Collegian (2013) 20, 187—194

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/coll

Perceptions of clinical safety climate of the

multicultural nursing workforce in Saudi Arabia: A
cross-sectional survey
Adel F. Almutairi, RN, Doctor of Health Science a,b,d,∗,
Glenn Gardner, RN, PhD c,d, Alexandra McCarthy, RN, PhD a,d

a
School of Nursing, Queensland University of Technology, Brisbane, Australia
b
King Abdullah International Medical Research Centre (KAIMRC), Riyadh, Saudi Arabia
c
School of Nursing, Queensland University of Technology & Royal Brisbane and Women’s Hospital, Brisbane, Australia
d
Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059, Australia

Received 20 May 2012; received in revised form 14 August 2012; accepted 15 August 2012

KEYWORDS Summary
Multicultural nursing Purpose: The purpose of this study is to explore the safety climate perceptions of the multi-
workforce; cultural nursing workforce, and to investigate the influence of diversity of the multicultural
Clinical safety; nursing workforce on clinical safety in a large tertiary hospital in Saudi Arabia.
Cultural diversity; Background: Working in a multicultural environment is challenging. Each culture has its own
Safety Climate Survey unique characteristics and dimensions that shape the language, lifestyle, beliefs, values, cus-
toms, traditions, and patterns of behaviour, which expatriate nurses must come to terms with.
However, cultural diversity in the health care environment can potentially affect the quality of
care and patient safety.
Method: A mixed-method case study (survey, interview and document analysis) was employed.
A primary study phase entailed the administration of the Safety Climate Survey (SCS). A popu-
lation sampling strategy was used and 319 nurses participated, yielding a 76.8% response rate.
Descriptive and inferential statistics (Kruskal—Wallis test) were used to analyse survey data.
Results: The data revealed the nurses’ perceptions of the clinical safety climate in this multicul-
tural environment was unsafe, with a mean score of 3.9 out of 5. No significant difference was
found between the age groups, years of nursing experience and their perceptions of the safety
climate in this context. A significant difference was observed between the national background
categories of nurses and perceptions of safety climate.

∗ Corresponding author. Current address: King Abdullah International Medical Research Centre (KAIMRC), Riyadh, Saudi Arabia.

Tel.: +966 1 25220088; mobile: +966 555900336.

E-mail address: almutairiAd1@ngha.med.sa (A.F. Almutairi).

1322-7696/$ — see front matter © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.colegn.2012.08.002
188
Conclusion: Cultural diversity within the nursing workforce could have a significant influence
on perceptions of clinical safety. These findings have the potential to inform policy and practice
related to cultural diversity in Saudi Arabia.
© 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction
Patient safety is most often related to physical and pro-
cedural factors as it relates to avoiding, eliminating or
removing adverse events. Patient safety was clearly defined
by the Institute of Medicine as ‘‘the prevention of harm to
patients’’ (Aspden, Corrigan, Wolcott, & Erickson, 2004).
However, a growing situation that poses risk to patient safety
is the cultural diversity of the healthcare workforce and
related issues such as a cross-cultural communication. These
issues can adversely affect interaction with people from
other cultures.
Culture shapes all aspects of an individual’s or a group’s
life; and is a significant determinant of their behaviour.
Each culture has its own unique characteristics that define
the normative values of its members (Ferrante & Ferrante-
Wallace, 2008). A wide range of cultural factors influences
the diversity of individuals, including ethnic identity, class,
education, language, gender, sexuality, spiritual traditions
and degree of acculturation (Heater, 2003; Kleinman &
Benson, 2006).
The literature indicates that differences across cul-
tures in the one health care setting can generate conflicts
between nurses or between nurses and the patients for
whom they care (Boi, 2000; Cioffi, 2005; Hoye & Severinsson,
2008; Kirkham, 1998). For example, different cultural
beliefs, biases, and family structures can influence the
way people experience their illness, adhere to medi-
cal advice and respond to treatment regimens (Cohen,
Gabriel, & Terrell, 2002). Cultural misunderstandings can
also result in difficulties obtaining medical histories and
gaining informed consent, as well as increasing the chance
of poor treatment adherence and limited patient satisfac-
tion (Nielsen-Bohlman, Panzer, & Kindig, 2004). The Institute
of Medicine further proposes that cultural incompetence,
which arises when providers use their own culture as a
template for the manner in which they interact with, and
treat, the patient and their illness, contributes significantly
to inequalities and disparities in health care (Institute of
Medicine, 2008). Health care providers who are unaware
of the potential impact of culture on health care (such
as language barriers, religious taboos and restrictions, cul-
tural explanations of diseases, and traditional remedies) are
likely to create dissatisfied patients, as well as be unable to
provide optimal health care (Cohen et al., 2002).
The literature highlights many instances of how, in clini-
cal settings, cultural differences and language barriers can
compromise quality health care and patient safety (Brown
& Busman, 2003; Cohen, Rivara, Marcuse, McPhillips, &
Davis, 2005; Johnstone & Kanitsaki, 2006). For example,
ethnic minority populations tend to receive health care of
poorer quality than non-minority populations (Chin, Walters,
Cook, & Huang, 2007; Crawley & Kagawa-Singer, 2007;
Johnson & Onwuegbuzie, 2004; Kagawa-Singer & Kassim-
Lakha, 2003). The infant mortality rates among African
American, Native American, and some Asian American and
A.F. Almutairi et al.
Pacific Islander groups are also twice as high as those
of other Americans of European origin in the US, while
the maternal mortality rate for African Americans is four
times that of white Americans (Kagawa-Singer & Kassim-
Lakha, 2003). As Johnstone and Kanitsaki argue, culture
and language differences, the failure to use interpreters,
and the risk of cultural misunderstanding all expose patients
from different backgrounds to preventable adverse events
(Johnstone & Kanitsaki, 2006).
From another perspective culture can influence the expa-
triate nurse’s approach to clinical practice, which can
vary from one culture to another; nurses practise the way
they are used to performing in their home countries (Yi
& Jezewski, 2000). Xu conducted a meta-synthesis of the
experiences of Asian nurses working in Western countries
and highlighted the challenges they encountered due to
differences in nursing practice (Xu, 2007). Xu found that
Asian nurses were challenged to assist their patients’ activ-
ities of daily living. In Asian nurses’ home countries, these
basic needs were mainly performed by the family members,
which contrasts with Western countries where the family
completely depends on the nurses for such tasks. Many
Asian nurses perceived such activities as humiliating and
demoralising due to their own cultural norms. These differ-
ences often generated stress and frustration among nurses
which have direct effects on safety and quality of patient
care.
It is clear that understanding the way that a patient’s
culture shapes their health behaviour is essential to main-
tain optimum standards of health care. Such understanding
can help health care providers to comprehensively assess
patients and their families, and enables them to identify and
deal proactively with issues that have the potential for con-
flict (Kagawa-Singer & Kassim-Lakha, 2003). Taking this into
account, within the context of a multicultural health care
environment, cultural competence is a significant require-
ment for health care providers. Cultural competence aims to
bridge the gap between the different cultures and languages
of patients and providers to enhance health the safety and
quality of care delivery.
The majority of studies on this topic address the issue
of culture differences when nurses encounter patients from
another culture; they do not investigate the issue of cultural
diversity in a multicultural work environment where the
nurses not only differ from the patients they care for; they
are significantly different from each other. The health care
system in Saudi Arabia relies heavily on expatriate health
care professionals with different cultural and linguistic
backgrounds, which comprise 67.7% of the total workforce
(Ministry of Health, 2009). This situation is similar in other
Gulf countries (Aldossary, While, & Barriball, 2008; Omer,
2005).
The purpose of this study is twofold: (1) to explore
the safety climate perceptions of the multicultural nursing
workforce in a Saudi tertiary hospital, and (2) to investigate
Clinical safety climate of the multicultural nursing workforce in Saudi Arabia
the association between diversity of the nursing workforce
and their perception of clinical safety climate.
Methods
Research design
The study reported in this paper comprises the survey
component of a larger mixed-method (survey, interview,
document review) case study. The qualitative compo-
nents are reported elsewhere (paper in review). The study
received ethical clearance from the Human Subject’s Com-
mittee of the Medical institution where the study was
conducted, and the principal researcher’s university.
Population, sampling and recruitment
The target population for this study comprised regis-
tered nurses, including both Arabic and non-Arabic nurses,
involved in direct patient care at King Abdul-Aziz Medical
City in the Riyadh region (KAMC-R). The KAMC-R hospital is
an 800-bed teaching hospital and medical referral centre.
In the preparation process to access the field, a memoran-
dum was sent to the nurse managers and educators to inform
them of the study and to seek their assistance in recruiting
participants. The lists of nurses working in the medical, sur-
gical, paediatric and gynaecological units were accessed.
These clinical units were included based on homogeneity
in terms of workload and patient acuity. The total popula-
tion in these units was 490 nurses. Nurses who had less than
3 months’ experience were excluded because they were
still in the probationary period; therefore, the number was
reduced to 415 nurses. Since the required sample size was
323 which determined based on sample calculation formu-
lae (Berenson, Levine, & Rindskopf, 1988; Israel, 1992) and
power analysis, population sampling from the participating
units were used.
Data collection
The Safety Climate Survey (SCS) was used to examine
the multicultural nursing workforce’s perceptions of clini-
cal safety in this organisation. The SCS was developed by
the University of Texas Centre of Excellence for Patient
Safety Research and Practice (McBride-Henry & Foureur,
2006; Sexton et al., 2006). The aim of the SCS is to examine
the degree of proactive commitment to safety as perceived
by individuals in the hospital. This instrument comprises
21 items using a 5-point Likert scale with responses from
1: disagree strongly to 5: agree strongly. The one nega-
tively worded item in the SCS was reverse scored to match
the positive questions. In order to consider any individ-
ual respondent to have a positive perception of safety,
their mean must be four or more (Kho, Carbone, Lucas, &
Cook, 2005; McBride-Henry & Foureur, 2006). The survey also
comprised a section for demographic data that includes age,
job position, experience and ethnic background.
The reliability of the SCS has been confirmed in several
studies and different contexts (Kho et al., 2005; Pronovost
& Sexton, 2005; Sexton et al., 2006; Shteynberg, Sexton,
189
& Thomas, 2005). In this study, the internal consistency of
the instrument was assessed using Cronbach’s alpha (coef-
ficient alpha) (Pallant, 2007). The Cronbach’s alpha of this
instrument was .88, which indicates very good reliability and
internal consistency in the study cohort.
Eligible nurses were contacted by to alert them to the
fact that the study was being conducted and a letter of
invitation was also placed in their unit’s internal mailbox.
Envelopes that contained a coded copy of the questionnaire,
a cover sheet that explained the study and the researcher’s
contact details were also provided. A collection box was
placed in each participating unit. Nurses were asked to
return the surveys, either completed or left blank, to the
collection box. The return of completed questionnaires sig-
nified consent. The time allowed for the collection of the
questionnaires was 1 month; a reminder was sent out after
2 weeks to all potential participants to improve the response
rate.
Data analysis
Descriptive statistics were used to measure the character-
istics of the sample. Frequencies were used to analyse the
categorical data, and means and standard deviation were
used for analysis of the continuous data.
Inferential statistics were employed to examine differ-
ences between the groups (including years of experience
in the organisation, age and national background) in terms
of their perception of the safety climate. Assumption of
normality was assessed using Kolmogorov—Smirnov tests
and visual inspection of histograms and boxplots. The data
were not normally distributed, therefore, the nonparamet-
ric Kruskal—Wallis test was employed which is appropriate
to detect differences among groups, such as one categorical
independent variable with three or more different groups
and one continuous dependant variable (Coakes, Steed, &
Ong, 2010).
Results
Response rate
A total of 415 nurses were sent a survey package. 319
completed and returned the questionnaire, resulting in a
response rate of 76.8%. The percentage of nurses who
responded to the study, differentiated by the units in which
they worked, is presented in Table 1.
Demographic data
Age
The age of the respondents ranged from less than 30 years
to 45 or over. The largest number of respondents fell in the
age range of 35—39 years (n = 88, 27.6%), while 24.5% (n = 78)
were aged 30—34 years. The percentage for those aged less
than 30 and from 40 to 44 years were equal (n = 57, 17.9%).
Only 12.2% (n = 39) of the nurses were 45 years or over.
190
Table 1 Responses of nurses differentiated by units.
Unit Frequency Percent
Medical 169 53
Surgical 62 19.4
Paediatric 43 13.5
Gynaecology 29 9.1
Medical rehabilitation 16 5 area take responsibility for patient safety’ with 67.7%
Participants’ country of origin
Participants reported 16 different countries of origin namely
Saudi Arabia, Jordan, Lebanon, Egypt, Palestine, Ireland,
the United Kingdom, Finland, Australia, New Zealand,
the Czech Republic, North America,1 South Africa, the
Philippines, and Malaysia. To protect the confidentiality and
anonymity of respondents in the hospital when reporting
the findings, the nationalities were combined into six major
global areas: Middle Eastern countries, European countries,
North America (US and Canada), Australia and New Zealand,
South Africa, and South-East Asia. More than half the par-
ticipants (n = 171) did not specify their ethnic background
or their country of origin and were categorised as ‘not
specified’.
The most common background (n = 98, 30.7%) was
South-East Asian. Eleven respondents were from European
countries (3.4%) including Ireland, the United Kingdom,
Finland and the Czech Republic, while 17 were from South
Africa (5.3%) and 15 from Middle Eastern countries (4.7%).
In addition, there were two participants from North Amer-
ica giving a percentage of 0.6%. Five respondents were from
Australia and New Zealand (1.6%).
Experience in the organisation
The length of respondents’ experience ranged from 6 months
or less to 21 years or over. Approximately 40.8% (n = 129) of
the nurses had 3—7 years’ experience in the organisation,
21.2% (n = 67) of the nurses had worked 1—2 years in the
organisation, while 15.4% (n = 49) had worked 6—11 months,
13.3% (n = 42) had worked 8—12 years, 5.4% (n = 17) had
worked 13—20 years, and 2.5% (n = 8) had worked less than
6 months in the organisation. Only 1.3% (n = 4) had worked
in the organisation for 21 years or more.
Results of the Safety Climate Survey
The overall mean for all items and respondents was 3.97
out of five (SD 0.59). If the mean score is 4 or more, this
indicates a positive perception of safety climate (Institute
for Healthcare Improvement, 2004; Taylor, 2004). Fifty-four
percent of the respondents viewed the safety climate of
KAMC-R as positive whereas 46% of the respondents had a
low safety perception. Seven items, that is, 1, 2, 8, 9, 10, 11,
and 18, were considered very important. These items were
used to measure the strength of KAMC-R’s safety culture
(Institute for Healthcare Improvement, 2004). The mean
score of these seven questions for the group was 3.91/5 (SD
1 Participants from North America did not specify their countries.
A.F. Almutairi et al.
0.66). Table 2 reports the means and standard deviations of
participants’ responses to individual items.
The statement that had the most positive responses
was ‘Patient safety is constantly reinforced as the pri-
ority in this clinical area’. Seventy-five percent of the
respondents strongly agreed with this statement and
15.7% slightly agreed. The second statement that was
positively rated was ‘The personnel in this clinical
strongly agreeing with it and 21.9% slightly agreeing.
In addition, 66.5% of the respondents strongly agreed
and 22.3% slightly agreed with the statement ‘Brief-
ing personnel before the start of a shift (i.e., to
plan for possible contingencies) is an important part of
patient safety’, while 46.7% strongly agreed and 28.5%
slightly agreed with the statement ‘Briefings are common
here’.
The relatively low-scoring (58.6%) statement was, ‘I
would feel safe being treated here as a patient’ with
16.7% of the respondents disagreeing and the remaining
respondents (24.8%) were neutral. Eighty-five percent of
the respondents also agreed that ‘Management/leadership
does not knowingly compromise safety concerns for pro-
ductivity’. More than half of the participants (54%)
agreed with the statement, ‘The culture of this clinical
area makes it easy to learn from the mistakes of oth-
ers’.
In the negatively worded statement, ‘Personnel fre-
quently disregard rules or guidelines that are established
for this clinical area’, only 8.5% of the respondents strongly
agreed and 17.6% slightly agreed with this, while 37.6%
strongly disagreed and 21% slightly disagreed.
Perceptions of safety climate according to
Age
Non-parametric testing of K-independent samples using the
Kruskal—Wallis test examined differences between respon-
dents’ safety climate perception based on their age groups
in order to determine if there is a relationship between
these two variables. There was no statistical difference in
the perception of safety climate across the age categories
(significance level 0.247 (>0.05) (H = 5.420)). However,
inspection of the mean ranks for the groups indicated that
the group aged 45 or over had the highest level of safety per-
ception, while the group aged 35—39 years had the lowest
level of safety perception.
Experience
The same test technique was used to determine differences
in safety perception among the groups based on their length
of experience in the organisation. This indicated that there
was no statistical difference in safety perception regarding
the length of experience in the organisation categories, with
p = 0.819 > 0.05 level (H = 2.922). It means that there is no
effect of the subjects’ experiences on their perception of
safety climate.
Country of origin
The Kruskal—Wallis test was conducted again to examine
the differences in perception of safety within the national
Clinical safety climate of the multicultural nursing workforce in Saudi Arabia 191

Table 2 The means and standard deviations of the responses on the items.

# Safety Climate Survey items Mean SD

1 The culture of this clinical area makes it easy to 3.52 1.214

learn from the mistakes of others
2 Medical errors are handled appropriately in this 3.99 1.152
clinical area
3 The senior leaders in my hospital listen to me and 3.47 1.268
care about my concerns
4 The physician and nurse leaders in my areas listen to 3.68 1.100
me and care about my concerns
5 Leadership is driving us to be a safety-centred 4.02 1.126
institution
6 My suggestions about safety would be acted upon if I 3.78 1.023
expressed them to management
7 Management/leadership does not knowingly 3.53 1.193
compromise safety concerns for productivity
8 I am encouraged by my colleagues to report any 4.18 1.026
safety concerns I may have
9 I know the proper channels to direct questions 4.47 0.780
regarding patient safety
10 I receive appropriate feedback about my 4.01 1.148
performance
11 I would feel safe being treated here as a patient 3.65 1.196
12 Briefing personnel before the start of a shift (i.e., to 4.51 0.824
plan for possible contingencies) is an important part
of safety
13 Briefings are common here 4.12 1.037
I am satisfied with the availability of clinical leadership (please respond to all three)
14 Physician 3.50 1.130
15 Nursing 4.21 0.963
16 Pharmacy 3.83 0.983
17 This institution is doing more for patient safety now, 4.25 1.004
than it did 1 year ago
18 I believe that most adverse events occur as a result 4.12 0.992
of multiple system failures, and are not attributable
to one individual’s actions
19 The personnel in this clinical area take responsibility 4.50 0.897
for patient safety
20 Personnel frequently disregard rules or guidelines 3.62 1.361
that are established for this clinical area
21 Patient safety is constantly reinforced as the priority 4.60 0.866
in this clinical area

background categories. The North American, Australia/New Discussion

Zealand categories were further combined with the West-
ern category because there were only two participants from
North America and five participants from Australia/New
Zealand, which is not statistically significant to compare
them with other categories. Collapsing the data in this cat-
egory was undertaken, as there are similarities between
these countries in terms of some cultural norms (Kim, Pan,
& Park, 1998). The significance level was 0.022, as shown
in Table 3, which is statistically significant (p = 0.022 < 0.05,
H = 11.457). This indicates that there is a difference in the
perception of safety across the broad groups of different
nationality.
Analysis of the data indicated that the nurses’ perception
of clinical safety climate in this multicultural environment
is not positive with a mean score of 3.9 (5 point scale
from strongly disagree to strongly agree). Whilst the mean
score of the nurses’ perceptions of safety climate is close
to positive (4), there is ambiguity and no clear agreement
regarding clinical safety among the surveyed nurses. The
safety climate at KAMC-R was viewed as positive by 54%
of nurses, whereas 46% perceived the safety climate as
being unsafe. When dealing with clinical safety, this is a
major issue and a significant finding as almost half of this
192 A.F. Almutairi et al.

Multiple cultural norms can exist within peoples from

Table 3 Differences in perception of safety within the par-
the same nation. However, based on the study findings,
ticipants’ broad country of origin.
the classification of respondents based on nationality and
Background N Clinical safety continent was helpful to determine nurses’ responses on
climate mean rankc,d safety climate.
Furthermore, 53% (n = 171) of participants did not dis-
Part A close information about their national background. This
Middle Eastern 15 213.70 significant finding indicates that this nursing workforce
West- 18 121.22 might be disempowered in this multicultural environment
ern/Australian/New and might not be able to discuss the safety concerns or
Zealander issues in their clinical practice. Importantly, this study dis-
South-East Asia 98 171.39 covered a statistically significant difference between the
South African 17 171.97 national backgrounds categories of nurses and the percep-
Not specified 171 151.65 tion of safety climate. This finding is important, because
Total 319 it indicates that the national diversity of nurses has a role
to play in clinical safety. The study found that the nurses
Safety perception from Middle Eastern countries had a higher safety perception
than other backgrounds, and nurses from Western countries
Part B
had the lowest perception of safety climate. This differ-
Test statisticsa,b
ence in safety perception may stem from cultural similarities
Chi-square 11.457
between the Middle Eastern countries in terms of values,
df 4
traditions, beliefs, behaviours, religion, language and even
Asymptotic sig. 0.022
of the management and leadership style, and the cultural
Note. differences the nurses from western countries experience
a Kruskal—Wallis test.
in this context.
b Grouping variable: country of origin.
c Mean rank is the sum of the group’s ranks divided by the
The literature did not reveal any studies with similar find-
ings in terms of the relationship between cultural or national
number of respondents in that group.
d The mean ranks of the groups are indicating which group has backgrounds of nurses and their perception of safety cli-
the highest and lowest perception of safety climate.
mate. Two studies regarding organisational culture found
that the ethnicity or cultural background of health care
providers influences the perception of organisational cul-
representative sample (N = 319) of nurses report that clinical ture (Seago, 2000; Staten, Mangalindan, Saylor, & Stuenkel,
safety is compromised and perceive their working environ- 2003). However, safety climate differs from the organisa-
ment as clinically unsafe. tional culture (Flin, 2007; Garcia, Boix, & Canosa, 2004;
There is no evidence in the literature that research has Guldenmund, 2000; Schein, 2004).
been conducted to measure the influence of a multicul- There was no significant difference between the age
tural clinical workforce on the perception of safety climate. groups and years of experience of nurses and the perception
Other studies have been done and found similar and vari- of safety climate in this context. This finding contrasted with
ant findings in terms of the overall mean of safety climate the study by Holden, Watts, and Walker who found signifi-
but the variables are different (McBride-Henry & Foureur, cant differences between the age group of participants and
2006; Sexton et al., 2006; Taylor, 2004; Thomas, Nelson, safety climate scores wherein the authors reported that the
& Silverman, 2005). These studies, conducted in different ‘younger age group’ had the lowest score (Holden, Watts, &
contexts, dealt with different populations and included a Walker, 2009). Their study was carried at four US Air Force
multidisciplinary sample, whereas the present study was ambulatory care facilities, and the sample included physi-
undertaken in a large urban hospital and the sample was cians, nurse practitioners, physician assistants, registered
purely nurses working in a foreign country and in a multicul- nurses, pharmacists and technicians. The contradiction in
tural environment where more than 25 nationalities exist. findings between the present study and Holden, Watts, and
One of the significant findings in this study is that almost Walker’s study could be related to the heterogeneity of their
half of the participants reported that they would not feel sample, as the present study is homogenous for registered
safe being treated in this environment if they were patients. nurses. Moreover, the study context might contribute to this
Their perception of insecurity could stem from the lack of difference, as the majority of nurses in the present study are
effective communication in this environment, as well as the expatriates from various cultural and national backgrounds
differences in cultures that shape people’s lives and patterns whereas the US study measured American nationals in an
of behaviour. American context.
Despite the assurance provided that anonymity and con-
fidentiality would be observed in this study, the majority
of participants failed to report their ethnic background as Limitation
opposed to their country of origin. It might be that they
considered their country of origin an indicator of their This study was conducted in a single organisation in Saudi
cultural background. However, it should be noted here that Arabia which may limit the generalisability of the study
‘nationality’, or place of birth, is not synonymous with findings to all multicultural settings. In addition, more than
the ‘‘ethnicity’’, which is more about cultural affiliation. half of the participants failed to disclose their ethnic or
Clinical safety climate of the multicultural nursing workforce in Saudi Arabia
national background as discussed earlier in this article.
Ethnic background is an important factor that contributes
to understanding the underlying phenomenon of this
study.
Conclusion
The results clearly demonstrate that the nurses in this multi-
cultural environment had a low perception of safety climate.
This study revealed new knowledge that the national diver-
sity in a multicultural nursing workforce can adversely affect
the quality of care and patient safety. There was strong evi-
dence that this multicultural workforce was not confident
about their own cultural and professional clinical safety. This
study suggests that there is a need for a well-structured con-
tinuing education programme for nurses that aim to increase
their cultural competence to enable them to provide high
quality and clinically safe care. Specifically, education is the
tool to enhance the sense of empowerment for the multi-
cultural nursing workforce. In addition, such an educational
programme should utilise and employ the best adult learn-
ing methods to ensure participation, comprehension and
understanding. This finding can contribute new understand-
ing about the influence of national and cultural diversity on
the perception of safety climate. No research with similar
findings was evident and published studies on safety climate
deal with culturally homogenous groups.
Competing interest
The author(s) declare that they have no competing interests.
Author contributions
The first author is responsible for designing, conducting the
study and drafting the manuscript. Second and third authors
made critical revision of the paper and supervised the
study.
Acknowledgements
The authors thank the National Guard Health Affairs, Chief
Executive Officer, His Excellency, Dr. Bander Al Knaway; Dr.
Mohammad Al Jumah, Executive Director of King Abdullah
International Medical Research Centre; the Associate Direc-
tor of Nursing Services, Ms. Joan Murray; and Dr. Mustafa
Bodrick, Director of Clinical Nursing; and all the Directors of
Clinical Nursing for their support and facilitation to conduct
this study. Our special thanks are extended to the nursing
staff who participated by responding to the questionnaire
survey.
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