الفهرس 
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Abstract
Healthcare organizations are characterized by their dynamic and multicultural
environment as well as their expanding globalization of business with growing worker
diversity. As a result of having broad cross-cultural competences, nurses can perform
overseas assignments and work with multicultural teams. Therefore, healthcare firms
demand nurse leaders and nurses with a high level of knowledge, attitudes, and skills to
deal with varied cultural backgrounds, in addition to administrative and corporate changes.
Aim of the study:
Evaluate effect of application of cultural intelligence model on patient centered care,
resilience at work and innovative work behavior among intern nurses.
Research hypothesis:
Intern nurses who attend the cultural intelligence model sessions exhibit higher level
of patient centered care, resilience at work and innovative work behavior after the
application of the model than before it.
Setting of the study:
This study was conducted in all Critical Care Units and Intensive Care Units (N=13)
at Alexandria Main University Hospital with bed capacity 1633 beds and number which
critical care units include (N=5) namely; First unit, Second unit, Third unit, Fourth unit,
and Medical Care Unit while intensive care units (N=8) namely; Anesthesia Care Unit,
Neurosurgery Care Unit, Cardiac Care Unit, Urology Care Unit, Burn Care Unit, Chest
Care Unit, Hematemesis Care Unit, and Maxillofacial Care Unit.
Subjects:
Probability, systematic random sampling technique of intern nurses was included in this
study (n=56) who were working in the previously selected setting. Total number of intern
nurses who were working in critical care units and Intensive Care Units (N=248) and using G
power in calculating sample size.
Tools of the study:
Five tools were used in this study as follow:
Tool (1): Cultural Intelligence Scale (CQS).
Self-administered questioner was developed by Ang et al., (2007) based on cultural
intelligence model and adapted by Barzykowski et al., (2019). It was adopted to assess
intern nurses‘ perception regarding CQ. It is composed of 20-items classified into four
dimensions, namely; cognitive (6 items), metacognitive (4 items), behavioral (5 items), and
motivational (5 items). The responses were measured on 5-point Likert scale ranged from
(1) strongly disagree and (5) strongly agree.
Tool (2): CARES® Observational Checklist (COC)
It was developed by Gaugler et al., (2013) and adapted by Bridges et al., (2019) to be
used in acute care setting. It was a systematic observational checklist was composed of 16
items to assess level of patient centered care delivered to patients during professional
practices and direct patients care. Each item of the tool reflects care interactions and care
behaviors toward patients such as greeting, calm manner, and explaining or involving
patient in care. Researcher observed care interactions between nurses and patients and each
item was scored as done (1) or not done (0). COT scores were calculated by summing the
number of items.
Tool (3): Resilience at Work Scale (RAW-S)
It was developed by Winwood et al., (2013). It was adopted to assess resilience level
at work for intern nurses. It was composed of 20-items classified into seven dimensions,
namely; Living authentically (3 items), Finding one‘s calling (4 items), Maintaining
perspective (3 items), Managing stress (4 items), Interacting cooperatively (2 items),
Staying healthy (2 items), and Building networks (2 items). The responses were measured
on 5-point Likert scale ranged from (1) strongly disagree and (5) strongly agree.
Tool (4): Innovative work behavior Scale (IWBS)
It was developed by Lukes & Stephan (2017). It was adopted to assess level of
innovative work behavior for intern nurses. It was composed of 23-items classified into
seven dimensions, namely; Idea generation (3 items), Idea search (3 items), Idea
communication (4 items), Implementation starting activities (3 items), Involving others (3
items), Overcoming obstacles (4 items) and Innovation outputs (3 items).The responses
were measured on 5-point Likert scale ranged from (1) strongly disagree and (5) strongly
agree.
Tool (5): Workshops Effectiveness Tool (WET)
It was developed by the researcher based on the review of related literature (Tarik,
2018; Sufi, 2016) to evaluate effectiveness of workshop sessions (strength and weakness
points) from intern nurses’ point of view. It is a structured form of questionnaire includes
20 items such as: objectives, time period, content, time schedule and methods of teaching
used...etc). The responses were measured on 5-point Likert scale ranged from (1) strongly
disagree and (5) strongly agree.
In addition, the researcher developed demographic characteristics data sheet, and
included questions related to gender, unit, age, marital status working shift, previous
experience of working in ICU, any training program about culture intelligence and region
(rural and urban).
Method
1. An approval for conducting the study was obtained from the Ethical Research
Committee of the Faculty of Nursing, Alexandria University prior to the start of
study.
2. An official permission was obtained from Vice Dean for community Service and
Environment Development, Faculty of Nursing, Alexandria University to collect the
necessary data from intern nurses.
3. An official letter from the Faculty of Nursing was sent to the hospital administrators
to collect the necessary data.
4. All tools were translated into Arabic and were tested for their face validity by five
experts in the field of the study and accordingly the necessary modifications were
done.
5. The tools were tested for their reliability to measure the internal consistency using
Cronbach‘s alpha Correlation Coefficient test. The result of tools revealed that they
were reliable with value of r = 0.886 for Cultural Intelligence Scale (CQS), r =
0.802 for CARES® Observational Checklist (COC), Resilience at Work Scale
(RAW-S) was reliable with value been r = 0.926, r = 0.862 for Innovative work
behavior Scale (IWBS) and Workshops Effectiveness Tool (WET) was reliable with
value been r = 0.844.
6. A pilot study was carried out on 10 % of intern nurses (n= 6 ), who was not
included in the study subjects in order to check and ensure the clarity of tools,
applicability, feasibility, identify obstacles and problems that was encountered
during data collection and estimated time needed to fill each questioner and the
necessary modifications were done.
7. Ethical considerations were assured
8. The study was conducted in the following phases:
IV. Assessment Phase
This phase was done as follows:
1. Self-administered questionnaire using tool (1) to assess intern nurses‘ perception of
CQ, tool (3) and tool (4) to assess resilience and IWB level for intern nurses, it was
distributed before observation and the researcher was explained the aim of study
and answer any queries related to study.
2. Tool (2) was conducted through structured intermittent observation by the
researcher, each study subject was observed separately three times during providing
direct patient care at long shift (morning and evening shift), total number of
observation sessions equal 168 times in this phase and the researcher was
documented actions of intern nurses in observation sheet which (1) mean done or
(0) not done.
V. Planning and implementation phase of application of culture intelligence model
(CQM):
A: Planning phase of application of (CQM)
This phase was done as follows:
1. Based on the result of the assessment phase, review of related literatures and the
model of CQ were applied through workshop sessions.
2. Intern nurses were classified into five groups based on their working days; each
group included from 11-12 intern nurses.
3. Total number of workshop sessions (20) was conducted for one month, total of
training sessions were 60 hours for the five groups; which each group was taken one
session for 3 hours per week. Total training hours for each subject 12 hours.
4. The workshop sessions‘ content and media were developed based on CQ model and
review of literatures (in the form of handout and visual materials) was prepared by the
researcher through using theoretical knowledge, pictures, role play, teamwork, brain
storming and discussion.
B. Implementation phase of the application of (CQM):
1. Pre-test was administered to intern nurses to collect data related to intern nurses’ level
of knowledge regarding CQ such as (what is the concept of CQ, why we need to use
this concept and component of model……ect) the test was completed in 10 minutes.
2. The workshop sessions were implemented for all groups and include general and
specific objective, relevant content, educational methods and evaluation technique.
3. Post-test the questionnaire was applied at the end of workshop sessions to evaluate
the gained knowledge in comparison with pretest.
4. Workshops effectiveness tool was used at the end of workshop sessions to evaluate
effectiveness of workshops (strength and weakness points).
VI. Evaluation phase:
This phase was done as follows:
1. Determine the effect of the model application was carried out after one month of
workshops implementation and the researcher was conducted data collection by
using tools of the study.
2. Self-administered questionnaire was done by using tool (1) to assess intern nurses‘
perception of CQ, tool (3) and tool (4) to assess level of resilience at work and IWB
level for intern nurses.
3. Observation, which was conducted by the researcher as mentioned previously by
using tool (2).
The main result of the study showed that:
The present study revealed that there were statistically significant differences were
found between the overall mean percent score of the intern nurses‘ cultural
intelligence (CQ) model application and its two dimensions (Cognitive CQ and
Motivational CQ), at the two evaluative times (before, and after one month.
Also, it stated that there were statistically significant differences were found between the
overall mean percent score of the intern nurses of Patient Centered Care (PCC) and its
dimensions, at the two evaluative times (before, and after one month) of CQ model
application, where (P = <0.001*).
This study illustrated that there were no statistically significant differences were found
between the overall mean percent score of the intern nurses‘ resilience at work and its
dimensions, at the two evaluative times (before, and after one month) of application of CQ
model, where (P = 0.087). The overall mean percent score of resilience at work was
increased from 47.16 % to 69.17 %. Also, it showed that highly significant differences were found between the overall
mean percent score of the intern nurses‘ Innovative Work Behavior (IWB) and its
dimensions, at the two evaluative times (before, and after one month) of application
of CQ model, where (P =.000**).
Finally, this study illustrated that, application of CQ model had a large effect size on
knowledge related to CQ where effect size (0.80) respectively. However, the
application of CQ model had medium effect on patient centered care (PCC),
innovative work behavior (IWB) and resilience at work where effect size (0.788,
0.480, 0.352) consecutively. Also, it can be seen that, the highest mean change was
found in knowledge related to CQ (39.47) rather than other variables.
The findings of this study lead to the following recommendation:
A. Recommendations for Nursing Faculty’s Administrators to develop CQ skills
among nurse educators, nursing students and intern nurses
In relation to nursing curriculum design
a) Applied concepts of CQ, PCC, resilience and IWB in theoretical and practical
courses for undergraduate and postgraduate nurse students both in terms of
knowledge and behavior in order to foster good attitudes and understanding of
cultural differences among nursing students throughout the educational period.
b) Development of evaluation tools for checking cultural skill and CQ for nursing
educators, nurse students and intern nurses.
In relation to educating academic nursing educators:
Development of systematic and continuous educational opportunities for nursing
educators through various of training programs and intercultural communication
workshops to raise awareness of the importance of cultural differences among them,
to be culturally competent and can motivate and encourage nurse students to improve
CQ skills.
Design and implement group discussions, exchange opinions and experiences
among multicultural peers, using reliable technological media, learning from
current case studies, and using CQ skills to solve problems.
Visiting multicultural communities and providing nursing students with
opportunities to deal with problems in real situations.
Restructuring the internship orientation program should be included training on CQ,
PCC and resilience skills.
B. Recommendations for academic nursing educators to develop CQ, resilience,
PCC skills and innovative behavior among nursing students:
Providing nursing students with the space to generate new ideas and innovations to
maintain and enhance their innovative behavior, resilience and promote their culture
skills through using innovative expression methods such as problem-based learning
on real-life case studies, stories telling, writing poems, role-plays, simulation, virtual reality, brainstorming, game-based and movies should be included in seminars and
conferences.
Design an innovation board where students ‗generate new ideas that have proven
successful could be easily accessed in the faculty.
C. Recommendations for internship preceptors to develop CQ, resilience, PCC skills
and innovative behavior among intern nurses:
Provide continuous in-service educational programs and training programs for intern
nurses related to CQ, PCC, resilience and innovative work behavior during internship
year especially during orientations.
Develop competency checklist for intern nurses to evaluate CQ level and give
constructive feedback without harsh criticism.
Encourage intern nurses‘ innovation, new ideas and critical thinking through create a
competition between intern nurses for selecting the best intern nurse who perform
innovative behavior and social intelligence during the working and motivating them
through putting their names and pictures on hospital board as well as giving them
certificate or non-minatory incentives to be role model for other intern nurses as well as
other health care providers.
D. Recommendations for intern nurses for enhance CQ, PCC, IWB and resilience:
Treat patients with love and respect, listen to patients, involving the patient and the
patient’s family in decision-making and demonstrate respecting for the patient’s
values, culture and needs.
Share social activities through conducting birthday parties, field trip, exchanging
gifts, offering more social support and attention for intern nurses through sending
congratulation card in case of success and identifying intern nurse‘s needs and try to
satisfy them in order to improve their work performance, productivity and increase
intern nurses‘ sense of belonging and obligation to be able to cope with workplace
stress and more resilient.
The following are suggestions for further studies in this area should be done:
Compare cultural intelligence levels between nurse educators and their students and
associated factors.
A qualitative research is recommended to address factors that contribute to cultural
intelligence from faculty perspectives and to identify the best educational strategies to
teach cultural intelligence in nursing programs.