Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 48(2): 135–149.

Leadership style and culturally competent care: Nurse leaders’ views of

their practice in the multicultural care settings of the United Arab Emirates

Souher El Amouri and Shirley O’Neill

University of Southern Queensland, Toowoomba, QLD, Australia

Abstract:  It is well recognized that nurse-leader-managers play an important role in facilitating the quality and
nature of hospital care, the improvement of work performance and work satisfaction. In the United Arab Emirates they
face the additional challenge of working within a context of significant linguistic and cultural diversity where leader-
ship in the provision of culturally competent care is a major requirement. With this goal at the fore, a sample of 153
­nurse-leader-managers, including matrons, nursing directors, supervisors, nurses-in-charge and in-service education staff
from 4 private and 6 government hospitals completed the multifactor leadership questionnaire (Bass & Avolio, 2004).
The survey also explored participants’ perceptions of the characteristics of good leaders and what they needed to do in their
particular work place to enhance culturally competent care. The results showed nurse-leader-managers used both transfor-
mational and transactional leadership attributes but in different combinations across the two hospital types.

Keywords: leadership style, multicultural leadership questionnaire, nurse-leader-manager, culturally competent

care, leadership in linguistic and culturally diverse health care settings

T he United Arab Emirates (UAE) is an Islamic

country where Arabic is the official language.
However, there is a large immigrant population
such that many other languages are spoken and
the multicultural mix of people infiltrates all
aspects of day-to-day living, and health care is no
exception. The particular linguistic and cultural
diversity among healthcare providers sets new
challenges for communication and cultural under-
standings in the need to provide culturally compe-
tent care. Understanding a patient’s symptoms can
depend on health care staff’s linguistic and cultural
knowledge but it is nurse-leader-­managers’ major
responsibility to ensure the effective delivery of
culturally competent care. Campinha-Bacotes
(1998, p. 6) defines culturally competent care as
a ‘process in which the nurse continuously strives
to achieve the ability and availability to effectively
work within the cultural context of a client, indi-
vidual, family or community.’
The situation in UAE is even more challenging
because nursing staff are mainly expatriates from
many countries combined with only a few from
Arabic speaking backgrounds, including Emiratis.
This creates a highly complex situation because
it requires non-Arabic nurse-leader-managers to
deliver a Western biomedical model of health care
in a host Islamic Arabic country to a culturally
and linguistically diverse population of patients
in both the public and private hospital contexts.
This is further complicated by their need to work
with staff that are also from diverse cultural and
linguistic backgrounds to ensure delivery of cul-
turally competent care. Expatriate nursing staff’s
cultural sensitivity may also be lessened by culture
shock (Campinha-Bacote, 2011). When people
move to live in an unfamiliar culture that has dif-
ferent attitudes and values, and way of life from
their own they can experience feelings of disori-
entation, which Hofstede (2011, p. 26) refers to
as culture shock. Although nursing education
includes strategies to develop cultural sensitivity
(Stewart, 2006), again it is ultimately the leader-
ship of nurse-leader-managers that is a major fac-
tor in ensuring quality outcomes (Curtis, de Vries,
& Sheerin, 2011; Dirschel & Klainberg, 2010).
Therefore, leadership that facilitates highly effec-
tive culturally competent care can add value by
enhancing patient care (Al Rifai, 2008). As well,
improvement of staff satisfaction and retention
also depends on leadership style (Bass & Avolio,
2004; Cummings et al., 2009; Curtis et al., 2011).
In response to the paucity of research into hos-
pitals in the Persian Gulf region, and especially
UAE, this research aimed to provide advice to help
enhance leadership in culturally competent care.

Volume 48, Issue 2, October 2014 CN 135

CN Souher El Amouri and Shirley O’Neill
Literature review
Leadership versus management
Clarification of the distinction between leadership
and management is crucial to any investigation of
the way leadership style may impact on the pro-
vision of culturally competent care. Managers are
seen as typically more concerned with procedural
compliance in the short term (Kotterman, 2006),
compared with leaders who think in the long term
and are more able to motivate, empower and work
with staff to achieve a common goal (Rogers,
2012). As Field (2002, p. 1) found, leadership is
‘about taking action and communicating values in
the context of a relationship … not about reinforc-
ing the status quo and the reliance on hierarchy.’
According to Luquis and Perez (2003), for the
UAE context in particular this means being able to
respond to the need for change to suit the challenge
of its cultural and linguistic diversity. It requires
staff to have insights into and knowledge about
cultures other than their own (Shirberg, Shirberg,
& Lloyd, 2002). Such knowledge is essential if
staff are to be able to communicate interculturally
and be comprehensively equipped to gain the trust
of their co-workers, and patients and their families
(Kelley & Abraham, 2007). Given the complex
phenomenon of the UAE health care context this
reinforces the need to identify the kind of leader-
ship style that best suits its particular diversity and
challenge. With this in mind the extensive work
on leadership styles by Avolio and Bass (1991,
1994) (for example Andrews, Richard, Robinson,
Celano, & Hallaron, 2012; Antonakis, Avolio, &
Sivasubramaniam, 2003; Kanste, Miettunen, &
Kyngäs, 2007) was taken as a basis for the design
of the present study.
Leadership style and culturally competent care
Avolio and Bass (1991) identify two major lead-
ership styles: Transformational and transactional.
The first encompasses five different factors that are
transformational in effect. They apply to a leader’s
ability to inspire and motivate staff, inspirational
motivation: (1), give individual consideration (2),
model idealized behavior (3) be charismatic, ideal-
ized attribute (4) and provide intellectual stimu-
lation (5). Idealized behavior is reflected in the
nurse-leader-manager’s ability to communicate
136 CN Volume 48, Issue 2, October 2014
and create a shared vision and m ­ ission (Bass,
1998; Bass & Avolio, 2004), which would
include modeling culturally competent care to
staff. Transformational leadership is seen as stimu-
lating staff to work together to achieve a common
goal (Behery, 2008; Walumbwa, Orwa, Wang, &
Lawler, 2005). Shirberg et al. (2002) raise the point
that while acknowledging and showing respect for
the distinctive nature of each cultural group there
is a need to find a common value that can moti-
vate the people to work collaboratively. Central
to this is the ability for nurse-leader-managers to
be able to build trust through making emotional
connections between people (Landa & López-
Zafra, 2011; Spence Laschinger, Wong, & Grau,
2012). The transactional nature of the second
involves the four factors of contingent reward: (6),
management-by-exception that is passive (7), lais-
sez-faire (8) and management-by-exception that is
active (9). Transactional leadership involves more
of an exchange of something of value between
the leaders and followers in order to get the job
done, or transmission of information based on
nurse-leader-managers’ authority and staff com-
pliance with rules and procedures (Spears, 1998).
Under these circumstances contingent reward
refers to the way ­nurse-leader-managers recognize
staff’s work in terms of their compliance with the
rules. When nurse-leader-managers manage-by-­
exception – passive they behave in a reactive man-
ner toward any problems that may arise and when
their behavior is laissez-faire their responses is typ-
ically indecisive. On the other hand managing-by
exception – active involves nurse-leader-managers
implementing processes to try to prevent prob-
lems arising but the focus remains transactional.
The communication involved in transactional
leadership differs dramatically from the more
authentic conversations and ‘making of mean-
ing’ (Murphy, 2005), engagement and building
of relationships (Rogers, 2012) that is associated
with the behaviors of transformational leaders
(Luzinski, 2011).
Transformational leaders value each
nurse’s beliefs, contribution and participa-
tion. They ‘invite, listen and value the opin-
ions of all staff, which decreases interpersonal
conflict and non-cooperative relationships’
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 Leadership style and culturally competent care: Nurse leaders’ views
(Stordeur, Vandenberghe, & D’Hoore, 2000,
cited in Murphy, 2005, p. 133). However, Rogers
(2012, p. 55) concludes that although hospital
administrators in her study were more aligned
with transformational leadership, ‘it is critical for
these leaders … to incorporate other leadership
styles according to situational factors.’ She notes
each style may apply to some extent in the work of
a leader depending on the demands of the tasks at
hand. This needs to be considered in any investi-
gation of leadership style in such contexts as UAE
because of the language and cultural diversity as
well as possible cultural differences and expecta-
tions across different hospitals (Clegg, 2001).
How leadership styles play out in the
workplace
Apart from those transactional leaders who dem-
onstrate laissez-faire leadership (tending to avoid
responsibilities by being indecisive or untimely
in taking appropriate action) the remaining three
transactional factors strongly relate to the notion
of leader as the figure of authority, who is there
to ensure compliance. But there are differences in
the way the leader carries this out. In leadership
that uses contingent reward the nurse-leader-
manager typically exercises authority by encourag-
ing subordination through a seemingly unwritten
system of rewards and punishment. However,
­management-by-exception – active is distinguished
from passive by the former involving the active
monitoring of staff to try to prevent mistakes
compared with being reactive by taking action
only when necessary. None of these factors alone
therefore could be expected to motivate staff, build
positive interpersonal relationships, or encour-
age effective, open communication (Walumbwa,
Wu, & Orwa, 2008) and create the level of trust
(Stewart, 2006) required to maximize the provision
of culturally competent care. It may also be argued
they have potential to contribute to negative out-
comes for patients’ health if applied alone.
In contrast, the behavior of transformative
leadership style reflects a respect for staff as profes-
sionals, whose judgment and work is valued and
trusted. Transformational nurse-leader-­managers
would be expected to be engaging with staff
to create a more democratic and collaborative
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CN
workplace that facilitates intrinsic rather than
extrinsic motivation, where there is room for
innovation. Unlike transactional leadership, this
leadership style is better able to facilitate the
development of high quality interpersonal rela-
tionships and communication skills because of
the mutual respect, trust, motivation and com-
mitment that it can create among staff. Such
nurse-leader-managers consider workers’ individ-
ualized needs and stimulate them intellectually.
They are charismatic and inspirational in their
approach to the extent that they engage in vision
sharing with staff. This style of leadership is more
able to overcome resistance to change by gaining
the confidence and commitment of workers (Del
Castillo, n.d., cited in Bass, 1998). As Barnett,
McCormick, and Conners (2001) note, transfor-
mational leaders totally engage staff emotionally,
intellectually and morally to encourage them to
develop and perform beyond expectations. This
style of leadership would be expected to better
create a context where staff can increase their
awareness of culture and personal biases that may
impact on care. As Reimann, Talavera, Salmon,
Nufiez, and Velasquez’s (2004, p. 2199) found
‘cultural competent actions are only predicted by
cultural awareness.’ For effective cross-cultural
communication and enhancing the likelihood of
provision of culturally competent care staff need
to be able to critique their own beliefs and values
about other cultures.
Leadership and culturally competent care in
the gulf
Although research is limited with respect to lead-
ership in nursing in UAE and the Gulf, recent
research has identified various issues related to
leadership and the challenge of providing cultur-
ally competent care. Al Rifai (2008) stressed the
importance of nurse-leader-managers facilitating
patient safety and creating positive and support-
ive, work environments. Ypinazar and Margolis
(2006) emphasized the need for staff to have trans-
cultural understanding. For example, they found
that since older Arab people associated being
healthy with not appearing visibly sick it was dif-
ficult to involve them in preventative health care.
On the other hand Almalki (2012, p. 7) noted
Volume 48, Issue 2, October 2014 CN 137
CN Souher El Amouri and Shirley O’Neill
that non-Arabic speaking ­ expatriate nurses in
Saudi Arabia were disadvantaged as care provid-
ers since they may experience stress because their
cultural backgrounds were incompatible with
Saudi Arabian culture. Shoqirat and Cameron
(2012) suggest that nurses in Jordan were oper-
ating more in a transactional mode with a cura-
tive focus rather than being transformational.
While these studies provide some insights into
care, practice and leadership in hospitals in the
Gulf area there remains a lack of direct focus on
the actual styles of leadership that might best
enhance culturally competent care as perceived by
nurse-leader-managers.
Universality and applicablity of leadership
style to different cultures
Of additional relevance is that a consultative style
of leadership was found in non-healthcare orga-
nizations in UAE (Ali, Azim, & Krishnan, 1995;
Yousef, 1998). Yousef (1998, p. 280) saw this style
as more applicable to the influence of Islamic
and tribalistic values and beliefs because of its
tendency to be participatory and democratic.
Randeree and Chaudhr (2007, p. 224) also noted
‘studies have been carried out in the Arab world
which suggest that leadership in Arab culture
nurtures consultative and participative tendencies
(e.g. Ali, 1993, 1997; Al-Jafary & Hollingsworth,
1983; Muna, 1980).’ The leader was seen to value
employe involvement and teamwork, and sought
consensus in decision-making, thus demonstrat-
ing a sharing of power (Sullivan & Decker, 2001).
However, while clearly relevant to transforma-
tional leadership, Yousef (1998, p. 280) noted
that the majority of participants were Arabs and
Muslims and therefore shared the same language
and culture.
Related to this, Randeree and Chaudhr
(2007) raised the issue of cultural variation in
leadership style and followers’ preferences. In cit-
ing the findings of Smith and Peterson (1988)
they pointed out that specific behaviors that
reflect the various styles might vary from culture
to culture. They noted that ‘cultural differences
may also limit the universality of the new leader-
ship paradigms, such as the theory of transac-
tional and transformation leadership’ (p. 223).
138 CN Volume 48, Issue 2, October 2014
However, if, as Shahin and Wright (2004) and
Bass (1998) argue, leadership styles are discern-
able across different cultures, it is possible that
UAE nurse-leader-managers may adapt their
behavior according to the cultural differences in
their workplace (Den Hartog, House, Hanges,
Ruiz-Quintanilla, & Dorfman, 1999). A typi-
cal scenario is when one society values leaders
who show their emotions whereas another may
see this as showing weakness (Shahin & Wright,
2004). It may mean leaders, in multicultural
workplaces, are interpreted differently by their
staff, or leaders’ expectations do not meet those
of workers. Thus, it cannot be assumed that a
propensity toward transformational leadership
style in the host culture will guarantee successful
transfer into the present linguistically and cul-
turally diverse context.
Researching leadership style
As a well-established instrument with high reli-
ability and validity, Jabnoun and Al Rasasi (2005)
used the Mulitfactor Leadership Questionnaire
to investigate the relationship between transfor-
mational leadership and service quality in six
UAE hospitals. Overall they found a positive
relationship between transformational leader-
ship style and service quality. Of interest for
the present research was the fact that employes
reported a prevalence of active management-by-
exception factor (9), but the issue of linguistic
and cultural diversity was not addressed. More
recently, Behery (2008) used the multifactor
leadership questionnaire with 500 business man-
agers in Dubai and found evidence of three fac-
tors of transformational leadership: inspirational
motivation (1), individualized consideration
(2) and intellectual stimulation (5), but inter-
estingly the influence of idealized behavior (3)
was absent. The researchers attributed this result
to the inherent cultural diversity (Spreitzer,
Perttula, & Xin, 2005), however this was not
definitive and so highlights the needed for fur-
ther research. On this basis, and bearing in mind
that Bass (1998) notes that leaders will typically
display evidence of all leadership styles to some
extent, this research sought to answer the follow-
ing questions:
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 Leadership style and culturally competent care: Nurse leaders’ views
1. What leadership styles are present in UAE
hospitals?
2. What leadership characteristics and actions
do nurse-leader-managers see as necessary for
culturally competent care in UAE’ hospitals?
Method
Using a quantitative descriptive design the study
aimed to identify the kind of leadership style
used by nurse-leader-managers to facilitate cul-
turally competent care in UAE hospitals. Given
the multicultural context it was expected that this
approach would help illuminate characteristics of
transcultural/multicultural leadership that nurse-
leader-managers perceived necessary for success-
ful nursing. Because of the lack of research on
leadership style and culturally competent care in
UAE hospitals and in general, this study’s find-
ings were seen as being able to contribute to this
important issue in a growing multicultural soci-
ety, although this research occurred in the context
of the Islamic culture of UAE. While the study
also investigated nurse-leader-managers’ views
on the design of a professional learning program,
organizational culture and strategies required to
support cross-cultural communication, it is their
views about leadership style that are reported
here based on the administration of a survey
(the multifactor leadership questionnaire Bass &
Avolio, 1995). A pilot study in one hospital (not
included in the main study) informed the final
design and procedures, including the decision to
use the English language.
Sampling
A purposive sample of 10 hospitals (6 government
and 4 private) was drawn based on UAE’s main
geographical regions and the fact that the major
hospitals are mainly government. Hospital selec-
tion was based on the criteria of number of beds
(100–500), cultural and linguistic diversity, and
the fact that cities are known to be more diverse
with more job opportunities. A total sample of
153 nurse-leader-managers volunteered to par-
ticipate from a potential of 12–35 per hospital,
depending on hospital size, therefore allowing
for some generalizability of the results. The study
defines nurse-leader-manager as a senior nurse who
© eContent Management Pty Ltd
CN
has several years of experience in administration
or has taken the role of leader for at least 2 years.
The sample included matrons, nursing directors,
deputy directors, supervisors, nurses-in-charge
and in-service education staff. Since the hospitals
did not have a culture of conducting research to
inform practice the request to hospital authorities
to gather data from staff was seen as unusual and
viewed with some suspicion, such that face-to-
face interviews were not supported.
Data collection and analysis
Data were collected on participants’ background
and their personal leadership style using the mul-
tifactor leadership questionnaire’s 36 items. This
was a five point Likert scale that asked participants
to ‘cross the rating that best tells what you do at
your work for the list of items.’ The ratings were
‘not at all,’ ‘once in a while,’ ‘sometimes,’ ‘fairly
often’ and ‘frequently.’ Their perceptions of the
characteristics leaders need to ensure provision of
culturally competent care and the actions needed
at the time to enhance this provision were also
investigated through two open ended questions.
This gave participants the opportunity to offer
their own opinions and ideas. These responses
were analyzed for common themes that emerged
from participants according to hospital type. The
proportion of participants that identified each
theme was also calculated.
This approach allowed for investigation of the
two major leadership styles: Transactional and
transformative and their respective, underpinning
nine factors as noted earlier. Four of the 36 mul-
tifactor leadership questionnaire items contribute
to each of the 9 factors. The analysis of the sur-
vey responses was conducted in keeping with the
multifactor leadership questionnaire guidelines
calculating mean scores. The multifactor lead-
ership questionnaire was selected because of its
well-established reliability and validity (Antonakis
et al., 2003; Bass & Avolio, 2004; Kanste et al.,
2007). In addition, a trial of the overall survey
showed the internal consistency of the component
of leadership styles to be high (Cronbach’s alpha,
r = 0.85). The research was conducted in keep-
ing with Australian national ethical standards as
part of a doctoral study. This was a requirement
Volume 48, Issue 2, October 2014 CN 139
CN Souher El Amouri and Shirley O’Neill

before hospitals could be approached to ask for
their cooperation and approval to access staff to be
volunteers. All participating hospital authorities
and nurse-leader-managers provided their written
approval. The multifactor leadership question-
naire was purchased with the proviso that no more
than 5 of the 36 items would be published. Thus,
reporting of the results abides by that contract.
Results and discussion
Participants’ background
Demographic data of participants was generally
representative of the nursing population in UAE.
As expected they were predominantly female (143;
93%) with the majority (66%) from Asian back-
ground and 17% from Western countries. Only
16% were from Arabic background. Most, 118
(77%) were working in government hospitals and
35 (23%) worked in private. Approximately 54%
were aged between 36 and 49 in both hospital
types, which generally reflected recruitment pol-
icy of employing people with
experience, who are likely to be Table 1: Gender, number and percentage of participants in government
mature. This may reflect peo- and private hospitals
ple seeking overseas employ- Characteristics Government hospitals
of years spent in a leadership position provided
a sound basis for the research. In both hospital
types 25% of participants had been in a leadership
position for between 2 and 5 years. However, the
majority of nurse-leader-managers in government
hospitals (73%) had more than 5 years experience
in such a position compared with less than half of
those in private hospitals (46%) (see Table 2).
Of further interest is the contrast between
the majority ethnic-background of nurse-leader-
managers in government hospitals compared
with private. The government hospital sample
showed 81% of participants from Asian back-
grounds (Indonesian, Filipino, Indian, Chinese,
and Pakistani) compared with the majority of
private hospital participants (74%) being from
Western backgrounds (British, Swedish, Irish,
South African, American, Australian, Canadian,
and New Zealand). There were no Western back-
ground nurse-leader-managers in the government
hospital sample. This may be the result of private
Private hospitals

ment while traveling and/or Gender Number of % Of Number of % Of

those seeking a higher income. respondents respondents respondents respondents
There was also a greater pro- N = 118 N = 35
portion of females employed Female N = 143 113 95.8 30 85.7
in government hospitals (96%) Male N = 10 5 4.2 5 14.3
compared with private (86%),
which may reflect UAE cul-
tural norms, that is the nursing Table 2: Time as leader and job classification
profession is considered a femi- Characteristics Government hospitals Private hospitals
nine job whereas the majority N = 118 N = 35
of males tend to seek jobs in
Number of % Of Number of % Of
the military. In addition, the
respondents respondents respondents respondents
majority of UAE nationals seek
care in government hospitals Time as a leader
(see Table 1).   <2 years 15 12.7 10 28.6
In keeping with hospital   >2–5 years 30 25.4 9 25.7
structures there was a domi-   >5 years 73 61.9 16 45.7
nance of nurses-in-charge: 73% Job classification
government; 60% private. In  Administrator 19 16.1 10 28.6
addition, both groups included in-charge
11% of participants who were  Nurse 86 72.9 21 60.0
in-charge
junior nurses and/or nurse
  Other staff 13 11.0 4 11.4
in-service educators. Details

140 CN Volume 48, Issue 2, October 2014 © eContent Management Pty Ltd
 Leadership style and culturally competent care: Nurse leaders’ views CN
hospital salaries being more lucrative. There was a overview of the comparative results (means) for
greater proportion of Arabic background nurse- each leadership factor for the nurse-leader-manag-
leader-managers in government hospitals (19%) ers groups in each hospital type. Figure 1 provides
compared with 9% in private (see Table 3). a graphic summary comparison. There was a statis-
tically significant difference between the 2 groups’
Comparison of nurse-leader-managers’ ratings on the total set of 36 items (p < 0.05, non-
ratings of leadership styles in government and parametric Mann–Whitney U test, two-tailed).
private hospitals on the multifactor leadership However, there was no statistically significant dif-
questionnaire ference between the two groups’ ratings on each
For the multifactor leadership questionnaire the of the two components of transformational and
participants indicated how often they addressed transactional leadership. In general the private
36 aspects of their work. Groups of four of these hospital participants’ responses suggested they
items contributed to each leadership factor that were more positive and confident about their lead-
was further categorized under the subscales of ership activities, with possibly more opportunity
transformational leadership or transactional leader- to make decisions compared with the responses
ship (Avolio & Bass, 1994). Table 4 presents an of government nurse-leader-managers. The latter’s
responses suggested that the gov-
Table 3: Nationalities characteristics, number and percentages of ernment hospital nurse-leader-
participants managers may have been more
Characteristics Government hospitals Private hospitals focused on getting the job done
within the workplace regula-
Nationalities Number of % Of Number of % Of
tions and therefore may have less
respondents respondents respondents respondents
N = 118 N = 35
need or incentive, or authority to
make decisions or changes.
Arab 22 18.6 3 8.6 Figure 1 shows a greater preva-
Asian 96 81.4 6 17.1 lence of all factors for private
European 0 00.0 26 74.3 hospital nurse-leader-managers
compared with those in gov-
ernment except for contingent
Table 4: Government and private hospital nurse-leader-managers’ reward (6) and management-by-
aggregated mean ratings for transformational and transactional exception: active (9). This implies
leadership components of the multifactor leadership questionnaire that government hospitals may rely
Leadership styles Government Private mean more on transactional leadership in
mean N = 118 N = 35 terms of staff compliance with rules
and procedures and monitoring to
Transformational leadership
 1. Inspiration motivation (IM) 3.523 3.621
prevent non-compliance. Of addi-
  2. Individualized consideration (IC) 3.506 3.564
tional interest is that a pair of factors,
  3. Idealized behavior (IB) 3.389 3.450
from each major style, was report-
  4. Idealized attribute (IA) 3.303 3.521
edly used more by private hospital
 5. Intellectual stimulation (IS) 3.080 3.271 nurse-leader-managers. These are:
Transactional leadership idealized attribute (4) intellectual
  6. Contingent rewards (CR) 3.502 3.457 stimulation (5) and management-by-
  7. Management-by-exception: 3.139 3.485 exception: passive (7) laissez-faire (8),
Passive (MBEP) respectively. The pairing of manage-
  8. Laissez-faire (LF) 3.125 3.664 ment-by-exception: passive (7) and
  9. Management-by-exception: Active 3.216 3.135 laissez-faire (8) is not surprising as
(MBEA) there is a typically positive correlation
(p < 0.05, non-parametric Mann–Whitney U test, two-tailed). between these two factors according

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CN Souher El Amouri and Shirley O’Neill

Nurse-leader-managers’
self-report on leadership
characteristics that facilitate
culturally competent care
Nurse-leader-managers were asked:
What characteristics does a good
leader in your workplace need to
help staff provide high quality cul-
tural competent care? From these
data emerged six common leader-
ship characteristics, which related
to: (1) giving individual consider-
ation, (2) demonstrating leadership
characteristics, (3) being a good
communicator, (4) providing a role
model, (5) demonstrating ideal-
Figure 1: Comparison of government and private hospital nurse- ized behavior and (6) giving fair
leader-managers’ aggregated mean ratings for the factors of treatment. Table 5 shows the per-
transformational and transactional leadership components of the
centage of nurse-leader-managers
multifactor leadership questionnaire
in each hospital type whose self-
report responses contributed to
to Avolio, Bass, and Jung (1995). The greater mean each theme and the frequency to which the theme
score for the transformational factor of idealized was referred.
attribute also suggests that leadership in the private While the first four were common to both
hospitals may be more discernable. This is rein- types of hospitals, only private hospital nurse-
forced by the percentage frequency of responses to leader-managers raised the importance of ide-
the items within the above factors that showed the alized behavior, and only government hospital
greatest differences. Responses to transformational nurse-leader-managers were concerned with fair
leadership items suggested that nurse-leader-man- treatment. However, independently of hospital
agers in government hospitals let their staff know type the nurse-leader-managers identified lead-
that they think they will achieve their goals more ership characteristics representative of transfor-
frequently than their private hospital counterparts. mational leadership style as those best suited to
However, nurse-leader-managers in private hospi- ensure effective delivery of culturally competent
tals seemed to be more actively engaged with each care. It shows the major organizational cultural
other in the work at hand and reported more fre- strategies that nurse-leader-managers offered in
quently that they sought the opinion of others before their responses, the Frequency (f ) refers to the
solving problems and they treated staff as individu- number of times participants proposed strategies
als and coached them. With regards to transactional that led to identification of each theme and the
leadership management-by-­exception: passive (7) percentage (%) refers to the proportion of the
and laissez-faire (8) the individual responses indi- sample of respondents who contributed (therefore
cated that nurse-leader-managers in private hospi- percentages do not total to a hundred percent).
tals were more likely to take action on a needs basis. Their responses highlighted the importance
Thus, they may have been more involved in work- of leaders providing safe working conditions and
ing collaboratively and participating in problem a positive atmosphere, along with the ability to
solving compared with nurse-leader-managers in appreciate and motivate staff. Culturally compe-
government hospitals being more reliant on ensur- tent care was also seen to be supported by leader-
ing compliance through active prevention (6) and ship that involved monitoring work, but coupled
contingent reward (9). with emphasizing and modeling how people from

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 Leadership style and culturally competent care: Nurse leaders’ views
Table 5: Nurse-leader-managers’ identification of leadership
characteristics that facilitate culturally competent care
ID Characteristics of Government Private
leadership N = 118 N = 35
f % f %
1 Giving individual 66 56 24
consideration
2 Showing leadership 59 50 21
3 Being a good 41 35 13
communicator
4 Being a role model 37 31 12
5 Showing idealized 12
behavior
6 Giving fair treatment 30 25
different cultural backgrounds can work together
and encourage cooperation among staff.
In addition, strategies to support culturally
competent care were identified. These included
implementing teamwork, setting up committees to
consider culturally competent care and patient sup-
port, and developing policy. Nurse-leader-managers’
abilities to be approachable, cooperative and flexible,
good listeners, able to encourage staff to talk and con-
vey a sense of trust were also viewed as necessary
qualities for provision of culturally competent
care. Both groups’ were of the opinion that if lead-
ers were not approachable this would have a detri-
mental effect on communication and the quality
of care. Although both groups’ responses clearly
conveyed a belief that nurse-leader-managers
needed knowledge about leadership styles and a
belief that transformational leadership was neces-
sary for ensuring culturally competent care, there
were some differences. Government nurse-leader-
managers emphasized the importance of the leader
listening to staff and being non-­discriminatory,
and treating them in a fair way. Whereas, private
hospital nurse-leader-managers especially raised
the issue of the leader being able to display cour-
age, self confidence, and a sense of responsibility and
have a vision for culturally competent care. Private
hospital nurse-leader-managers were seemingly
more explicit about their expectations of the
leader’s role compared with their government
counterparts, who highlighted the importance
of affective/humanistic considerations in terms
© eContent Management Pty Ltd
CN
of interpersonal communication, and
the quality of the work environment to
achieve culturally competent care.
Nurse-leader-managers’ perceptions
of how good leaders can best help
69 staff provide high quality culturally
competent care
60 In response to the open ended question: In
37
your opinion, what action does a good leader
34
in your workplace need to do now to help
34
staff to provide high quality cultural compe-
tent care? four common themes emerged.
These related to: (1) method of delivery of
professional learning, (2) staff motivation,
(3) provision of professional learning pro-
grams and (4) non-discrimination and cultural
respect. An additional five themes were identified
by private hospital nurse-leader-managers, which
related to: (5) documentation, (6) assessment,
(7) evaluation, (8) communication skills and (9)
leadership role modeling. Government hospi-
tal nurse-leader-managers’ again identified (10)
the affective or more humanistic area as needing
action for enhancing culturally competent care.
Table 6 shows the frequency of references to each
theme and the percentage of participants whose
responses related to each theme.
Nurse-leader-managers in both hospital types
identified a need for professional learning programs
and viewed the method of their delivery as an impor-
tant consideration. While staff had access to profes-
sional learning the small proportion of respondents
highlighted action specifically for improving cultur-
ally competent care. Suggested learning experiences
included provision of group discussions, lectures and
seminars. Connected to this was the need to moti-
vate and encourage staff to participate. Importantly,
it was seen necessary to also allocate time to attend
professional learning and give appraisals of staff to
help improve culturally competent care.
Both groups also raised the issue of cultural
respect and their being no discrimination. Their
view was that nurse-leader-managers needed to
act to: (a) ensure all staff were given an equal/
fair chance to attend professional develop-
ment workshops and (b) show mutual respect
for all religions. Related to their view that
Volume 48, Issue 2, October 2014 CN 143
CN Souher El Amouri and Shirley O’Neill

Table 6: Nurse-leader-managers suggested actions to were implementing both t­ ransformative

improve culturally competent care in UAE hospitals and transactional leadership styles to some
Government Private extent, but there were some differences in the
N = 115 N = 34 combination of the various factors involved.
ID Theme f % f % Private hospital nurse-leader-managers
apparently used all of the style factors more
1 Method of delivery of 45 39 12 35 frequently than government nurse-leader-
professional learning managers except for contingent reward and
2 Staff motivation 32 28 6 18 management-by-exception, active. Although
3 Provision of professional 21 18 5 15
differences were relatively small for these lat-
learning
4 No discrimination and 20 17 12 35
ter two factors, when considered against the
cultural respect private hospital nurse-leader-managers’ more
5 Documentation 6 18 frequent use of other factors, this suggests
6 Assessment 5 15 there may be subtle differences in practice.
7 Evaluation 5 15 The prevalence of active management-by-­
8 Communication skills 4 12 exception in givernment hospitals reflects the
9 Role modeling 3 9 findings of Jabnoun and Al Rasasi (2005).
10 Humanistic/affective 21 18 Given government hospital nurse-leader-
considerations managers’ lower use of intellectual stimula-
tion and idealized attribute, as well as the
two transactional factors that imply less sys-
nurse-leader-managers should be humanistic, tematic monitoring (7 and 8), it would seem that
government nurse-leader-managers (17%) were a system of compliance is more central to their
of the opinion that leaders’ actions should be practice. This would typically involve achieving
supporting, helping and caring for all staff. Finally, the necessary outcomes though implementing a
a small number of nurse-leader-­ managers in system of rewards for compliance in conjunction
private hospitals raised the importance of com- with mechanisms to prevent errors. Contingent
munication and accountability. This related reward, in particular, clearly takes precedence over
to language needs and management practices. the other transactional and transformative factors
Firstly, they saw a need to provide written mate- except for inspirational motivation (1) and indi-
rials on culturally competent care in both Arabic vidualized consideration (2). Thus, it appears that
and English language. Secondly, they identified in government hospitals these nurse-leader-man-
a need to evaluate the outcomes of professional agers are achieving a balance between ensuring
learning in both scope and effectiveness, and to compliance but also recognizing the importance
set up an assessment system to help staff identify of motivation and consideration of individual
and assess the cultural needs of patients. Actions needs. While nurse-leader-managers in private
to improve nurse-leader-managers’ communica- hospitals were also concerned with compliance as
tive skills with regards to expressing their feelings shown by their similar use of contingent reward,
and their needs were also identified. Similarly, the fact they differed most on the frequency of
the importance of demonstrating leadership use of ­management-by-exception: passive (7) and
through being active and having a vision was ­laissez-faire factors (8), requires more in-depth
noted. It was the majority view that such actions exploration. Since these two factors are known
would have a positive impact on encouraging to be positively correlated (Avolio et al., 1995),
staff to improve their performance. and the associated leadership behavior reflects a
tendency to be reactive and indecisive, when con-
Discussion and conclusions sidered against their more frequent use of some
These research findings show that nurse-leader- transformational factors, it raises the question
managers in both government and private hospitals as to why this is so. It is not clear whether these

144 CN Volume 48, Issue 2, October 2014 © eContent Management Pty Ltd
 Leadership style and culturally competent care: Nurse leaders’ views
differences might reflect the different ­ cultural
backgrounds between the two groups (predomi-
nantly Asian in government hospitals and Western
in private hospitals) or nurse training experiences.
Of note is the lack of any evidence to suggest that,
as reported by Randeree and Chaudhr (2007), the
leadership style in either group was necessarily
influenced by the consultative and participative
approaches associated with leading and managing
in the host Arabic culture. Neither did govern-
ment hospital nurse-leader-managers, where 19%
were from Arabic culture, indicate any sharing
of power (Sullivan & Decker, 2001). However,
individualized consideration was reported in
equivalent prevalence across hospital types but
participants’ open ended question responses
showed a need for more cultural understanding
and fairness in the workplace. Thus, there is a
need for future research to interview staff to fur-
ther investigate the universality and applicablity
of leadership style across cultures.
The issue of time as leader may also have
importance in government hospital nurse-leader-
managers views since the vast majority had been
in their positions for more than 5 years. This may
be reflected in their greater use of contingent
reward above others. It might be that they had
refined their practice compared with a possibly
more fluid work environment in private hos-
pitals where Western staff may move jobs more
frequently because of monitory and possibly cul-
tural considerations (Almalki, 2012). Again there
is a need for face-to-face discussions to enable
researchers to explore this more deeply.
Importantly, both groups of nurse-leader-
managers showed a knowledge of leadership and a
sensitivity to the nature of their leadership style in
their provision of culturally competent care. Their
responses were insightful in identifying the issues
and actions that could enhance its provision. They
leave no doubt that the complexity of such multi-
cultural care contexts presents significant challenges
and nurse-leader-managers need to draw on a com-
bination of leadership styles and associated factors.
Bearing in mind that ultimately it is the health of
the patient that is paramount, it is logical to build
on a platform of regulations, protocols and proce-
dures that are made clear to all and are monitored
© eContent Management Pty Ltd
CN
for compliance. It is also essential that this clarity
can be achieved by a system of two-way commu-
nication with professional learning, and language
and cultural supports to ensure comprehension in
practice. However, in addition to staff complet-
ing professional learning with regard to culturally
competent care, it is the style of leadership that
impacts on the way staff work within these require-
ments and in relation to the expectations of hos-
pital authorities’ management and accountability.
Nurse-leader-managers may not have the equiva-
lent amount of freedom to lead in the way that
they prefer, and embark on a goal of continuous
improvement. For instance, in a more authoritar-
ian system leaders are more likely to be constrained
in their opportunity to make changes and so model
the attributes of the ideal in transformative leader-
ship including stimulating staff intellectually. Since
following regulations and monitoring compliance
would be uppermost, when combined with not
having the imprimatur to make changes the incen-
tive would be low. Although compliance is neces-
sary, these private hospital nurse-leader-managers
may be more confident and may perceive they have
more freedom, with more trust placed in staff, and
more responsibility to make changes, or follow
rules with regard to the two transactional factors
(7 and 8). Of relevance is that in the context of
schooling, Barnett, Marsh, and Craven’s (2005,
p. 11) research found that laissez-faire leadership
‘may foster collegial relations to the point where
no one group member’s decision-making is consid-
ered more important than another’s, and so a gen-
uine atmosphere of working together is created.’
If this is the case then the nurse-leader-managers
in private hospitals may be more open and confi-
dent about their leadership activities with possibly
more opportunity to make decisions, and make
them collaboratively. The reported much lower
use of management-by-exception – passive and
laissez-faire factors in government hospitals – sug-
gests these nurse-leader-managers may have been
more focused on getting the job done within their
workplace checks and balances, but also within
the context of their clear goal setting and giving
of feedback. This was reinforced to some extent by
their perceptions of leadership characteristics neces-
sary for culturally competent care. However, while
Volume 48, Issue 2, October 2014 CN 145
CN Souher El Amouri and Shirley O’Neill
both groups raised the issue of the need for non-
discriminatory behavior, it was the government
hospital nurse-leader-managers that emphasized
the humanistic aspect of the provision of cultur-
ally competent care. They highlighted the need for
a caring environment (Tomey, 2009) where the
leader was clearly expected to model this behavior.
Figure 2 attempts to draw together the key fea-
tures of the care environment that intermingle to
create the challenge of achieving and enhancing
culturally competent care. The presence of the
contrasting but to some extent complementary
styles of transactional leadership and transforma-
tive leadership, and their major attributes that
impact in the workplace are shown in the broader
part of the spiral which culminates in a focus
on delivering culturally competent care. Nurse-
leader-managers are seen as drawing upon vari-
ous characteristics of leadership and combinations
of styles to suit the particular context at various
times, depending on the enabling or disabling fea-
tures of the host authority and culture. To achieve
effective culturally competent care according to
this research the care context needs to create a
Figure 2: The challenge of achieving and enhancing culturally competent care
146 CN Volume 48, Issue 2, October 2014
supportive work environment with respect for and
awareness of other cultures, and have non-discrim-
inatory practices where staff under go professional
learning. Importantly, strategies to assess patients’
cultural needs should be introduced so that staff
are able to act in a culturally competent way and
the accumulative target effect of successful cultur-
ally competent care is achieved. The accumulative
target effect is defined as the desired level of cul-
turally competent care that would be expected to
result from hospitals where nurse-leader-managers
are involved in transformational leadership where
there are language and cultural supports, two-way
communication, mutual trust, cultural respect
and awareness, non-discrimination, faireness and
equity, and assessment of patients’ cultural needs
that lead to culturally competent actions.
It therefore may be argued that while both
hospital contexts implemented transactional
leadership but with contrasting emphases, trans-
formational leadership was also evident but was
manifested in different ways. For instance, the
idealized attribute was seemingly more overt in
private hospitals, yet nurse-leader-managers in
© eContent Management Pty Ltd
 Leadership style and culturally competent care: Nurse leaders’ views
government hospitals set expectations for staff
and made explicit their confidence in their staff’s
ability to get the job done. Nurse-leader-managers
in private hospitals reported more collaborative
practice and flexibility to model and respond to
problems as they emerged, and were more likely to
take action on a needs basis. They were also more
explicit about their expectations of the leader’s role
compared with their government counterparts
who highlighted the importance of interpersonal
communication and the quality of the work envi-
ronment to achieve culturally competent care.
In conclusion, this research provides important
insights into this growing contemporary phenom-
enon of linguistic and culturally diverse health
care settings. It shows the diversity of two particu-
lar types of hospital contexts and the complexity
involved in ensuring provision of culturally com-
petent care. It also shows that there may be varia-
tions in leadership factors although key aspects
of transactional leadership are necessary in con-
junction with transformative leadership as a pos-
sible ideal for enabling a collaborative approach
that can build capacity for staff participation in
the search for further enhancement of their abili-
ties to provide effective culturally competent care.
Besides being pertinent to the delivery of cultur-
ally competent care because of the growing mobil-
ity of expatriate nurses in the UAE, leadership
that builds staff’s capacity to provide effective cul-
turally competent care is also relevant to all health
care settings where there is a growing multicul-
tural mix. This includes where nursing staff are
from non-English speaking backgrounds working
in Western health care contexts. However, the
researchers note the limitations associated with a
survey-only methodology despite the present rich-
ness of data. On the basis of these findings they
recommend further research that can drill down
more deeply through face-to-face interviews into
the issues raised. These particularly include the
influence of different cultural mix on leadership
style and potential influences of non-Arabic/non-
English speaking background staff on motivations
and retention. This research also provides a basis
for future research to consider the question of
what working within the cultural context of a cli-
ent, family and community entails and how this
© eContent Management Pty Ltd
CN
might be negotiated, demonstrated and evaluated
for its effectiveness in such diverse health care
contexts. This would allow a greater focus on how
nurse-leader-managers’ and other staff’s awareness
of culture is actioned in practice. It would also
be valuable to compare across multicultural con-
texts through replication of this study where the
cultural make-up of staff differs for other reasons
such as migrant nurses in Western settings. This
would allow further exploration of the challenges
of achieving and enhancing culturally competent
care presented here and the extent to which the
host culture may influence leadership style.
Acknowledgment
The authors express their deep gratitude to the
participating NLMs and their hospital authorities
who made this research possible, including those
who assisted in the initial trial and survey distri-
bution and collection.
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N O W AVA I L A B L E
Advances in contemporary transcultural nursing: Pathways
of cultural awareness (2nd edn)
A special issue of Contemporary Nurse – Volume 28 Issue 1–2 – xii+212 pages ISBN 978-0-9757710-5-1 – April 2008
Guest Editors: Akram Omeri (University of Western Sydney, NSW, Australia) and 
Marilyn McFarland (University of Michigan, Flint MI, USA)
Nurses are facing new challenges in a culturally diverse world. This issue provides a timely opportunity to reflect on some of
these challenges and on the ways in which nurses might respond effectively to them. It also provides a timely reminder of the
importance and moral imperatives of the theory and practice of transcultural nursing and its emphasis on care as a universal,
but diverse culturally constructed phenomenon, that lies at the heart of nursing research, education, and practice.
http://www.contemporarynurse.com/archives/vol/28/issue/1-2/advances-in-contemporary-transcultural-nursing

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