Study design and sampling
The statistical population of the present cross-sectional study included all staff members of the ED working in three hospitals (Ayatollah Mousavi, Vali Asr and Beheshti hospitals) affiliated to Zanjan University of Medical Sciences in Iran. The ED of these three hospitals have 158 active beds in the medical, trauma, cardiovascular, pediatrics, phycology, and midwifery units and 287 staff members. These members include 149 nurses with MSc, BS, and diploma education, 40 practical nurses, 30 housekeepers, 23 ED guards, 26 general physicians, and 19 emergency physicians. The other medical experts such as cardiologists, gynecologists, pediatrics, psychiatrist, and surgeons were not included in this study due to their irregular attendance in the ED.
In Iranian hospitals, the patients first are referred to the triage unit nurse and then to the general physician. If the patient must be hospitalized, he/she is visited and triaged by the emergency physician. Based on the initial diagnosis of the emergency physician, the patient is referred to different medical, or surgery units. Patient care in the ED is performed by nurses with the education levels of master of sciences of emergency nursing (MSEN), bachelor of science of nursing (BSN), and diploma of nursing (DN). Primary health care of the patients is provided by licensed practical nurses. Although practical nurses do not have specialized nursing education, they are trained through short courses. Cleaning the units and patients transfer to other units is performed by housekeepers. To prevent unnecessary referral of patients’ families to the ED and prevent probable conflicts between the staff members and patients’ families, there are at least three guards at the entrance of the ED. Practical nurses, guards, and housekeepers have different levels of education ranging from diploma to even academic education. Some of these highly educated people work in such jobs due to not finding a proper job related to their field of study.
In the present research, the sample size was estimated to be 197 by considering a 95% confidence level, 0.1 effect size and 80% power. The inclusion criteria of the study were having at least a one-year job experience in the ED and the willingness to participate in the study. Finally, 217 questionnaires were distributed among the eligible ED staff members. The inclusion criteria were: (1) at least one year of experience working in the ED and (2) the desire to participate in the study.
Iran has 24 cultural and religious ethnicities . The official language of the country is Persian and its official state religion is (Shia) Muslim. The Zanjan Province with a population of 1,057,461 and 8 cities is located in the northwest of Iran. The capital of this province is Zanjan city. The urbanization rate in Zanjan province over the past 40 years has jumped from 28.8% to 63.4%. Moreover, migration from other cities has caused a variety of demographic and cultural diversities. The population of Zanjan speaks the Azari language and their religion is (Shia) Muslim. Due to the proximity to the Kurdish cities and the northern cities of Iran, where the people speak in local dialects, the city encounters a wide variety of languages (Gilaki dialect and Kurdish language) and (Sunni) Muslim. The location of Zanjan city across the Silk Road has created many job opportunities since many decades ago. Moreover, the city has several mines that have attracted many immigrants from other cities. Today, some immigrants from other countries such as China, Afghanistan, and Turkey live in Zanjan city. Moreover, because the city is located in the Iran transit route to Europe, the staff members of the ED, visit foreign victims of traffic accidents, as well. Some ED staff members of the city are non-native and speak only Persian. On the other hand, most illiterate patients cannot speak Persian and they only speak their native language and dialect. Thus, communication between staff and patients difficult is a difficult task.
The data needed in the present research were collected using three questionnaires of the Cultural Intelligence Scale (CQS), Social Interaction Questionnaire (SIQ), and Communication Skills Scale (CSS). All three scales were translated to Persian and back-translated to English. Next, all three retranslated scales were matched to their original version by a person proficient in English. In our study, qualitative and quantitative content validity were used to assess the validity of the scales. The scales were provided to 10 experts and the necessary corrections were made. Finally, the content validity index and content validity ratio of the scales were calculated.
The researcher referred to the ED and explained the study goals to the people meeting the inclusion criteria. Then, if they were willing to participate in the study, they submitted informed consent and received a small gift for completing the questionnaire. The questionnaires were distributed on paper. The time of submitting the questionnaire to the researcher was decided by the participants such that they could fill it accurately and conveniently. The deadline for completing the questionnaires was two weeks. Data were collected over a period of three months.
Data gathering tools
CQ was evaluated using the CQS . The scale includes 4 dimensions and 20 items (metacognitive CQ, 4 items; cognitive CQ, 6 items; motivational CQ, 5 items; and behavioral CQ, 5 items). It is scored by a 7-point scale (ranging from 1 = strongly disagree to 7 = strongly agree), with its scores varying from 20 to 140 (20-60 = Low CQ; 61-100 = Moderate CQ; and 101-140 = High CQ). This scale has been used in several studies in Iran [22, 23]. Shomoossi et al. (2019) in a study on 136 employees in Sabzevar University of Medical Sciences calculated the reliability of the total score of CQ using Cronbach’s alpha as 0.85 , while in our study it was 0.75. In this study, the content validity index and content validity ratio were estimated to be 0.83 and 0.79, respectively.
To study the SIs of the participants, the 30-item Social Interaction Self-Statement Test (SISST) was used . This scale includes two dimensions of negative thoughts (NTs) and positive thoughts (PTs) in communication. Each dimension contains a 15-item 5-point Likert scale, where the scores vary from 15 to 75. A high score in the negative dimension indicates the weak SIs, suggesting that the individuals believe in the negative role of inappropriate conditions in communicating and feeling fear and anger in social situations. However, a high score in the positive dimension shows the high ability of individuals in communicating with others, low anxiety, and their belief in facilitating communication with others. In the present study, the reliability of the questionnaire was calculated to be α = 0.701 by Cronbach’s alpha. Also, its content validity index and content validity ratio were estimated to be 0.87 and 0.89, respectively.
CSs were calculated using an 18-item scale . The scale has three dimensions of verbal, listening, and feedback skills, each containing 6 items. The scoring is done based on a 5-point Likert scale. The minimum and maximum scores of each dimension are 6 and 30, respectively. The total score of the scale varies from 18 to 90 (<42 = Low CS; 42-66 = Moderate CS; and >66 = High CS). In Iran, the scale was psychometrically analyzed on 191 health volunteers and its Cronbach’s alpha was reported to be 0.91 29; however, in our study, the reliability of the scale was 0.787. Also, in this study, the content validity index and content validity ratio was estimated to be 0.87 and 0.89, respectively.
This study was conducted after granting the approval of the ethics committee of Zanjan University of Medical Sciences and obtaining an ethical code (IR.ZUMS.REC.1396.305). The researcher, after referring to the research environment and explaining the research goals, received written consent from the participants. The participants were assured that all their information would be kept confidential and they could leave the study any time they want. To make the participant comfortable and control the confounding factors such as noise and workload in the hospital, they were asked to complete the questionnaires at any time they desire.
The data were analyzed using SPSS V.16 software. The Kolmogorov-Smirnov test was applied to evaluate the normality of the data. The results showed that the data had a normal distribution. Independent t-test and analysis of variance (ANOVA) test were performed to evaluate the relationship between the demographic variables and three main variables. Moreover, the Pearson correlation coefficient was applied to investigate the relationship of CQ with communication skills and social interactions. Finally, the General Linear Multivariate Model test was applied to predict the CQ for criterion variables including communication skills and the positive and negative thought dimensions of the social interaction questionnaire.