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Impact of nurses' cross-cultural competence on nursing intellectual capital

from a social cognitive theory perspective

Article  in  Journal of Advanced Nursing · May 2016

DOI: 10.1111/jan.12901

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ORIGINAL RESEARCH: EMPIRICAL RESEARCH –
QUANTITATIVE
Impact of nurses’ cross-cultural competence on nursing intellectual
capital from a social cognitive theory perspective
Hsien-Cheng Lin
Accepted for publication 19 November 2015
Correspondence to H.-C. Lin:
e-mail: u0028909@nkfust.edu.tw
Hsien-Cheng Lin PhD
Associate Professor/Director
Department of Health-Business and
Administration, Fooyin University,
Kaohsiung City, Taiwan/Department of
Planning, Fooyin University Hospital,
Pingtung County, Taiwan
1144
L I N H . - C . ( 2 0 1 6 ) Impact of nurses’ cross-cultural competence on nursing intellec-
tual capital from a social cognitive theory perspective. Journal of Advanced Nurs-
ing 72(5), 1144–1154. doi: 10
1111/jan.12901
Abstract
Aims. To understand the relationships among certain key factors such as
organizational climate, self-efficacy and outcome expectation on registered nurses,
with regard to the development of registered nurses’ cross-cultural competence.
The focus is specifically on the use of a social cognitive framework for nurses for
providing intercultural nursing care to international patients. This study also aims
to examine the relationship between nurses’ cross-cultural competence and
nursing intellectual capital.
Background. Given the influence of globalization on healthcare services,
healthcare providers need to have enough cross-cultural competence to effectively
care for patients from different cultures. Thus, the development of cross-cultural
competence in nursing care has become an important issue.
Design. A quantitative method and a cross-sectional design were employed in this
study.
Methods. Data were collected from 309 RN working in 16 healthcare
institutions in Taiwan from May to August 2013. Structural equation modelling,
in combination with the smart partial least squares method, was used to measure
the relationships in the research model.
Results. The results show that outcome expectation has a stronger impact on
nurses’ cross-cultural competence than self-efficacy. In addition, it was found that
the cross-cultural competence of nurses has a positive impact on nursing
intellectual capital.
Conclusion. Nursing supervisors should promote a higher level of outcome
expectation on nurses to enhance the improvement of their cross-cultural
competence. Raising the cross-cultural competence of nurses will aid in the
accumulation of nursing intellectual capital.
Keywords: cross-cultural competence, nursing intellectual capital, social cognitive
theory
© 2016 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
Why is this research or review needed?
 Cross-cultural competence is a necessary skill when inter-
acting with people of different cultures.
 Social cognitive theory explains that personal behaviour is
affected by organizational climate and personal cognition
(i.e., self-efficacy and outcome expectation).
 It is not clear if organizational climate and personal cogni-
tion have any influence on nurses’ behaviour with regard
to cross-cultural competence.
What are the key findings?
 Outcome expectation plays a more important role than
self-efficacy with regard to nurses’ cross-cultural compe-
tence.
 Nurses’ cross-cultural competence has a positive influence
on nursing intellectual capital.
How should the findings be used to influence policy/
practice/research/education?
 Nursing supervisors should offer a greater incentive to the
nursing staff as a positive outcome expectation, leading to
a better development of cross-cultural competence.
 Increasing nurses’ cross-cultural competence helps to accu-
mulate nursing intellectual capital in a nursing department.
Introduction
In recent years, the international medical tourism industry
has been growing at an extremely fast pace. As looking to
overseas providers of medical services becomes ever more
popular, healthcare providers are now faced with the chal-
lenge of serving patients with diverse racial and cultural
backgrounds. As a consequence, the cross-cultural compe-
tence (CCC; Rothschild 1998) of nurses could be expected
to have an impact on individual work performance and
organizational intellectual capital. This study applies social
cognitive theory (SCT; Bandura 1981, 1982, 1997) and
nursing intellectual capital (NIC; Covell 2008) perspectives
to explore the process of developing nurses’ CCC and how
CCC influences organizational intellectual capital in nursing
departments.
Background
The healthcare service industry is rapidly going global as
an increasing number of people cross borders receive
© 2016 John Wiley & Sons Ltd
Cross-cultural competence
affordable, high-quality healthcare services. According to a
statistical report by Horowitz et al. (2007), over 750,000
people attend outbound medical tours each year from the
USA and the population of medical tourists is growing at
a rate of 18% every year. In fact, many healthcare institu-
tions have been receiving patients from various racial, eth-
nic and cultural backgrounds. Recent research has
indicated that cultural difference between healthcare provi-
ders and patients influences the provider–patient relation-
ship, treatment outcomes and levels of patient satisfaction
(Capell et al. 2008). Therefore, understanding how to fos-
ter CCC in healthcare professionals has become an inter-
national issue of concern in the healthcare service
industry.
Culture is a complex whole, which includes aspects of
beliefs, knowledge, law, morals, customs, art and many
other capabilities acquired by people as members of a soci-
ety (Hedi et al. 2010). Previous studies have found that the
CCC of healthcare professionals plays an important role on
the effect of patient treatment. For instance, Ingram (2012),
through the Campinha-Bacote’s cultural competence model,
found that nurses’ CCC can enhance the quality of clinical
care and improve patient outcomes. Kim-Godwin et al.
(2001) have provided specific guidelines for community
nurses in developing CCC. They found that CCC and
health outcomes have statistically significant relationships
in culturally diverse populations. Betancourt et al. (2005)
verified that healthcare professionals’ CCC will result in a
healthcare organization that is capable of providing the
highest-quality care to patients regardless of race, ethnicity
or cultural background. These studies have meaningfully
contributed to understanding intrinsic CCC in healthcare
professionals.
However, previous studies are somewhat incomplete
because of the fact that they did not include environmental
influence or certain personal factors that can have an
impact on individual behaviour and performance outcome.
SCT (Bandura 1982, 1997) states that factors of environ-
ment, personal features (cognition) and behaviour are inter-
acting determinants that are antecedents to performance
outcome. In addition, nursing is a knowledge-intensive
healthcare service. Nurses’ expertise and know-how of
nursing practice are vital intellectual property in any nurs-
ing department. Therefore, the author adopts the perspec-
tive of NIC for measuring the nurses’ CCC on the influence
of organizational performance. Based on the abovemen-
tioned view, the author suggests that a better understanding
of the issues relating to nurses’ CCC should include the per-
spectives of SCT and NIC.
1145
H.-C. Lin

Research model and hypotheses

Organizational climate, self-efficacy and outcome
The research model is shown in Figure 1. This study aims expectation
to investigate the relationships among several constructs.
For this study, Organizational Climate is considered to be
Different hypotheses will be posited and examined.
an environmental factor that influences personal
cognition. Organizational Climate is defined as the staff
Social cognitive theory perception relating to work in a particular workplace, i.e.
decision-making, outcome expectation and norms in the
SCT has been widely adopted in the field of behavioural
work environment (Stone et al. 2006). The Organizational
sciences with demonstrated content validity (Tsai & Cheng
Climate has been recognized as a variable which can
2010). The theory generally involves a psychological pattern
impact employees’ cognition and attitude toward
of human behaviour that defines individual behaviour as a
performing their work duties (Bronkhorst et al. 2015).
reciprocal interaction between the factors of environment
In the field of healthcare management, Snow (2002)
and personal cognition, in a social context. The theory pro-
indicated that some studies have consistently linked the
vides three meaningful insights in the domain of behavioural
climate around nursing teams to nursing staff cognition;
science. First, the environmental climate can affect personal
consequently, having an impact on their actual job perfor-
cognition. Second, personal cognition determines personal
mance. Dawson et al. (2008) also found that the level of
behaviour and personal behaviour can also impact the envi-
strength in terms of Organizational Climate has a positive
ronmental climate. Third, the personal cognitive factor con-
relationship on the development of health care profession-
sists of SE and OE (Tsai & Cheng 2010, Zhou et al. 2014).
als’ cognition and workability. This was determined
SE is defined as a person’s belief in his/her ability to per-
through an empirical study which amassed 11,903
form a specific behaviour to achieve a particular goal (Ban-
responses from 56 hospitals in the UK. Abdelhadi and
dura 1997). The improved SE of individuals can be achieved
Drach-Zahavy (2012) also explained that a nursing team
through learning via observation and imitation (Zhou et al.
climate of patient-centred care has a strong effect on
2014). OE is defined as a judgment of the likely consequence
nurses’ SE and OE in relation to how they provide
such behaviour will produce (Bandura 1997). That is, OE is
patient-centred care to patients. From a SCT perspective,
the potential motivating factor that determines how an indi-
the environmental factor can produce contextual social
vidual will perform (Bandura 1982). Moreover, SE (as indi-
influences on individual cognition (i.e. SE and OE).
vidual ability) and OE (as incentive) are important for
Accordingly, the following hypotheses were proposed:
individuals in terms of developing the motivation to achieve
objectives (Bandura 1997, Zhou et al. 2014). The theory is H1a: Organizational Climate has a positive effect on nurses’ SE.
appropriate for explaining the effects of the environmental
factor and personal cognition on behavioural outcomes. H1b: Organizational Climate has a positive effect on nurses’ OE.

The perspective of social cognitive theory

Environment Personal cognition Behavior Performance

H1a Self-efficiency H2

Cross-cultural Nursing
Organizational H4
competence intellectual
climate capital
Outcome
H3
H1b
expectation

Figure 1 Research model.

1146 © 2016 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Cross-cultural competence

Cross-cultural competence, self-efficacy and outcome the effort will result in favourable consequences (Bandura
expectation 1982, Zhou et al. 2014). Resnick and Simpson (2003) mea-
sured the OE of nursing professionals’ performance in
According to Rothschild (1998), CCC is defined as the
restorative care. They found that the OE is a useful way to
capability of understanding, and employing, interpersonal
improve nursing professionals’ performance. Therefore, the
skills with patients whose beliefs, values and histories are
following hypotheses were proposed:
different to one’s own. At an individual level, the compo-
nents of CCC include Cultural Awareness, Cultural Knowl- H2: SE has a positive effect on nurses’ behaviour in relation to
edge and Cultural Skill (Reimann et al. 2004). In the CCC.
literature on healthcare management, Cultural Awareness,
in terms of health care, is defined as the ability to recognize H3: OE has a positive effect on nurses’ behaviour with regard to
that all clients (patients) are not from the same cultural CCC.
background (Gray & Thomas 2006). Cultural Knowledge
is defined as a health professional’s familiarity with infor-
mation relating to culturally diverse clients (Reimann et al. Nursing intellectual capital
2004). Cultural Skill is defined as the ability to gather the
Covell (2008) defined NIC as nursing knowledge and skill
relevant cultural data about a client’s problems, and accu-
that is embedded in an organization; the result of which
rately execute cultural assessments (Campinha-Bacote
can influence patients’ treatment outcomes and organiza-
1999).
tional performance. NIC can be represented by two
Previous studies have indicated that the awareness–
dimensions: Nursing Human Capital and Nursing Struc-
knowledge–skill model for determining CCC is the accepted
tural Capital (Covell & Sidani 2013a,b). According to
model used for the evaluation of nursing professionals. For
Covell and Sidani (2013a,b), Nursing Human Capital is
instance, Reimann et al. (2004) investigated how Cultural
defined as the nursing knowledge and skills of nursing per-
Awareness and Cultural Knowledge influence culturally
sonnel; Nursing Structural Capital is defined as the trans-
competent actions, in a sample of 134 Mexican-American
ference of this knowledge and skill to information
physicians. The results indicated that (1) Cultural Aware-
structures that nurses employ to assist them in daily
ness can be predicted by Cultural Knowledge and (2) Cul-
patient care. Covell and Sidani (2013a,b) verified that
tural Awareness can predict culturally competent actions.
enhancing nurses’ knowledge and experiences improves
Ingram (2012) verified that cultural competence and health
their professional competence. Consequently, nurses’ pro-
literacy are related to health care in the specific context of
fessional competence contributes to the ongoing improve-
nursing practice. Moreover, in terms of enhancing Cultural
ment of organizational performance and NIC, as verified
Awareness, Cultural Knowledge and Cultural Skill can help
by an investigation of 147 inpatient units from six Cana-
nurses improve their own cultural competence. Based on
dian hospitals.
these findings, the author employed Cultural Awareness,
The author proposes that nurses’ CCC benefits their pro-
Cultural Knowledge and Cultural Skill to measure the con-
fessional knowledge and general competence in nursing
struct of behaviour of CCC.
practice. Furthermore, NIC is influenced by the variety of
Previous studies have verified that SE has an impact on
nurses’ professional knowledge and competence, including
personal behaviour (Bandura 1997, Zhou et al. 2014). In
CCC. Therefore, the following hypothesis was proposed:
the context of nursing care, Salanova et al. (2011) stated
H4: Nurses’ behaviour, in relation to CCC, has a positive
that nurses with high SE perceive troubles as challenges,
effect on NIC.
had more confidence and spend more time and effort on
their nursing activities. That is, an individual with high SE
is more likely to perform related behaviour than someone The study
with low SE (Tsai & Cheng 2010). Lee and Ko (2010)
found that strong SE can also improve nurses’ work perfor- Aims
mance. Thus, the author proposes that higher SE can help
This study has three specific aims:
nurses to improve their CCC.
The OE provides guidance in driving individual beha- • First, this study aims to examine the relationship
viour because individuals are more likely to engage in a between the Organizational Climate and personal cog-
particular behaviour when they believe that the outcome of nition (including SE and OE).

© 2016 John Wiley & Sons Ltd 1147

H.-C. Lin

• Second, this study aims to examine the relationship Table 1 Participant demographics (n = 309).
between personal cognition (including SE and OE) and Items N (%)
nurses’ CCC.
Gender
• Third, this study aims to examine the relationship
Male 3 (0
9%)
between nurses’ CCC and NIC. Female 306 (99
1%)
Age (mean = 33
4, SD 7
2)
Below – 19 years old 0 (0
0%)
Design 20-29 years old 175 (56
6%)
Two theoretical frameworks were used in this study – the 30-39 years old 97 (31
4%)
Above – 40 years old 37 (12
0%)
perspectives of SCT and NIC – to identify the factors influ-
Educational level
encing nurses’ CCC and organizational intellectual capital. Below-Junior College 0 (0
0%)
Lindell and Whitney (2001) recommended that tests on the Bachelor’s degree 259 (83
8%)
research design of attitude–behaviour relationships, without Graduate degree 47 (15
2%)
manipulating the study context, should use cross-sectional Missing 3 (1
0%)
Year of serving international patient experiences (mean = 2
6, SD = 1
1)
rather than longitudinal designs. Therefore, a method of
Below – 1 year 28 (9
1%)
cross-sectional relational study was employed for this study. 1 year 72 (23
3%)
2 years 147 (47
6%)
3 years 39 (12
6%)
Participants Above – 4 years 23 (7
4%)
In this study, of the 309 participants, 306 (99
1%) were
female and three (0
9%) were male. The ratio is similar to
the overall population of RN in Taiwan; i.e. 99
2% female experience in caring for international patients, were
and 0
8% male (Chen et al. 2008). The participants’ mean selected. These were the two conditions of inclusion criteria
age was 33
4 years old (SD 7
2). By age group, they were for participation in the study.
20-29 years old (175, 56
6%), followed by 30-39 years old Second, the author explained the purpose and procedure
(97; 31
4%). Concerning educational level, 259 (83
8%) of the study to representatives from the nursing depart-
had a bachelor’s degree and 47 (15
2%) had a graduate ments of the 16 participating healthcare institutions. The
degree. In addition, regarding the number of years provid- representatives were given instructions on how the investi-
ing to care to international patients, the participants’ mean gation would be conducted. The author suggested that the
number of years of experience was 2
6 (SD 1
1). The largest representatives provide 10 minutes for each participant to
group of participants had 2 years (147, 47
6%). Table 1 fill in the questionnaire. The number of questionnaires
shows the participants’ demographic information in the that were distributed in each healthcare institution varied
study. from 15-60, depending on the nursing department’s repre-
sentative requirements. These nursing departments’ repre-
sentatives forwarded the questionnaires to the registered
Data collection
nurses in their particular healthcare institution. The ques-
For the survey, questionnaires were distributed and col- tionnaires were returned in sealed envelopes and mailed to
lected from May to August 2013. The participants were the author’s home. After a period of 4 weeks, the author
selected by way of a purposive sampling scheme in three made reminder calls and sent reminder emails to the nurs-
phases. ing departments’ representatives about questionnaires that
First, for the experimental settings to match as closely as had not been received. To increase the response rate, all
possible, the healthcare institutions that were selected had participants were given an incentive in the amount of
more than 300 beds and had received the qualification for New Taiwan Dollar $100 (USD $3), in the form of a cash
international medical tourism services by Taiwan Task coupon for a convenience store, on completion of the
Force for Medical Travel (TTFMT). The author distributed questionnaire.
invitations via phone calls and email to each healthcare Finally, relative to the calculation of the sample size, the
institution on the list. From the list of 42 healthcare institu- questionnaire was distributed to 580 registered nurses in 16
tions, 16 agreed to participate in the investigation. Regis- healthcare institutions and 357 responses were obtained.
tered nurses who had completed cultural competence Given 48 were incomplete; the valid sample size was 309,
training; meeting the requirements of TTFMT and who had with an effective response rate of 53
3%. The response rate

1148 © 2016 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
from each hospital varied, from 34-76%. Among the partic-
ipants, 66 (21
4%) were employed at healthcare institutions
with bed numbers ranging from 300-499. A further 107
(34
6%) were employed at healthcare institutions with bed
numbers ranging between 500–999 and the remaining 136
(44
0%) were employed at hospitals with over 1000 beds.
The ratio is similar to Cook et al. (2009) investigation con-
clusion; they found the average response rate of mail sur-
veys among healthcare professionals was 57
5%, through
350 healthcare-related service studies. In addition, Gefen
et al. (2000) suggested that the sample size required for a
study that uses a SEM needs to have at least 10 times the
number of measurement items. The instrument consisted of
26 measurement items, so the expected sample size for the
study should be greater than 260. The sample size was 309,
which meets the sample size requirement. Taken together,
these results imply that this study had an acceptable
response rate and sample size.
Ethical considerations
This study is approved by the Institutional Review Board of
the Fooyin University Hospital (No: FYH-IRB-101-04-01-A).
Instruments development
The measurement items used for this study were adapted
from previous literature. Three senior registered nurses and a
faculty member of healthcare management at a university
were invited to review the measurement items prior to com-
mencement. The registered nurses and faculty member were
asked to comment on the format and select the appropriate-
ness of each item for inclusion in the instrument, as part of a
pilot test of the questionnaire. They were also asked to make
suggestions on the measurement items’ progression and word
choices, leading to some minor modifications being made to
the questionnaire, to comply fully with the context of nursing
work. Depending on the conceptualization of the previous
studies, the five constructs mentioned above were opera-
tionally defined as follows: 1.Organizational Climate: a nurse
could directly or indirectly perceive the importance of CCC
in nursing care in a healthcare institution (Dawson et al.
2008). 2. SE: a nurse believes that she/he is capable of per-
forming appropriate CCC behaviour in the care of her/his
patients (Salanova et al. 2011). 3. OEs: a nurse can assess
that patient care behaviour, in regards to CCC; will lead to
certain rewards and associations (Resnick & Simpson 2003).
4. CCC: the degree to which a nurse in a healthcare
institution actually performs nursing care with regard to mul-
ticultural competence, including cross-cultural awareness,
© 2016 John Wiley & Sons Ltd
Cross-cultural competence
cross-cultural knowledge and cross-cultural skills (Reimann
et al. 2004). 5. NIC: the degree to which the stock and flow
of nursing knowledge in a nursing department are embedded
in two sub-constructs: Nursing Human Capital and Nursing
Structural Capital (Covell & Sidani 2013a,b).
Following the pilot tests, a 28-item questionnaire was
finalized as relevant for the context of this study; with the
purpose of measuring the five constructs in the original
instrument (Appendix). Organizational Climate was mea-
sured with four items, as adapted from Dawson et al.
(2008). These items assessed four characteristics of content
in terms of Organizational Climate: organizational commit-
ment, clarity of organizational goals, providing training and
recognizing and fostering an intercultural healthcare envi-
ronment. SE was assessed with four items, as adapted from
Lee and Ko (2010) and Salanova et al. (2011). The mea-
surement focused on the nurses’ level of confidence in their
CCC in caring for international patients. OE was measured
with five items, adapted to reflect the benefits of CCC,
including sense of achievement, social ties, reputation, job
position or financial rewards and helping the organization
grow, as per Resnick and Simpson (2003) and Chiu et al.
(2006). CCC was measured with seven items, as adapted
from Reimann et al. (2004) and Echeverri et al. (2010).
The items were divided into three parts of the scale, which
were: Cultural Awareness (four items), Cultural Knowledge
(three items) and Cultural Skills (three items), as adapted
from Isaac et al. (2010) and Covell and Sidani (2013a,b).
NIC was measured by a total of five items, in two parts of
the scale: Nursing Human Capital (three items) and Nurs-
ing Structure Capital (two items). The measurement of all
of items in this study employed a 5-point Likert-type scale
from strongly disagree (1) to strongly agree (5). In addition,
a pretest of the questionnaire was completed by 36 regis-
tered nurses before the questionnaire was distributed to the
target population.
Data analysis
This study used Smart PLS-Version 2.0 (Ringle et al. 2005)
to analyse the research model and test all hypotheses. PLS
is broadly used in the field of management science (Karimi
et al. 2004); SEM that applies principal component analysis
to calculate the correlation among constructs. Hence, the
author employed the PLS approach for data analysis.
Validity and reliability
This study employed confirmatory factor analysis (CFA) to
assess the reliability and validity of the multi-item scale.
1149
H.-C. Lin

The factor loading analysis used principal component anal-
ysis with varimax rotation and eigenvalue above one. Any
item with a factor loading of greater than 0
6 was consid-
ered retained (Antony et al. 2002). The results demon-
strated that factor loading of two items – SE 3 (0
477)
and OE 2 (0
560) were lower than the recommended
threshold and these items were deleted from the original
instrument. Crobach’s a was above the required minimum
of 0
7, as suggested by Hair et al. (1998). The composite
reliabilities (CR) for all constructs exceeded 0
8, well sur-
passing the threshold of 0
6 (Bagozzi & Yi 1988). The
average variance extracted (AVE) measurements were
greater than the minimum acceptable value of 0
5 (Hair
et al. 1998) (Table 2).
Discriminant validity was tested employing the criteria
recommended by Fornell and Larcker (1981); the square
root of the average variance extracted is higher than all
other cross-correlations shared between one construct and
the other constructs in the model. Table 3 shows that
the correlation coefficients between constructs and all of
the square roots of average variance extracted exceeded
the inter-construct correlations coefficient, demonstrating
acceptable discriminant validity. In addition, the variance
inflation factor (VIF) of the research model measurements
range from 1
558-1
719. The values of the variance infla-
tion factor were lower than 10 and as such; the results
imply that no multicollinearity exists in this data set,
according to Verena et al.’s (2008) suggestion. In conclu-
sion, these results indicate that all the scales used have
good reliability and validity.
Since PLS could not provide the overall goodness-of-fit
measures, the author employed R-square value to be a mea-
sure of goodness-of-fit between the model and data, as per
Bentler and Bonett’s (1990) suggestion. The proportions of
the R-square value were 19% for SE, 36% for OE, 23%
and 31% for CCC (SE and OE; respectively) and 22% for
NIC. According to Correia Loureiro et al. (2014), an
R-squared value below 10% is indeed low, suggesting the
model is a poor fit. In this study, the values of all
R-squared were greater than 10% and therefore the results
imply that the research model is appropriate to a model of
goodness-of-fit.

Table 2 The results of items used to measure the constructs.

Factor Average Variance Composite
Constructs Items no. Mean SD Loading Cronbach’s a Extracted (AVE) Reliabilities (CR)

Organizational OC1 3
37 0
61 0
834 0
820 0
622 0
868

climate (OC) OC2 3
26 0
42 0
794
OC3 2
29 0
41 0
781
OC4 2
60 0
54 0
744
Self-efficacy (SE) SE1 2
74 0
60 0
819 0
907 0
636 0
840
SE2 2
78 0
58 0
803
SE4 2
89 0
61 0
770
Outcome OE1 3
20 0
62 0
901 0
820 0
670 0
889
expectation (OE) OE3 2
97 0
56 0
880
OE4 2
88 0
59 0
774
OE5 3
13 0
58 0
702
Cross-cultural CCC1(CA) 3
10 0
60 0
885 0
886 0
594 0
935
competence (CCC) CCC2(CA) 3
12 0
39 0
838
CCC3(CA) 3
35 0
45 0
732
CCC4(CA) 3
22 0
44 0
707
CCC5(CK) 2
96 0
50 0
879
CCC6(CK) 2
88 0
57 0
814
CCC7(CK) 3
23 0
33 0
767
CCC8(CS) 3
02 0
42 0
716
CCC9(CS) 3
15 0
55 0
691
CCC10(CS) 3
16 0
50 0
637
Nursing intellectual NIC1(NHC) 3
11 0
44 0
842 0
742 0
653 0
903
capital (NIC) NIC2(NHC) 2
94 0
46 0
790
NIC3(NHC) 3
36 0
49 0
689
NIC4(NSC) 2
88 0
33 0
857
NIC5(NSC) 2
79 0
31 0
850

CA, Cultural Awareness; CK, Cultural Knowledge; CS, Cultural Skill; NHC, Nursing Human Capital; NSC, Nursing Structural Capital.

1150 © 2016 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Cross-cultural competence

Finally, as Podsakoff et al. (2003) suggest, there is poten-

tial for common method bias with all self-reported data. To
examine the potential existence of common method bias,
the author performed Harman’s one-factor test to examine
whether common method variance (CMV) might impact
the results of this research (Chen et al. 2014). The results
of this study demonstrated five factors with eigenvalues
greater than 1, with the first factor accounting for 31
7%
of the total variance. Taken together, the results indicated
that common method variance is not a problem with the
data.
Results
Table 4 displays the results of the research hypotheses mea-
surements. As was expected, all of the hypotheses were sup-
ported. Organizational Climate has a positive influence on
SE (b = 0
358, t-value = 3
365, P < 0
001) and OE
(b = 0
587, t-value = 7
367, P < 0
001). Hence, H1a and
H1b are supported. SE and OE have statistically significant
influence on the behaviours linked to CCC (b = 0
282,
t-value = 2
792, P < 0
01; b = 0
487, t-value = 5
605,
P < 0
001; respectively), supporting H2 and H3. Moreover,
the results show that the behaviour relating to CCC has sta-
tistically significant influence on NIC (b = 0
302,
t-value = 4
640, P < 0
001) and therefore, H4 was
supported.
Discussion
The results of this study have provided some theoretical
contributions and practical implications to the field of nurs-
ing management. Regarding theoretical contributions, previ-
ous nurses’ CCC literature has mainly focused on exploring
the influence between training programs (i.e. Cultural
Awareness, Cultural Knowledge and Cultural Skill) and
CCC (Brathwaite & Majumder 2006, Ingram 2012). This
research provides an insight into the influences of Organiza-
tional Climate and personal cognition on individual beha-
viour with regard to CCC in the nursing context, from the
perspective of SCT. In addition, this research is one of the
first studies to reveal a relationship between nurses’ CCC
and NIC.
The research findings also provide some implications for
practitioners. Firstly, the results of this study have demon-
strated that Organizational Climate has a statistically signif-
icant impact on both factors of SE and OE. The findings
are similar to those from Tsai and Cheng (2010), who
found that Organizational Climate has a statistically signifi-
cant impact on personal cognition (i.e. SE and OE) through
the investigation of 225 knowledge-intensive workers.
Based on Dispersion Theory (Brown & Kozlowski 1999),
individual level constructs combine, through interpersonal
communication and social interactions, to emerge as group-
level phenomena, such as Organizational Climate (Dawson

Table 3 Correlation matrix (n = 309).

Constructs OC SE OE BCC NIC

Organizational Climate (OC) 0
789

Self-Efficacy (SE) 0
358*** 0
797
Outcome Expectation (OE) 0
578*** 0
370*** 0
819
Cross-Cultural Competence (CCC) 0
339*** 0
591*** 0
463*** 0
771
Nursing Intellectual Capital (NIC) 0
460*** 0
174** 0
485*** 0
292** 0
808

Square root of AVE extracted for each latent construct is shown in diagonals.
**P < 0
01; ***P < 0
001.

Table 4 The analysis results of research hypotheses (n = 309).

Hypotheses b t-value Result

H1a: Organizational Climate has a positive effect on nurse’s Self-Efficacy. 0
358*** 3
365 Supported
H1b: Organizational Climate has a positive effect on nurse’s Outcome Expectation. 0
587*** 6
367 Supported
H2: Self-Efficacy has a positive effect on nurses’ behaviour related to 0
282** 2
792 Supported
Cross-Cultural Competence.
H3: Outcome Expectation has a positive effect on a nurse’s behaviour 0
487*** 5
065 Supported
with regard to Cross-Cultural Competence.
H4: Nurses’ behaviour in relation to Cross-Cultural Competence has 0
302*** 4
640 Supported
a positive effect on Nursing Intellectual Capital.

**P < 0
01; ***P < 0
001.

© 2016 John Wiley & Sons Ltd 1151

H.-C. Lin
et al. 2008). Conversely, Organizational Climate can also
influence personal cognition and attitude through social
interaction processes. Since hospitals are usually large orga-
nizations with divisions of professional work, nurses typi-
cally interact with other staff members who may only be
connected to a subset of the healthcare team. Thus, the for-
mation of a specific organizational culture is likely to be
difficult and slow. Based on the results of this study, the
author suggests nursing departments that are trying to build
up a multicultural climate are probably more dependent on
top-down, rather than bottom-up, management mecha-
nisms.
Second, the results of this study indicate that, in nurses,
OE has a stronger influence than SE on their CCC. These
results imply that nursing supervisors need to emphasize to
nurses how to create and maintain the factors of OE, to
manage nurses’ CCC effectively. For example, nursing
departments should offer positive incentives to encourage
nurses to develop Cross-Culture Competence as an OE.
These could be tangible incentives (i.e. salary increase,
bonuses or fringe benefits) and intangible incentives (i.e.
thank-you letter, public acknowledgement of accomplish-
ments or personal development opportunities). Ongoing
support should also be provided to nurses to assist in fos-
tering their CCC.
Third, the results also indicate that nurses’ CCC can
improve NIC. The findings are consistent with Covell and
Sidani (2013a,b) who found that NIC would be accumu-
lated by nursing staff’s capabilities, skills and expertise in
the field of professional nursing practice. Thus, the author
suggests that nursing department officers need to consider
and develop a set of policies or a plan that encourages and
supports nurses by delivering knowledge, experience and
skills of CCC, so that these become organizational Intellec-
tual Capital, and personal capital. For example, a mecha-
nism of collaborative practice could be constructed, to
advance nurses’ experience in the provision of care to inter-
national patients. This could be done by nurses sharing
multicultural competence with other staff members, thus
enabling nursing departments to improve overall NIC.
Limitations
Although this study provides three meaningful findings,
there are three limitations to acknowledge. First, the data
of this research were collected from registered nurses in
Taiwan. Due to cultural differences between countries hav-
ing statistically significant influence over individual beha-
viours, norms and patterns of decision-making (Martinsons
& Davison 2007), the results may not be representative of
1152
other countries. Second, this study may suffer from selec-
tion bias due to the purposive sampling method employed
to select the study participants. Third, the author applied a
cross-sectional approach; however, the development of
Organizational Climate, SE and OE leading to individuals’
CCC is a dynamic process. The study results are lacking
time richness of explanation. Hence, there will be a future
attempt to expand this research with a longitudinal design.
Conclusion
In conclusion, my study verified that Organizational Cli-
mate has a statistically significant positive relationship on
personal cognitive factors such as SE and OE. Furthermore,
OE has a stronger relationship when applying Organiza-
tional Climate than SE. In addition, SE and OE both
directly influence CCC, and OE having a more statistically
significant relationship on CCC than SE. The results of this
study can help supervisors in nursing departments to distin-
guish the different relations between the constructs to find
an effective way for developing nurses’ CCC, from the per-
spective of SCT. Simultaneously, increasing nurses’ CCC
will contribute to the accumulation of NIC.
Funding
This work was funded by Fooyin University Hospital (No:
FY-HR-101–01).
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
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