The Relationship Between the Cultural Intelligence, Communication Skills, and Social Interactions of Emergency Department Staff: A Cross-Sectional Study

Background: Globalization is accompanied by cultural diversity. Although cultural differences are an integral part of this phenomenon, it seems that language barriers would make communication dicult. This study investigates how cultural intelligence (CQ) correlates with communication skills (CSs) and social interactions (SIs) of emergency department (ED) staff members. This study investigates how cultural intelligence (CQ) correlates with communication skills (CSs) and social interactions (SIs) of the emergency department (ED) staff members. Methods: This Cross-sectional study was performed on 197 ED staff members of three hospitals in Zanjan-Iran in 2019. The tools used for data collection include the Cultural Intelligence Scale, Communication Skills Scale, and Social Interaction Questionnaires. Results: The results of this study revealed that the mean CQ score of participants was 85.78 ± 6.24 out of 140 and the total mean score of CSs was 55.41 ± 3.9 out of 90. In terms of SIs, the mean score of the positive thoughts dimension of the subjects (47.86 ± 4.14) was more than that of negative thoughts (33.01 ± 3.92). The total score of CQ had a positive correlation with CSs such that an increase in the CQ level results in an increase in positive thoughts and a decrease in negative thoughts (P< 0.001). Conclusions: An increase in CQ of the ED staff members is accompanied by an increase in their CSs and positive thoughts. To improve the communication and service quality of the ED, leaders are recommended to provide some courses to enhance the CQ and cultural competence level of their employees.

simply talking one to another but to understand true cultural diversity and how those differences affect both the delivery of and receiving health care. Cultural diversity, particularly not having a common language, pose barriers to having effective communication. Even nonverbal communications have various implications in different cultures [16]. Proper knowledge of clinicians about the culture, language, values, traditions, practices, and beliefs of patients can be of great assistance in communicating with patients without prejudgment [17]. In this regard, the communication and interactions of ED staff members are of particular importance in the satisfaction of patients and their relatives [18,19].
Therefore, studying the status of communication skills (CSs) and social interactions (SIs) in healthcare staff members in multicultural environments may have great bene ts. Since patients and their families face different workers in the ED, the proper interaction between them is critical. Considering the multicultural nature of the city of Zanjan and the lack of a study in this regard, this study aimed to investigate the status of cultural intelligence and its relationship with social interactions and communication skills of staff members in the ED of hospitals a liated to Zanjan University of Medical Sciences.

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) a liated 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 rst 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 con icts 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 nding a proper job related to their eld of study.
In the present research, the sample size was estimated to be 197 by considering a 95% con dence 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.

Study setting
Iran has 24 cultural and religious ethnicities [20]. The o cial language of the country is Persian and its o cial 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 tra c 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 di cult is a di cult task.

Data collection
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 pro cient 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 ll 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 CQS CQ was evaluated using the CQS [21]. 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 [23], 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.

SIQ
To study the SIs of the participants, the 30-item Social Interaction Self-Statement Test (SISST) was used [24]. 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
CSs were calculated using an 18-item scale [25]. 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. The ndings of this study indicated that the mean CQ of the participants was 85.78 ± 6.26 of 140 so that 99.5% (196 subjects) and 0.5% of the staff members had moderate (61-100) and high CQ levels (101-140), respectively. In terms of SIs, the mean scores of PTs dimension (47.86 ± 4.14) were more than the mean scores of NTs. Moreover, CSs total score was 55.41 ± 3.9 out of 90 so that 100% (197 subjects) of the participants had moderate CSs (43 to 66) ( Table 2). The results of the t-test showed that sex and marital status did not correlate with CQ, PTs, NTs, and CSs. Also, the ANOVA results demonstrated that occupation type and education level did not correlate with CQ, PTs, NTs, and CSs (Table 3). The results of the Pearson correlation coe cient test indicated the statistically signi cant and positive relationship between the total score of CQ and CSs.  (Table 4). The results of the Pearson correlation coe cient test revealed the signi cant and positive relationship between the PTs dimensions of SIQ, CQ total score, and all dimensions of CQ so that an increase in CQ level correlates with an increase in PTs. Moreover, there was a statistically signi cant negative relationship between the NTs dimension of social interactions scale, CQ total score, and all dimensions of CQ, except the metacognitive CQ dimension that correlates with a decrease in NTs ( Table 4).
The result of the Pearson correlation coe cient test indicated a statistically signi cant positive relationship between the PTs dimension of social interactions scale with verbal skills and total score of CSs so that an increase in CSs is associated with an increase in PTs. Moreover, there was a signi cant negative relationship between the NTs dimension of SIQ, feedback skills, and total score of CSs such that an increase in the total score of CSs correlates with a decrease in NTs (Table 4). The results of the general linear model show that CQ correlates with PTs (Table 5). It has been reported that frequent contact with different cultures associates with an increase in cultural competence of staff members [11,32,33].
Furthermore, it has been evidenced that training the cultural competence and practicing cultural competency communication increase the CSs between staff members and students [34][35][36][37]. Therefore, authorities are suggested to hold education workshops on dealing with different cultures such that to promote the cultural intelligence and competence of ED staff members. In this way, they can improve communication and interactions of staff members with patients and their families.

Limitation
In Iran, despite considerable cultural diversity, few studies have been conducted on CQ. The present study aimed to provide basic knowledge about the state of CQ, CSs, and SIs of ED staff members in Zanjan City. However, the obtained results are not generalizable to other societies due to the speci c culture of Zanjan. Moreover, since all questionnaires were simultaneously provided to the participants, social response bias may threaten the validity of the results.
Thus, the researchers tried to minimize this bias by anonymizing the name of those who lled the questionnaires.

Conclusion
According to the results of the present study, an increase in the CQ level associated with an increase in CSs and SIs of the ED staff members. Considering the globalization and facing different cultures and ethnicities, the managers should increase the CQ level of the staff members. In this way, they can enhance their cultural competence to increase their service quality and patients' satisfaction level. Since most parts of the CQ, CSs, and SIs are acquisitive and they can be enhanced, authorities of the medical science education should try to increase CQ and cultural competence of students in a multiethnic country such as Iran to have healthcare staff members with high CQ in the future. Also, hospital managers should identify the strengths and weaknesses of their staff members by measuring their CQ and provide retraining courses based on the obtained results.

Consent for publication
Informed consent was obtained from all participants in the form of written.
Availability of data and materials Not applicable