

Cultural Action Ability

The Cultural Action Ability subscale items were all described as “moderate”, with mean

scores ranging between 2.78 – 3.17: a) Handling spending more time communicating (M-2.78,

SD-1.26), b) Handling misunderstandings due to language barriers (M-2.95, SD-1.25), c)

Handling different degrees of treatment guidelines due to cultural differences (M-2.98, SD-

1.12), d) Handling the degree of fear in individual cases or patients (M-2.98, SD-1.12), e)

Handling the difficulty in building nurse-patient relationships (M-3.16, SD-1.31), f) Handling

different levels of nursing care due to religious rituals or living habits differences (M-3.17, SD-

1.20), with the highest mean score shown by the item f and the lowest mean score shown by

the item a.

Cultural Resource Application

The Cultural Resource Application subscale items were all described as “moderate”,

with mean scores ranging between 2.90 – 3.14: a) Looking for internet resources such as mobile

phone applications or computer translation (M-2.90, SD-1.28), b) Seeking assistance from

helpers or foreign workers (M-3.10, SD-1.34), c) Seeking help from social workers, religious

personnel, or colleagues (M-3.14, SD-1.31), with the highest mean score shown by the item,

“Seeking help from social workers, religious personnel, or colleagues”, and the lowest mean

score shown by the item, “Looking for internet resources such as mobile phone applications or

computer translation”.

Self-Learning Cultural Ability

The questions on the Self-Learning Cultural Ability subscale had mean scores of

between 2.90 and 3.14, which means they were all considered "moderate." a) Looking for

internet resources like mobile phone apps or computer translation (M-2.90, SD-1.28); b)
 64

Asking for help from helpers or foreign workers (M-3.10, SD-1.34); and c) Asking for help

from social workers, religious staff, or coworkers (M-3.14, SD-1.31). The item c while item a

got the lowest mean score.

According to this, nurses understand and can deal with some cultural parts of patient

care, but they can do better in every way. The moderate scores suggest a foundational

knowledge in these areas, but also highlight potential gaps in fully understanding and

addressing these nuances. Being culturally conscious means looking into your own cultural and

professional background (Gradellini et al., 2021). Cultural awareness is one of the components

of cultural competence (Sharifi et al., 2019).

Regarding cultural action ability, the scores indicate the nurses' perceived ability to

handle misunderstandings due to language barriers, build nurse-patient relationships, spend

time communicating, adjust treatment guidelines, and manage patients' fear and religious or

living habits. These moderate scores suggest that while nurses can act, there may be a need for

further training and resources to optimize these interactions. Cultural skill showcases

competency (Salinda et al., 2024). Nurses must have confidence in performing their duties,

including creating a plan of care appropriate based on their patient's beliefs or practices

(Salinda et al., 2024).

The self-learning cultural ability scores indicate nurses' capacity to be willingly involve

in self-directed learning to improve their cultural competence. Again, the moderate level

suggests a willingness to learn, but further support and structured learning opportunities could

enhance this ability. Educational preparation is an important antecedent to cultural competence

(Sharifi et al., 2019). Active support from medical and healthcare institutions is crucial in

improving the cultural competency (Kim et al., 2019).

Cultural literacy is becoming more important as the number of people who use

healthcare grows. Osmancevic et al. (2023) say that healthcare providers need to know about
 65

their patients' cultures in order to give them safe, effective, and good care. Ryu and Lee (2021)

say that there is a link between cultural competency, clinical competence, and being able to

talk to people from other countries. To get rid of obstacles to quality care, it is important to

find the best ways to teach nurses how to be culturally competent in clinical settings (Červený

et al., 2022). Building cultures that are accepting, continuing education (Paatela et al., 2023),

and making cultural training programs (Cai et al., 2021) are all ways to get better at

understanding other cultures.

Table 6

Perception of Patient-Centered Care Provided of Nurses per Subscale per subscale

Subscale Mean Standard Deviation

Support of Patient Individually through Nursing Intervention (ICS-A-Nurse)
Clinical Situation 4.03 0.82
Personal Life Situation 3.84 0.90
Decisional Control 4.03 0.89
Maintenance of Individuality in Care they Provided (ICS-B-Nurse)
Clinical Situation 3.96 0.90
Personal Life Situation 3.84 0.98
Decisional Control 4.03 0.90
Perception of Patient-Centered Care 3.96 0.86

The perception of patient-centered care provided by nurses was interpreted as “high

perception of patient-centered care” (M-3.96, SD-0.85). The subscales related to this

perception also reflected moderate patient-centered care. In the support of patients individually

through nursing intervention (ICS-A-Nurse), the subscales for Clinical Situation (M-4.03, SD-

0.82), Decisional Control (M-4.03, SD-0.89), and Personal Life Situation (M-3.84, SD-0.90)

indicated moderate to slightly higher levels of patient-centered care. Keeping care unique for

each person (ICS-B-Nurse) showed similar results, with Clinical Situation (M-3.96, SD-0.90)

and Personal Life Situation (M-3.84, SD-0.98) reflecting moderate perceptions, while

Decisional Control (M-4.03, SD-0.90) showed a slightly higher level of care that was focused

on the patient.
 66

The data shows that the nurses' view of patient-centered care is mostly moderate. This

implies that people understand and use patient-centered ideas, but there is still potential for

development. Patient-centered care prioritizes the patient's concerns and opinions, shared

decision-making, and attention to psychosocial needs (Ward, 2004). The emphasis on the

patient's perspective is crucial in creating a healthcare environment that truly meets individual

needs (Chen et al., 2021).

When looking at specific areas of care, nurses seem to be more confident in addressing

immediate clinical needs and involving patients in treatment decisions. This aligns with the

core tenets of patient-centered care, where the patient participates in and has a responsible role

in decision-making (Ward, 2004). However, addressing the broader life factors that impact a

patient's health may present more of a challenge (Smith, 2025). It is now known that getting

people involved in their own health and care is a key part of creating the best healthcare (Han

et al., 2022). Respecting patients' autonomy, and knowing what counts in care and how it

should be accomplished from the patients’ and nurses’ perspective seems crucial (Humbeeck

et al., 2020).

Table 6

Perception of Patient-Centered Care Provided of Nurses per Item

Standard
Item Mean
Deviation
Support of Patient Individually through Nursing Intervention (ICS-A-Nurse)
Clinical Situation
I talk with patients about the feelings they have about 3.93 0.84
their illness/health condition.
I talk with patients about their needs that require care 4.21 0.96
and attention.
 67

I make an effort to find out how their illness/health 3.99 0.96

condition has affected them.
I talk with patients about what the illness/health 4.03 0.92
condition means to them.
I ask patients what kinds of things they do in their 4.06 0.98
everyday life outside the hospital (work, leisure
activities).
I ask patients about their previous experiences of 3.99 0.85
hospitalization.
I ask patients about their everyday habits (e.g. personal 3.94 0.93
hygiene).
Personal Life Situation
I took into account the feelings patients had about their 3.77 0.96
illness/health condition.
I took into account their needs that require care and 3.77 0.98
attention.
I took into account the way the illness/health condition 3.80 1.03
has affected them.
I took into account their everyday activities (e.g. work, 4.01 0.98
leisure activities) outside the hospital
Decisional Control
I took into account their previous experiences of being 4.11
0.99
in hospital.
I took into account patients’ everyday habits during 3.92
0.95
their stay in hospital (e.g. personal hygiene).
I took into account patients’ wishes about their care. 4.04 1.06

I took into account the opinions patients expressed 4.03 1.03

about their care.
I give patients the chance to take responsibility for their 4.08 0.97
care as far as they are able.
I ask patients what they want to know about their 3.99 0.95
illness/health condition.
Maintenance of Individuality in Care they Provide (ICS-B-Nurse)
Clinical Situation
I took into account the feelings patients had about their 4.01 0.98
illness/health condition.
I took into account their needs that require care and 4.07 0.94
attention.
Patients assumed responsibility for their care as far as 3.95 0.92
they were able.
I took into account the changes in how they felt. 3.98 0.96

I took into account their fears and anxieties. 3.97 1.04

 68

I took into account the way the illness/health condition 3.99 0.99
has affected them.
I took into account the meaning of the illness/health 3.91 1.07
condition to the patient personally.
Personal Life Situation
I took into account their everyday activi- ties (e.g. 3.77 1.10
work, leisure activities) outside the hospital.
I took into account their previous experiences of being 3.81 1.12
in hospital.
I took into account patients’ everyday habits during 3.95 1.05
their stay in hospital (e.g. personal hygiene).
Patients’ families took part in their care if they wanted 3.85 0.99
them to.
Decisional Control
I made sure that patients understood the instructions 4.14 0.97
they received.
I gave patients enough information about their 3.98 1.02
illness/health condition.
I took into account patients’ wishes about their care. 4.02 0.98
Patients took part in decision-making concerning their 4.09 0.96
care.
I took into account the opinions patients expressed 4.09 0.92
about their care.
Patients had the opportunity to make their own 3.93 0.96
decisions on when to wash.

Mean and standard deviation in terms to the patient-centered care questions were used

to assess each item of nurse-patient interaction. The mean scores across all items range from

3.77 to 4.21, signifying a Moderate to High Level of Patient-Centered Care (3.60–4.39).

 69

Support of Patient Individually through Nursing Intervention (ICS-A-Nurse)

Items related to "Support of Patient Individually through Nursing Intervention" showed

moderate to high levels of patient-centered care, with mean scores ranging from 3.93 to 4.21.

In the "Personal Life Situation" subscale, the mean scores ranged from 3.77 to 4.01, reflecting

a similar pattern. The "Decisional Control" subscale demonstrated slightly higher mean scores,

ranging from 3.92 to 4.14, indicating a higher level of patient-centered care in allowing patients

more involvement in their care decisions.

Clinical Situation

The questions about "Clinical Situation" were all rated as "moderate to high," and the

mean scores were between 3.93 and 4.21: a) Talking to patients about how they feel about their

illness or health condition (M-3.93, SD-0.84); b) Making an effort to find out how their illness

or health condition has affected them; d) Talking to patients about what the illness or health

condition means to them (M-4.03, SD-0.92); e) Asking patients about what they do in their free

time (work, hobbies) (M-4.06, SD-0.98); f) Asking patients about their past hospital stays (M-

3.99, SD-0.85); and g) Asking patients about their daily habits (e.g., personal hygiene) (M-

3.94, SD-0.93). Talking with patients about their needs that need care and attention got the

highest mean score on the other hand, "Talking with patients about how they feel about their

illness or health condition" got the lowest mean score.

Personal Life Situation

The items that had to do with "Personal Life Situation" were all rated as "moderate,"

with average scores between 3.77 and 4.01: a) Taking into account how the patients felt about

their illness or health condition (M-3.77, SD-0.96), b) Taking into account their needs that need

care and attention (M-3.77, SD-0.98), c) Taking into account how the illness or health condition

has affected them (M-3.80, SD-1.03), and d) Taking into account their everyday activities

outside the hospital, like work and leisure activities (M-4.01, SD-0.98). The item "Taking into
 70

account their everyday activities outside the hospital" had the highest mean score (M-4.01, SD-

0.98), while the items "Taking into account the feelings patients had about their illness/health

condition" and "Taking into account their needs that require care and attention" had the lowest

mean scores.

Decisional Control

The items related to "Decisional Control" were all described as “moderate to high,”

with mean scores ranging from 3.92 to 4.11: a) Taking into account their previous experiences

of being in hospital (M-4.11, SD-0.99), b) Taking into account patients’ everyday habits during

their stay in hospital (e.g., personal hygiene) (M-3.92, SD-0.95), c) Taking into account

patients’ wishes about their care (M-4.04, SD-1.06), d) Taking into account the opinions

patients expressed about their care (M-4.03, SD-1.03), e) Patients should be able to take part

in their own care as much as possible (M-4.08, SD-0.97), and f) Patients are asked what they

want to know about their illness or health situation (M-3.99, SD-0.95). The highest mean score

was shown by the item, “Taking into account their previous experiences of being in hospital”,

while the lowest mean score was shown by the item, “Taking into account patients’ everyday

habits during their stay in hospital”.

Maintenance of Individuality in Care they Provide (ICS-B-Nurse)

Items related to "Maintenance of Individuality in Care they Provide" demonstrated

moderate to high levels of patient-centered care, with mean scores ranging from 3.77 to 4.14.

In the "Clinical Situation" subscale, the mean scores ranged from 3.91 to 4.07, indicating a

moderate to high level of patient-centered care. The "Personal Life Situation" subscale showed

mean scores ranging from 3.77 to 3.95, reflecting a moderate level of attention to personal

circumstances. The "Decisional Control" subscale exhibited slightly higher mean scores,

ranging from 3.93 to 4.14, suggesting a stronger focus on empowering patients to participate

in their care decisions.

 71

Clinical Situation

The questions about "Clinical Situation" were all rated as "moderate to high," and the

mean scores were between 3.91 and 4.07. (a) How the patients felt about their illness or health

condition (M-4.01, SD-0.98); (b) Their needs that need care and attention (M-4.07, SD-0.94);

(c) How much they were able to take responsibility for their own care (M-3.95, SD-0.92); (d)

How their feelings changed over time (M-3.98, SD-0.96); (e) How their fears and anxieties

affected them (M-3.97, SD-1.04); (f) How the illness or health condition had changed them

(M-3.99, SD-0.99); and (g) What the illness or health condition meant to them personally (M-

3.91, SD-1.07). Considering their needs that need care and attention got the highest mean score

and on the other hand, “Taking into account what the illness or health condition means to the

patient personally” got the lowest mean score.

Personal Life Situation

The items related to "Personal Life Situation" were all described as “moderate,” with

mean scores ranging from 3.77 to 3.95: a) Taking into account their everyday activities (e.g.

work, leisure activities) outside the hospital (M-3.77, SD-1.10), b) Taking into account their

previous experiences of being in hospital (M-3.81, SD-1.12), c) Taking into account patients’

everyday habits during their stay in hospital (e.g. personal hygiene) (M-3.95, SD-1.05), and d)

Patients’ families taking part in their care if they wanted them to (M-3.85, SD-0.99). The

highest mean score was shown by the item, “Taking into account patients’ everyday habits

during their stay in hospital”, while the lowest mean score was shown by the item, “Taking

into account their everyday activities outside the hospital”.

Decisional Control

The items related to "Decisional Control" showed moderate to high levels of patient-

centered care, with mean scores ranging from 3.93 to 4.14. These included: a) Ensuring patients

understood the instructions they received (M-4.14, SD-0.97), b) Providing enough information
 72

about the patient's illness/health condition (M-3.98, SD-1.02), c) Considering patients' wishes

about their care (M-4.02, SD-0.98), d) Involving patients in decision-making regarding their

care (M-4.09, SD-0.96), e) Considering patients' opinions about their care (M-4.09, SD-0.92),

and f) Allowing patients to make decisions on when to wash (M-3.93, SD-0.96). The highest

mean score was given to the item, "Ensuring patients understood the instructions they

received", while the lowest was shown by the item, "Allowing patients to make decisions on

when to wash".

This suggest that while nurses demonstrate a foundational understanding and

application of patient-centered care principles, challenges remain in consistently integrating

patients' broader life contexts into care plans. Several sources support this multifaceted view.

Person- and Family-Centered Care Final Report, 2024; Person- and Family-Centered Care

Final Report, 2023) are important parts of the National Quality Strategy because they say that

every patient and family member should be involved in their care. This aligns with the idea

that a shift is needed from patients being passive recipients to active participants in their

healthcare. The data suggests nurses are making strides in this direction, particularly in clinical

settings, but there's room to grow.

To provide patient-centered care, nurses and patients must both agree on what is

important in care (Humbeeck et al., 2020). Studies have shown that healthcare workers who

prioritize on the patient can improve one's health and make them happier (Greiner & Knebel,

2003). The current data show that nurses know how important it is to care about their patients'

needs and feelings (Humbeeck et al., 2020). But nurses and patients may not share the same

values, which can make it harder to provide patient-centered care (Humbeeck et al., 2020).

Time constraints and resource limitations in the clinical setting might prevent nurses from

delving into patients' lives outside of their immediate health issues (Smith, 2025). To fully

understand patient-centered care, it is very important to know that patients and their families
 73

will no longer be "order takers," but will instead be active "team members" (Catalyst, 2017).

Therefore, while nurses are making efforts to provide patient-centered care, systemic and

practical barriers may hinder the full integration of a patient's life context into their care

approach. Further research and targeted interventions could help address these challenges,

leading to better and more comprehensive patient-centered care (Hsu et al., 2019).

The results show that nurses have a deep understanding of patient-centered care, with

certain areas where they are strong and others where they may improve. Nurses know how

important it is to meet patients' immediate emotional and physical needs in the clinical setting

(Humbeeck et al., 2020). They think about how their sickness affects their patients' feelings,

needs, and emotional states (Humbeeck et al., 2020). However, it is always hard to take into

account the patient's whole life, including their daily routine and past experiences (Hsu et al.,

2019). This problem might be caused by structural factors, including not having enough time

or not having easy access to information, which makes it hard to provide completely

comprehensive care (Smith, 2025). On the plus side, nurses are great at giving patients control

over their decisions, making sure they follow instructions, and getting them involved in care

decisions (Catalyst, 2017; Greene et al., 2012). This dedication to letting patients make their

own decisions fits with the bigger goals of patient-centered care, which stresses making

decisions together and respecting each person's choices (Catalyst, 2017). To make patient-

centered care better, interventions should focus on bridging the gap between clinical

interactions and taking into account patients' everyday situations. Overtime, this will lead to

more tailored and effective care (Hsu et al., 2019).

Table 7
 74

The Relationship Between Cultural Competence Level and Perception on Patient-Centered

Care Provided Among Nurses in a Tertiary Hospital in Saudi Arabia

Correlation p-value
Variable Mean SD
Coefficient
Cultural Competence Level 2.85 1.09 0.1285 0.098954

Perception on Patient- 3.96 0.86

Centered Care
Note. p < 0.01 indicates a statistically significant relationship.

The table illustrates the correlation between Cultural Competence Level and Perception

of Patient-Centered Care among the respondents. The average score for cultural competence is

2.85, accompanied by a standard deviation of 1.09, signifying a moderate level with significant

variances in responses. The average perception of patient-centered care is 3.96, with a standard

deviation of 0.86, indicating a predominantly high and more uniform positive perception

among respondents. The Pearson correlation coefficient of 0.1285 signifies a negligible

positive association between the two variables (p-value = 0.098954). This indicates a minor

tendency for those with greater cultural competence to view patient-centered treatment more

favorably. Nonetheless, the correlation is negligible and may lack considerable practical

relevance in this setting.

The result argues against the claim that these two factors are linked. It was more likely

for nurses who were culturally competent to think that their care was patient-centered. In

comparison, Almutairi et al. (2018) found a link between nurses' cultural competence and their

ability to care for patients in a patient-centered way. However, there is some disagreement

about the claim because different healthcare settings have shown different results (Grinberg &

Nissim, 2021). Researchers have found mixed results about the link between nurses' cultural

skills and their desire to provide patient-centered care (Saha et al., 2008). A lot of people think

that culturally competent care will improve the quality of care overall, but there is still a huge
 75

need for strong evidence that clearly links carefully developed curriculum of cultural

competence with real patient-centered and clinical outcomes (Lie et al., 2010). Also, a lot of

studies that look at cultural competence use self-report tests, which can be skewed in many

ways, and there are not many objective measures of how well interventions work (Truong et

al., 2014).

Table 8

The Relationship Between Demographic Profile and Cultural Competence Among Nurses in a

Tertiary Hospital in Saudi Arabia

Chi Square
Demographic Profile df p-value
value (x 2)
Gender 1.859 4 0.762
Nationality 64.750 20 <0.001
Educational Attainment 7.065 8 0.530
Years of Expertise (in the unit) 12.338 12 0.419
Note. p < 0.01 indicates a statistically significant relationship.

The purpose of the study with nurses from a major hospital in Saudi Arabia was to look

at how demographics and cultural competence are related. The test result showed among the

demographic variables analyzed, only nationality (x2(20) = 64.750, p = <0.001) shows a

statistically significant relationship with cultural competence, indicating that cultural

background significantly influences the nurses' cultural competence. However, gender (x2(4)

= 1.859, p = 0.762), educational attainment (x2(8) = 7.065, p = 0.530), and years of expertise

in the unit (x2(12) = 12.338, p = 0.419) have no significant relationship with cultural

competence among nurses in this tertiary hospital in Saudi Arabia.

This corresponds with what Betancourt et al. (2005) found that nurses' cultural

competence is affected by the types of patients they see, often different because of their country

and culture. Cultural familiarity improves conversation, empathy, and the ability to understand

how cultural differences affect the way care is given. In addition, this aligns with the claim of
 76

Abubakari et al. (2024) that nationality influenced nurses' perceptions of cultural competence,

with those from multicultural societies demonstrating higher adaptability in handling diverse

patient populations. Based on these data, nationality plays a big role in cultural competence.

However, gender, level of education, and years of experience in the unit do not have a big

impact on cultural competence among nurses in this Saudi Arabian tertiary hospital. As Hegney

et al. (2006) found, female nurses are more likely to be culturally aware and use culturally

competent care methods, which means that this study is not valid. This view is different from

the current study, which might not focus on sex as a key factor in cultural competence.

In conclusion, this study differs from Hegney et al.'s (2006) results in how sex affects

cultural awareness. However, it supports the idea that nurses need to keep learning about

different cultures and have a lot of different kinds of experiences to become more culturally

competent. Culturally competent healthcare providers are able to provide caring, respectful,

and patient-centered care to people from all cultural backgrounds. They learn these skills

through both formal education and hands-on practice.

Data show that nationality is a big part of being culturally competent. However, other

factors, like sex and academic success, may have a bigger effect in some situations. This shows

how important it is to have customized programs that teach cultural skills, especially for nurses

who work with people from many different countries. Over time, being around events and

people from different cultures can also help you learn more about other cultures. The study

shows how important it is for institutions to help people become culturally competent by giving

them special training and support. This is especially true in places like hospitals where a lot of

different kinds of people work. Hospitals and clinics can help nurses care for a bigger range of

patients better by focusing more on cultural competence.

 77

Table 9

The Relationship Between Demographic Profile and Perception of Patient-Centered Care

Provided Among Nurses in a Tertiary Hospital in Saudi

Chi Square
Demographic Profile df p-value
value (x 2)
Gender 4.902 4 0.298
Nationality 69.935 20 <0.001
Educational Attainment 13.340 8 0.101
Years of Expertise (in the unit) 10.383 12 0.582
Note. p < 0.01 indicates a statistically significant relationship.

The study investigated the relationship between demographic profiles and the

perception of patient-centered care among nurses in a tertiary hospital in Saudi Arabia. The test

result showed that nationality (x2(20) = 69.935, p = <0.001) shows a statistically significant

relationship with perceived patient-centered care, indicating that nationality does affect how

nurses think about patient-centered care. On the other hand, gender (x2(4) = 4.902, p = 0.298),

educational attainment (x2(8) = 13.340, p = 0.101), and years of expertise in the unit (x2(12) =

10.383, p = 0.582) have no significant relationship with the perception of patient-centered care

among nurses.

These ideas could be caused by differences in cultural background, beliefs, healthcare

standards, or communication methods linked to nationality. Several studies show that the

country is essential in determining cultural competence, directly affecting patient-centered

care. Abubakari et al. (2024) say that nurses from different countries better understand and

provide the needs of a wide range of patients. Lim et al. (2021) found that nurses in

multicultural settings are better at talking to and caring for patients, which are important in

providing individualized care.

This means that nurses' views on patient-centered care are the same no matter what

gender they are, how much schooling they have, or how long they have worked in the unit.
 78

This shows how important things like getting along with others, understanding other cultures,

or working together in a structured way might be. Lim et al. (2021) also found that the gender

of healthcare workers does not automatically change how well they can provide patient-

centered care. For patient-centered care to work, things like training help from the institution

are more important. This also fits with Chau et al.'s 2025 study, which found that nurses' level

of schooling did not have an effect on the quality of patient-centered care they gave. Sibandze

and Scafide (2017) also found that nurses' loyalty to patient-centered care principles did not

always go up when they got additional schooling. This means that things other than formal

schooling are more important for establishing patient-centered ideals.

The substantial link between nationality and patient-centered care relatively high

indicating that a nurse's cultural history, attitudes, and ways of communicating that are based

on their nationality may make it harder for them to deliver compassionate and personalized

care. Teaching and practicing nursing should focus on developing cultural competence,

especially in locations like Saudi Arabia where people from different origins work together in

healthcare settings. But there were no strong links between how nurses felt about patient-

centered care and their sex, level of education, or years of experience.

 79

Chapter 5: Summary of Findings, Conclusion and Recommendation

Summary of the Findings

The survey covered a culturally diverse nurses, with many them being women and a

significant number of them being expats, mostly from the Philippines. Most of the people who

took part had graduate degrees and a range of work experience levels. This diversity in

demographics is like the culturally dicerse nature of healthcare facilities in Saudi Arabia, which

is attracting more trained nurses from many nations, especially the Philippines.

To find out if someone was culturally competent, they had to show that they knew

about other cultures, could do the right thing, use tools, and learn on their own. When religion

or lifestyle choices came up in their care, the nurses were pretty good at noticing them and

adapting their care to fit those differences. The study did, however, find some things that

needed to be fixed. For example, people needed to improve their communication skills and

learn how to use technology to make it easier to communicate and provide services. The nurses

know a lot about different cultures, but they need to keep learning and being trained to become

even more culturally competent. Results showed that nurses had a great understanding of

patient-centred care, especially when it came to things like communicating clearly, getting

patients involved in decision-making, and generating individualized care plans. It was clear

that they were committed in providing nursing care that respects patients' desires encouraging

participation in self-care. Nationality was a major demographic factor in cultural competency.

Multicultural nurses were better at adapting to a variety of patients. However, gender,

education, and work experience did not seem to affect cultural competency. This suggests that

engaging with a variety of patients and specific training programs are more crucial for cultural

competency than demographic factors.

It is not always true that cultural knowledge leads to better patient-centred care, as

shown by some studies that question this thought-to-be link. There were different results, which
 80

suggests that the connection between cultural competence and patient-centred care might not

be as simple as was thought before. It could be affected by things like the healthcare setting,

the patients, and the tools used to measure these variables. There are a lot of problems with

putting cultural competence into healthcare settings. This could be why some study results are

not consistent. Some of these problems are that there are not any agreed upon definitions or

tools for measuring cultural competence, healthcare workers do not get enough training and

education, and there are systemic issues that make it hard to use culturally sensitive practices.

In conclusion, the nurses had a basic grasp of diverse cultures and were committed to

patient care, but they needed further training. This is crucial for cultural competency via

improving communication and technical skills. Nurses can provide better, more individualised

care that puts patients first as they learn more about their patients' cultures and how to respond

to them. Addressing these issues can enhance patient experience and health outcomes,

benefiting Saudi Arabian and other patients and healthcare providers.

Conclusion

To conclude, strong patient-provider communication is vital for high-quality care and

good health results. Nurses, who patients often first see in the healthcare system, are crucial to

this conversation. Communicating with patients is essential to providing personalized treatment

that makes them happy and helps them manage their health. This study reveals Saudi tertiary

hospital nurses are becoming more culturally competent. They acknowledge and value their

patients' cultural habits. The nurses were praised for understanding cultural variety, indicating

that they can alter their care to fit the demands of diverse cultures. This implies they have all

they need to deliver expert and culturally sensitive care. The study also reveals that nurses in

Saudi Arabia are working hard to get past cultural barriers by using the tools they have access

to and asking for help when they run into problems. Culture competency is actively sought

after, indicating a willingness to improve patient care and address complex culture elements
 81

that affect healthcare delivery. This proactive approach allows nurses to provide the most

respectful, acceptable, and effective treatment while creating trust and strong relationships with

patients of many ethnicities. This study also shows how important it is for nurses to

continuously learn about different cultures. Continuing professional growth in cultural

competence and sensitivity is good for healthcare organizations. Giving nurses chances to learn

about cultural differences and how to respect and accept them can help healthcare organizations

give care that is proper for all cultures. In the end, this means that patients have better outcomes,

are happier, and get better care generally in healthcare settings. The study also talks about how

committed the nurses at the major hospital in Saudi Arabia are to patient-centered care. In the

study, nurses showed they cared about giving each patient individualized care by letting

patients make choices and being clear about their health problems and treatment plans. Patients

feel respected and able to do things on their own. A lot of the study is about how important it

is to communicate properly and include patients in care. These are two important parts of good,

patient-centered care.

Finally, cultural competency is a crucial part of healthcare that needs more study

because it has a clear and consistent impact on care that is focused on the patient. In the future,

researchers need to focus on making accurate measuring tools, looking into how context affects

outcomes, and using strict methods to see how well cultural competence techniques work in

different healthcare situations. To make sure that all patients, no matter what country they are

from, get the fair and good care they need, we need to learn more about the connection between

cultural competence and patient-centered care. Being culturally competent is a journey that

never ends. This is very important since neighborhoods, health systems, and cultures are all

changing all the time. There should be more than easy definitions of cultural competence. To

meet the needs of all people and groups, the topic should be open to complexity and

intersectionality.
 82

Recommendation

The study's results of nurse cultural competence and patient-centered care in a tertiary

hospital in Saudi Arabia led to the following suggestions:

For Nursing Administration. All nurses should have to take these courses, and they should

be updated regularly to keep up with the current changes in healthcare.

For Organizational Policy Makers. It One way to do this is to make rules for the

company that put a high value on diversity and inclusion. Another way is to start programs

that reward nurses who are good at showing cultural competence.

For Professional Development Coordinators. It is very important for the people in charge

of staff development to give nurses chances to improve their communication skills. This may

include workshops, seminars, and practice exercises that help nurses give patients clear and

easy-to-understand instructions.

For Healthcare Team Leaders. To make sure that patient care is coordinated and complete,

healthcare team leaders need to make it easier for all providers to work together. This can be

enabled by shared care plans, regular team meetings, and effective care coordination systems.

For Direct Patient Care Providers. Nurses and other healthcare workers who work directly

with patients should talk to them and encourage them to be engaged decision making about

their own care. Being a good listener and answering patients' questions can help create a

collaborative environment that gives patients more authority.

Organizations may create an atmosphere that supports both nursing excellence and better

patient outcomes by customizing these suggestions to various roles within the healthcare

system.
 83

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