Journal of Psychology & Psychotherapy
Open Access

COVID-19 and Well-being among Nurses: The Role of Cross-Cultural Practices and Emotional Intelligence in the Tertiary Hospitals of Pakistan

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Introduction

The emergence of COVID-19 was reported in Wuhan, Hubei province, China, during December 2019. COVID-19 has taken intense consideration across many countries around the globe. The advent of the COVID-19 emergency in Pakistan, there are a total of 577 confirmed nurse’s cases on Sunday, June 20, 2020. This rapid increase in the number of patients with COVID-19 infection raised a serious concern of nurse's physical and emotional stress. Such severity is causing a detrimental effect on work engagement and well-being among nurses. This pandemic has enormous implications on health care systems, particularly in the workforce. Nurses, as the largest group of a health profession. They are at the frontline of the pandemics. Nurses deliver care directly to patients in close physical proximity and as such, are often directly exposed to the viruses and are at high risk of developing disease. Moreover, nurses have to cope with overtime work, frustration, isolation, and deal with patients with overwhelming emotions. To date, there is limited research about nurses’ experiences of the emergence of COVID 19, particularly as distinct from other health professionals. However, it’s important to understand how to maintain levels of work engagement and well-being during the pandemic.

Suggested that cross-cultural practices may contribute to better outcomes in the emergency. It has been shown that diverse cultural competencies had a positive impact on work engagement and well-being. Cross-Cultural approaches are organizational behavior and practices within the host country that compares organizational behavior and practices across other countries and cultures. Most essentially, it seeks to comprehend and advance the interaction of co-workers, suppliers, clients, and business partners from diverse cultures [1]. The previous empirical evidence showing that a nurse's cross-cultural practices can improve their knowledge, skills, and attitude [2]. During an emergency situation, nurses having cross-culture competencies can practice appropriate medical services which may significant for patient’s treatment.

Similarly, revealed the effectiveness of emotional intelligence as an imperative construct associated with favorable outcomes, for example, cultural awareness, pro-social behavior, positive conduct with patients, and peers. Emotionally intelligent nurses utilize various methods to handle their sentiments and stress. Suggested that emotional intelligence may help nurses to manage stress in chaotic work environments [3]. Emotional intelligence is important in creating and maintaining a caring environment during an emergency situation. According to this evidences, the purpose of this study was to investigate the impact of cross-cultural practices and emotional intelligence on work engagement and well-being among nurses during the COVID-19 pandemic.

Conceptual Framework and Hypotheses Development

Cross-cultural practices, work engagement and well-being in emergency situations

Cross-cultural refers to the behavior of individuals in organizations of diverse cultures around the world that cross-cultural is a relationship between individuals of different cultures performing in the same organization sector [4]. In healthcare sectors, cross-cultural health practices efficiently provide standard health care to the patients of the host as well as diverse cultural backgrounds in critical situations. According to cross-cultural competencies are defined as the ability of understanding, and engaging, social skills with patients whose values, norms, beliefs, and histories are dissimilar to one’s own. Argued that working with culturally diverse patients can be challenging for nurses due to differences in attitudes, beliefs, perceptions, norms, values, customs, and traditions. Lack of cross-culture competencies result in maladaptive behaviors, miscommunication, interpersonal conflicts and patient dissatisfaction.

Previous studies confirmed the evidence that cross-cultural health practices are significant for nurse’s staff to respond and deliver care series appropriately. Nurses who develop knowledge of diverse cultures can improve health services, increasing satisfaction levels, and mutual understanding with patients. Argued that in healthcare sectors, dealing with patients of diverse cultural backgrounds is critical and can be challenging for nurses in emergency situations. If poorly managed, it will cause huge damage in terms of dissatisfaction, stress, and causality. If the nurses have a lack of cross-cultural knowledge, patients’ lives are at higher risk and having undesirable health consequences. Moreover, showed that cross-cultural competencies not only enhance patients’ satisfaction but are also positively associated with nurses’ well-being.

According to, cross-culture competencies psychologically engage individuals to perform their tasks effectively and it boosts behavior, knowledge, and skills for their well-being. Therefore, competencies of diverse cultures are considered as a predictor of work engagement and well-being among nurses because cross-cultural knowledge increases their practice and experience that reducing the stress and anxiety level. Moreover, when perform cross-cultural skills, nurses can easily assist patient care by. Consequently, nurses’ can enhance their professional growth and can efficiently engage in their tasks for the betterment of the organization as well as their well-being. This seems to play a fundamental role in the pandemic of Covid19 which expose nurses to experience pressure, fear, exhaustion, isolation and stress.

Thus, the following hypotheses were proposed:

H1: There is a positive relationship between Cross-culture competencies and work engagement among nurses during the covid19 pandemic.

H2: There is a positive relationship between Cross-culture competencies and well-being among nurses during the covid19 pandemic.

Emotional Intelligence, work engagement and well-being and the COVID 19 emergency

The nursing profession is emotionally demanding and even more in an emergency situation. Various empirical studies have found the effectiveness of emotional intelligence as a construct associated with favourable outcomes. The emotional intelligence (EI) concept was originated back in the 1920s but it gets attention when it described formally. They defined it as ‘the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and actions. Nurses with higher levels of emotional intelligence have lower stress levels, higher levels of perceived control, satisfaction, and commitment. Moreover, it’s found that EI moderates the impact of emotional demands on emotional exhaustion and fosters self-efficacy in the nursing contest. Preliminary investigation specifies that emotional intelligence ability plays a positive moderating role to control chaotic work environments. Several theories suggested a connection between emotions and the individual ability to manage stress in chaotic work environments [3]. Previous studies find out the value of EI in health care sectors. The results revealed a link that low EI was correlated with higher perceived stress and burnout among nurses.

In the healthcare sector emergencies are constantly expected by the nurses, therefore, it is predictable that emotional intelligence can assist nurses to perform standard services in uncertain situations appropriately and for enhancing well-being among nurse’s staff. In this perspective, the contemporary approach of hospitals requires emotionally intelligent nurses to manage the work demands and provide standard healthcare services to the patient and to improve supportive consultation with peers [5]. To stimuli work-engagement and well-being of nurses in healthcare sectors, nurses need high levels of emotional intelligence. Some studies revealed that emotional intelligence correlated with stress management and welfare. Therefore, the present study intends to find out the influence of emotional intelligence on nurses’ work engagement and their well-being during the COVID emergency.

Based on the above arguments, we hypothesize:

H3: There is a positive relationship between emotional intelligence and work engagement among nurses during the covid19.

H4:There is a positive relationship between emotional intelligence and well-being among nurses during the covid19.

Emotional intelligence and Cross-culture interactions

In today’s healthcare sectors to provide quality care services, nurses are required to have cross-culture competencies because they often face patients from diverse cultures. By adopting diverse cultural competencies nurses are facing difficulties such as adaptation in cross-culture, the difference in norms and values, communication barriers, possibilities of biases, and prejudices by some health professionals. Cultural diversity is common in the healthcare sectors. For encountering cross-culture challenges, the emotional intelligence of nurses is considered a significant factor. Previous research has shown that emotional intelligence has a strong influence by adopting cross-cultural competencies such as adaptation and the work-engagement and well-being of employees. Claim that emotional intelligence can effectively increase the culture's proficiencies, consequently, it leads toward the standard performance; moreover, it helps to reduce uncertainty and nervousness that can often arise in a cross-cultural environment. Demonstrated that individuals having a high level of intelligence would constantly explore new cultural competencies. This is particularly important when nurses deal with an emergency situation because nurses frequently have a direct link with patients belong from diverse cultures.

Figure 1: Theoretical framework.

Previous studies have revealed that lack of emotional or cultural intelligence has been cause the failure of many organizations [6]. In the present decade, even in decision makings and administrative changes, emotional intelligence is considered a major factor [7]. Therefore, EI is becoming appropriate individual competencies to manage cultural diversity as well as nurse’s work engagement for their well-being. Emotionally intelligent nurses, who can understand different cultures, not only high-quality services but also enhance their practical skills which are required for work engagement and their well-being. Therefore, we hypothesized that: H5.Emotional intelligence moderates the relationship between cross-culture competencies and nurses’ well-being. H6.Emotional intelligence moderates the relationship between cross-culture competencies and nurses’ work-engagement.

Materials and Methods

Participants

This is a cross-sectional study. A multidimensional anonymous questionnaire survey was distributed among nurses working in four different tertiary healthcare sectors in Khyber Pakhtun Khwa (KPK) Province, Pakistan from 10 March 2020 to 20 April 2020. Based on the study, the nurses who were working in the COVID-19 clinical ward was selected in each hospital. To increase the appropriate response rate, several techniques were adopted such as a cover letter for clarifying that data will be only used for academic purposes, follow-up reminders, avoid unbiased responses and confidential premises to ensure their privacy. We adopted a survey methodology by self-report survey and 350 questionnaires were distributed with the help of nursing assistants working in hospitals. A total of 297 nurses volunteered to respond to the survey but 263 questionnaire were concluded for the further analytical procedure by considering 99% confidence level, 0.5 standard deviation, and ±1% margin of error, the rest feedbacks were neglected due to the error or missing data. Applying software for the statistical algorithm of computing the absolute smallest sample size, the minimum range of sample size for our SEM model is 250 cases. Based on four latent variables and 30 indicator variables having a statistical power 0.80 and significance of 0.05 respectively. Thus, our sample of 263 meets the recommended minimum criteria for sampling adequacy. Table 1 demonstrates the descriptive statics of the respondents.

Table 1: Demographic characteristics of respondents (N = 263).

Measures

Emotional intelligence

To measure the self-report emotional intelligence, 8 items scale was used developed. Sample of items included: “I have a good understanding of my own emotions”. Respondents were asked to state their choice for each statement respectively, using a five-point Likert scale that ranged from 1 (strongly disagree) to 5 (strongly agree). The Cronbach’s alpha of the scale was 0.920.

Cross-culture competencies

Developed 8 items scale, adopted to measure the cross-culture competencies. The 8 items were distributed among three components behavior, knowledge, and managing skills. A sample item includes, ‘I have been using the skills presented in the training course to help complete my job duties?’ Nurses were queried to report how they experience each cross-culture practice on a five-point Likert scale ranging from 1 (not influential) to 5 (strongly influential). The Cronbach’s alpha reliability of this scale was 0.931.

General well-being

To assess this measurement, 6-items scale of well-being was used to capture nurse's well-being, Physical and mental health, stress, and general. Moreover, Nurses were enquired to indicate how frequently they had feelings of symptoms of COVID, (e.g. fever, sore throat…). A Likert scale ranging from ‘never’ (0) to ‘all the time’ (4). The Cronbach’s alpha of this scale was 0.955.

Work engagement

Items scale for Work Engagement was developed. A total of 8 items are tested. Sample items for the Work Engagement include “I am enthusiastic about my job.” The Cronbach’s alpha of this scale was 0.918.

Data analysis

Before running and analyzing the model hypotheses, we tested the modeling process involved in two steps i.e. measurement model and structural model by using (PLS-SEM) partial least square structural equation modelling. First, we analyzed the measurement model and tested it for convergent validity. A factor loadings, Composite Reliability, and Average Variance Extracted were measured. The confirmatory factor analysis of all the factor loadings items found to be in the range of 0.70 to 0.91, and satisfy the minimum requirement of the recommended value of 0.6. Composite reliability provides the degree to which the construct indicators specify the latent construct, and it ranges from 0.933 to 0.961 which exceeded which satisfies the minimum criteria 0.7. While average variance extracted (AVE), which reveals the inclusive amount of variance in the indicators accounted for by the latent construct, which fell in the range of 0.591 to 0.690 exceeded the minimum value of 0.5 as shown in Table 2.

Table 2: Reliability and validity.

Furthermore, discriminant validity was measured which indicated low correlations between variables. Some recent condemnation of the Fornell and Larcker (1981) criteria recommends they do not consistently identify a lack of discriminant validity in common research conditions. Have recommended an alternative method to measure discriminant validity: the heterotrait-monotrait (HTMT) ratio of correlations was tested for discriminant validity as shown in Table 3. The HTMT value as shown in Table 3 is in the range of recommended criteria which is below 0.85. Therefore each variable within the model is reliable and shows the reliable measurement model.

Figure 2: Structural model.

Results

Table 3 represents the correlations among the variables in this study. The correlations between the targeted construct were in the anticipated directions and provide a significant positive relationship between cross-culture competencies and work engagement (0.512, p < 0.01), the correlation between cross-culture competencies and well-being also significantly positive (0.559, p < 0.001).There were significant positive correlations between emotional intelligence and well-being (0.716, p < 0.05), and emotional intelligence and work engagement (0.539, p < 0.001).

Table 3: Correlations and reliabilities N=263.

Table 4: Structural model testing direct and moderating relationship between variables N=263.

The structural model was run to test the relationship between the targeted variables. PLS-SEM structural model has run to analyze the interaction among independent, dependent, and moderating variables. Looking at R², beta, and t-values through 5000 bootstrapping procedure. It is also suggested that with these basic measures, predictive relevance (Q²) and the effect sizes (f²) should also report by the researchers. First, we observed the relationships between the targeted variables. Table 4 represent the results of Hypothesis 1 and 2, was positively significant and enlighten the effect of cross-culture competencies on work engagement (β = 0.413, p < 0.01), and well-being (β = 0.262, p < 0.01). The influence of emotional intelligence on work engagement (β = 0.521, p < 0.01), and well-being (β = 0.204, p < 0.01) was positive and significant, therefore supporting Hypothesis 3 and 4. Furthermore, cross-culture competencies explains 37.9% of variance in work engagement (R² = 0.379) whereas cross-culture competencies explain 42.7% of variance in well-being (R² = 0.427) as shown in Figure 2. The R² values of 0.379 and 0.427 exceeded the recommended figure of 0.26 which suggests a substantial model. Afterward, we measured the effect sizes (f²). In our results, the p-value shows significant relationships however it does not show the effect. Therefore, scholars have a problem in data interpreting and results. Hence, substantive significance (f²) as well as p-value must be described. Recommended that change in R² value must be observed. For the measurement of effect size, guidelines are used, which indicates .35 for large effects, .15 for medium and 0.02 suggested for small effects. Table 4 provides a medium effect for all relationships. The Q² provides how fit the data can be reassembled using the model and the PLS constraints. A value of Q² greater than 0 shows a predictive relevance of the model, while a value of Q² less than 0 suggests lacks predictive relevance of the model. As shown in Figure 2, Q² for both variable indicate acceptable predictive relevance.

Moderation analysis

Finally, this study hypothesized emotional intelligence possesses a moderating impact on the relationships between cross-culture competencies, work engagement, and well-being among nurses. To measure the moderation analysis, a PLS product-indicator approach is used to test the hypothesis, According to, PLS can provide precise and accurate assessments for moderation effects (Henseler & Fassott, 2010).To test the moderating impact, cross-culture competencies (predictor) and emotional intelligence (moderator) were multiplied to generate an interaction construct to predict work engagement and well-being. The predictable standardized path coefficients for the effect of the moderator on the work engagement (β = 0.263; p < 0.01) and well-being (β = 0.219; p < 0.01) were significant as shown in Table 4. This specifies that the emotional intelligence of nurses moderates the relationships between cross-culture competencies, work engagement, and well-being among nurses. Consequently, H5 and H6 were also accepted. The present study revealed that cross-cultural competencies and intelligence engage employees in their work which improves their skills and experience, consequently lead to their well-being. Similarly, our study finding explored that emotional intelligence plays a moderating role in the relationship between cross-culture competencies and work engagement and well-being. The respondents reporting higher emotional intelligence possess a strong relationship between cultural practices, work engagement, and well-being.

Discussion

Our study’s general aim was to examine the relationship between Cross-culture competencies, emotional intelligence, work engagement, and well-being during the COVID 19 emergency. Our findings revealed that nurses with having multi-cultural competencies appropriately engage them in their job tasks even in the pandemic situation. Moreover, cross-cultural competencies increase nurse’s well-being. Our results are consistent with past research [8]. Showed that nurses having cross-cultural competencies have a progressive influence on inspiration; it strengthens their work-engagement during an emergency situation. In addition, our results showed that emotionally intelligent nurses demonstrated high levels of work engagement and low levels of job-stress. This is consistent with various empirical studies, which have found the effectiveness of emotional intelligence as a construct associated with favourable outcomes. Emotional intelligent nurses can manage emotions in different situations to engage them in their work and also for their well-being. Moreover, our results confirmed that the effect of cross-culture competencies on work engagement and well-being is moderated by emotional intelligence. Precisely, our result found that nurses having low emotional intelligence practiced low levels of job performance compare with higher emotional intelligence. Emotional intelligence can be useful to understand and developed multicultural skills and practices. This is consistent with previous observations. Argue that emotional intelligence regulates emotions appropriately in culturally diverse situations. Thus, regulating, managing, and controlling of cultural differences and emotions are hypothetical essential for successful dealings. Revealed that growing emotional and cultural challenges in health care sectors lessen negative health consequences for nurses. They are capable of adopting an emotional environment, can appropriately assess, express, and respond effectively to others’ emotions, which can increase their well-being because millions of lives were affected, not only physically but also emotionally (e.g. obsessional behavior anxiety, panic attacks, stress, and fear).

Multi-Cultural competencies and emotional intelligence are significant in health sectors and it seems to play a crucial role in the pandemic because of cross-cultural patients, cultural and emotional intelligence competencies of nurses can efficiently encounter the challenging behaviors and manners of diverse culture patients [9-14]. Furthermore, health sectors must also encourage their nurses and other staff to participate in multi-cultural development curricula to strengthen their bonds with different communities in terms of understanding cultural diversity and their health practices The hospital management needs to formulate a cross-culture practices program that can appropriately and realistically integrate cultural intelligence in a nursing occupation such as hiring those nurses who have stronger cultural awareness and emotional intelligence capacity which can engage them in their job tasks and to deal effectively also with the most emotionally demanding situations. These observations play a more relevant role in an emergency health situation like the covid19 which expose nurses to stress, burn out and negative outcomes. It seems fundamental to enhance those elements which can protect nurses from overwhelming stress and burn out.

Conclusion

The conclusion of this study examines the relationships among cross-culture competencies, emotional intelligence, work engagement, and well-being of nurses in the current COVID-19 scenario. Our findings suggest that cross-culture training and emotional intelligence development program should constantly be included in the curriculum of nursing courses. This can enhance nurse’s skills and abilities regard with effectively interact action with diverse culture patients, hospital professionals, improvement in quality service, patient satisfaction, and engagement appropriately to their work which will be useful for nurse's well-being as well.

Limitations and directions for future research

The current study is not without limitations. First, this study focused only on the health sectors in the current scenario of the COVID-19 pandemic. All the respondents were nurses and based on self-report measurement, there might be biased reactions during filling the survey. Though in future research respondents can be considered from doctors, assistants, and other staff. Second, we relied on questionnaire data which were collected from one country, In the future, scholars can investigate the same study in different areas like Western countries. Third, to expand the generalizability of the present results, future studies should imitate this model in other fields such as project management, marketing areas. In the existing study, the relationship between cross-culture competencies and emotional intelligence is tested with work engagement and well-being among nurses; future scholars could also take other dependent variables like job satisfaction, burn-out and can be tested with mediating variables such as motivational approaches.

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