Jerry D. Estenson, California State University, Sacramento


Intercultural communication skill is becoming a threshold competence in the selection of nurse managers. This study explored the intercultural communication competence of a population of nurse managers in three Northern California hospitals. The staff nurses who spoke English as a second language (ESL) viewed managers who spoke English only or managers who spoke ESL to be equally competent communicators. The creation of a common language through nurse development programs may provide a model for other intercultural management programs. The present study examined communication skills of nurse managers in three Northern California hospitals employing significant numbers of staff nurses who spoke English as a second language (ESL). The following questions were examined:

(1) Do nurse managers who speak English only (EO) and staff nurses who speak ESL place similar values on joint agreement on job-specific terms?
(2) Do ESL and EO staff nurses perceive any differences in the communication
climate at work?
(3) Do ESL staff nurses perceive EO AND ESL nurse managers to be competent

The study indicates that when a manager is leading a linguistically diverse workforce care needs to be taken to ensure that agreement is reached between all workforce members on the meaning of terms used to communicate critical messages. The study also supports the need to create a supportive communication climate when working with a diverse work group. When a supportive climate is created the manager was viewed as an effective communicator even when lacking the ability to communication in a subordinates native language.


Immigration, social policies, global economics, and skilled nursing shortages have all changed the demographic profiles of hospital patients and their licensed and unlicensed staffs (Rakich & Darr, 1992). In large hospitals, nurse managers operate as the primary management representative responsible for coordinating the activities of several staff nurses. This is accomplished through the use of various hierarchical structures employing head nurses, lead nurses, nurse supervisors, and nurse with various titles as part of the management team. Because of this role, the nurse manager is at the nexus of issues created by a multiethnic, multilingual environment and has primary responsibility for creating responsive communication systems for staff nurses.

Nurse managers have traditionally combined bureaucratic communication systems (Freidson, 1989)] with parallel systems of interpersonal relationships based on professional training and similar work experiences (O'mara, 1995, pp. 513-541) to coordinate their management team and to supervise staff nurses. In the current health-care environment, the cultural diversity of patients and staff challenges nurse managers to create new communication systems and to learn new communication skills. Lack of training in management of diverse work groups has caused some managers to become frustrated and engage in defensive communication behaviors such as formality, control, masking, or depersonalizing messages (Gibb, 1961, pp. 141-148). In addition, the lack of well-constructed selection criteria including skills in intercultural management or adequate training in complex intercultural issues may affect a manager's ability to communicate effectively in a multicultural environment.

Attempts to define intercultural communication competence create difficulties similar to those associated with measuring communication competence in general. Spitzberg and Cupach (1984) found 136 distinct conceptual labels attached to factors empirically derived and associated with competence. Hammer, Gudykunst, and Wiseman (1978, pp. 382-393) moved toward uniformity in measuring intercultural communication competence, but did not provide the rigor necessary for general usage.

In attempting to find a more universal definition of competence, Lonner (1990, pp. 143-204) identified several common concepts that can be used to integrate research from several domains. Spitzberg and Cupach (1984) proposed that multiple dimensions of competence operate under the overarching concepts of appropriateness and effectiveness. These dimensions were used to define intercultural communication competence in this study. Thus, nurse managers perceived to be competent in intercultural communication would behave in a manner appropriate to the context of the message (appropriateness), and the message would be received by staff nurses in a manner that would lead to behavior appropriate to completing job assignments (effectiveness) (Estenson, 1997).

The present study examined communication skills of nurse managers in three Northern California hospitals employing significant numbers of staff nurses who spoke English as a second language (ESL). The following questions were examined:
(1) Do nurse managers who speak English only (EO) and staff nurses who speak ESL
place similar values on joint agreement on job-specific terms?
(2) Do ESL and EO staff nurses perceive any differences in the communication climate at work?
(3) Do ESL staff nurses perceive a difference in EO AND ESL nurse managers communication competent ?

Two communication skill instruments were used to derive numeric measures of staff nurses' perceptions of the intercultural communication competence of their nurse managers. Study findings provide a perspective on intercultural communication in a high-risk environment and have implications for selecting and development of nurse managers and supervisors.




The volunteers who participated in the study included 112 staff nurses, 27% ESL and 73% EO, and nine nurse managers two ESL and 7 EO working at two teaching hospitals and one private medical center in Northern California. Senior nurse administrators selected the cohorts to be studied. Cohort selection attempted to include work units, which employed significant numbers of ESL staff nurses and ESL nurse managers. The search revealed only two ESL nurse managers in a population of 102 nurse managers working in the three hospitals.

Among staff nurses, 40.2% had earned the Associate of Arts as their highest nursing degree; all others had Bachelor of Arts degrees or higher. All nurse managers had undergraduate degrees, with four Masters of Arts and one Master of Business Administration. The study population had a high level of professional experience. Among staff nurses, 90.2% had more than five years' experience with 71.5% having had more than 10 years' experience. All nurse managers had more than 10 years' experience, with 33% having had more than 20 years' experience (Estenson, 1977 pp. 128-132). Because of study limitation a comparison of the study population to the entire nurse population in the three hospitals was not accomplished.



Staff nurses completed two instruments: one that measured communication competence and one that identified common language systems. Nurse managers completed the common language instrument. Both groups completed a demographic survey that identified 14 variables, including first language, second language, and intercultural training.

The communication competence and common language instruments were used to test Spitzberg and Cupach's communication competence dimensions (1984). To evaluate Spitzberg and Cupach's cognitive or effectiveness dimension, nurse managers and staff nurses were asked to complete a word importance survey defining the manager's ability to create joint understanding of ten terms used in directing the work of staff nurses. The ten terms were developed using a Delphi group consisting of five senior nurse managers working in different organizational settings in California. Subjects rated the urgency of joint agreement on the meaning of the following terms: critical values, skills, vital signs, performance expectations, assessments, standard, responsibility, laboratory values, accountable actions, and patient outcomes. Subjects ranked the importance of joint agreement on each term with a score ranging from 1 (unimportant) to 5 (important). They were also asked to predict how their counterpart (nurse manager or staff nurses) would evaluate the criticality of joint agreement on each term.

Staff nurses also completed a second instrument, a communication climate inventory (CCI). The CCI consisted of 36 statements designed to measure staff nurses' perceptions of supportive or defensive communication by their managers (appropriateness) and 10 statements designed to measure the staff nurse's degree of satisfaction with the quantity of job-specific information received from the nurse manager (effectiveness). The statements used to measure supportive or defensive communication climates were modeled after a communication climate survey constructed by Costigan and Schmeidler (1984, pp. 112-118). The Costigan survey provided metrics to analyze communication climates discussed by Gibb (1961). The statements used to determine effectiveness were based on a survey designed by an International Communication Association (ICA) study group to measure different managerial communication attributes (Goldhaber & Krivonos, 1977, pp.41-55).

Respondents rated the 36 statements on communication style on a Likert scale from 1 (strongly agree) to 5 (strongly disagree). These ratings were combined to produce an overall rating of the degree to which the nurse managers' communication behaviors were perceived as defensive or supportive. The 10 questions about the quality of job-specific information were scored separately to generate an ICA score.



Table 1 shows nurse managers' perceptions of ESL and EO staff nurses and ESL and EO staff nurses' perceptions of nurse managers' communication competence. These data show the following:
(1) Nurse managers and ESL and EO staff nurses had a high level of agreement on the need for joint agreement on critical terms. Word error scores were low throughout the population.
(2) ESL staff nurses thought their nurse managers had a supportive communication style. ESL staff nurses had low supportive communication (SUP) scores.
(3) Nurse managers received lower marks for supportive communication from EO staff nurses. EO staff nurses had higher SUP scores than ESL staff nurses.
(4) ESL staff nurses were more satisfied than EO nurses with adequacy of job-related information provided by nurse managers. ESL staff nurses had lower ICA scores than EO staff nurses).

(Insert Table 1 here)

Multiple regression analysis was used to evaluate similarities between EO nurse managers and ESL staff nurses perceptions of the importance of joint agreement on job-specific terms. From Table 2, it was predicted that high defensive communication style scores, low ICA job-specific information scores, and low supportive communication style scores would predict low word error scores.

(Insert Table 2 here)

Word error scores and ICA scores were evaluated in relation to attributes of intercultural communication. Low supportive communication scores predicted low word error scores, independent of the other variables (word error score, 0.15; supportive communication score, -1.13). The supportive communication score predicted approximately 13% of the variability of the word error score. However, bivariate correlation analysis supported the direction of relationships described in Table 2.

Table 3 shows that subjects with the lower word error scores had lower ICA scores, higher defensive communication scores, and lower SUP scores.

(Insert Table 3 here)

Similarly, low supportive communication scores predicted low ICA scores, independent of the other variables. However, bivariate correlation analysis again supported the direction of the predictor relationships. As highlighted in Table 4, subjects with lower ICA scores had lower word error scores, higher defensive communication scores, and lower supportive scores.

(Insert Table 4 here)

These data showed a statistically significant relationship between the instrumental (effectiveness) and affective (appropriateness) attributes of intercultural communication competence.



The limited variability in word error scores may be the result of several factors, including:
(1) the limited number of study sites, all in Northern California,
(2) the similar demographics of the nine cohorts,
(3) the similar minimum levels of formal education among staff nurses and nurse managers, and
(4) the significant amount of professional experience in the study population.

The relationship between supportive communication scores (affective) and word error scores (instrumental) may be explained by viewing the word error score as representing Spitzberg and Cupach's (1984) effectiveness dimension, which indicates the strength of messages. This relationship between scores indicates that the strength of a message (how valuable the receiver perceives the information contained in the message) may be directly related to how the receiver feels or perceives the individual sending the message. In practice, nurse managers who construct a common symbolic system (language and messages) for their staffs using a supportive communication structure appear to help create agreement on word meaning across the work group. Data supports this explanation when the nurse manager's behavior is analyzed using Spitzberg and Cupach's (1984) appropriateness dimension, represented in this study as a supportive communication style score. The positive relationship between effective and affective scores supports the proposition that the use of a flexible and supportive communication style may help subordinates understand critical information and symbols used by nurse managers.

Although the limited scope of this study does not allow for generalization of results, these data do indicate that a receiver's acceptance of the strength of a message may depend on his or her perception that it was delivered in a supportive manner.


Nursing education trains nurses in a common language. Education appears to play a significant role in the high degree of agreement on the criticality of words used by ESL and EO staff nurses and nurse managers caring for patients at a variety of locations. It appears that the highly structured nature of domestic and international nurse education provides a learning system that provides common meaning to critical symbols and these symbols can be used to bridge cultural and first-language barriers.

This study indicates that nurse managers skilled in creating dynamic common symbol systems are more likely to succeed in cross-cultural communication and in creating communication climates perceived as supportive by both ESL and EO staff nurses than less skilled communicators. The relationship between development of common symbols combined with supportive communication systems and attainment of organizational goals merits further study.

The finding that ESL staff nurses tend to accept greater responsibility for understanding a message and to view their managers as more supportive than EO staff nurses is worth considering when evaluating a work environment. A manager might perceive an ESL subordinate's satisfaction with communication style as indicative of an effective communication climate. However, the ESL nurse may be saving face rather than admitting failure to understand a message. Hall (1959) describes such behavior as typical in high-context cultures in which subordinates are responsible for understanding messages sent by the superior.

This study indicates that the power of common language, common goals, a common view that the nature of the work performed has innate value, and a supportive climate help promote intercultural communication competence. Translating these findings into a metaphor may help in understanding how effective cross-cultural communication may work.

A look at the operation of "Velcro" may provide such a metaphor: Velcro strips attach to one another by small similarly constructed hooks. A multi-lingual work force may also attempt to connect through similarly constructed language hooks (Estenson, 1997).

In a Velcro strip these miniature hooks are engineered and produced in a way similar to other strips yet each strip and hook is slightly different. In a multicultural work group, each hook (individual) is formed through a combination of group, organizational, and cultural experiences. When it is necessary for a connection to take place, hooks on a strip (groups of diverse individuals) are brought together. Connection and bonding with other Velcro material (work group members) occurs because of the similar construction of the hooks.

The results of this study indicate that common communication hooks development has occurred in the nursing profession. One place to look for this development is in the basic and advanced education of ESL and EOL staff nurses and their nurse managers. The educational process created common symbols (medical language), common views of humankind, and common agreement on the primary goal of reducing human suffering.

A manufacturer of Velcro attempts to create strips with similarly designed and shaped hooks that form a strong bond under pressure. Like the Velcro manufacturer, nursing education process allows for individual nurses to form a common language (hooks) which is used to form a strong bond under the pressure of critical work (promoting patient survival), congruent goals (professional standards of behavior), or external forces (skills shortages, affirmative action, ethnic marketing programs).

Velcro is unique because it comes together to form a cohesive bond while allowing each hook to retain its individuality. A diverse, cross-cultural workforce may have similar characteristics: each individual contributes special attributes to basic group goals, individual uniqueness is valued, and the cohesion of similar elements allows for a greater strength than that of an individual. Thinking about a multi-cultural environment as operating similar to Velcro allows individual to separate after the need for joint effort has past. After the separation the individual remembers the shared goals, symbols, and common learning systems created by the contact.

It may be worthwhile to review the actions taken in the training and professional development of nurses to determine actions nurse managers and other managers of multicultural employees may wish to pursue. First nurses tend to be drawn to the profession by the Superordinate goal of relieving human suffering. This reminds us that extrinsic motivational factors are important and a competent intercultural communicator would provide linkage between the tasks assigned and accomplishment of a worthy organizational purpose. Second nurses worldwide are trained using the same medical terminology. In other contexts efforts by managers to ensure that each employee understands key concepts and words would be rewarded with focused employee effort. Third nurses work in an environment where behaviors are controlled by law and professional ethical standards. A manager directing the work of a multicultural work force may need to establish clear behavior boundaries for employees. These boundaries will send the message that racism, sexism, and outside inter-cultural conflicts will not be tolerated. Fourth the training and work of nursing tends to be performed in an environment with a high level of contact with other nurses and managers. Managers outside of nursing may need to set up opportunities for members of the diverse group to interact. This will help reduce the social isolation which appears to be a significant inhibitor of intercultural group performance. Fifth nurses tend to be trained to exhibit a universal set of skills, knowledge and abilities. Managers of diverse employees may be required to set up fundamental skills and knowledge building courses. The courses could include writing and oral presentation as well as skills unique to assigned tasks. Last the study indicates that managers need to create a supportive communication environment in which they can ensure that their messages are heard, understood and accepted. This environment requires a communication style which is provisional (flexible, experimental, and creative), empathetic (manager attempts to listen and respects employee feelings and values) equal (does not make employee feel inferior), spontaneous (communications are free of hidden motive), problem oriented (manager defines problems while not giving solutions and remains open to discussion), and descriptive (clear about their perception and describes situations fairly)

It is becoming apparent that intercultural communication skill is a threshold competence in the selection of nurse managers and managers in other fields. Those interested in managing and leading will need to build the skills discussed in this article. Those who lack the skills will be well served to explore new learning opportunities. A model for the operation of an effective cross-cultural communication style maybe found in the supportive communication system created and used by nurse managers in this study. This systems celebrates both the similarity and differences of individual nurses.

Works Cited

Costigan JI, Schmeidler M.(1984). Exploring supportive and defensive communication climates. In: Pfeiffer JW, Goodstein LD, eds. The 1984 Annual: Developing Human Resources. San Diego: Pfieffer :112-118.

Estenson J.D.(1997). Communication Competence: Mono-lingual Managers in a Multi-lingual Work Force. Los Angeles: University of Southern California; Dissertation.

Freidson E.(1989). Medical Work in America. New Haven: Yale Univ Press

Gibb J (1961). Defensive and Support Communication. J of Communications 11, 141-148

Goldhaber GM, Krivonos PD. (1997) The ICA communication audit. Process, status, critique. J Bus Commun ;15(1):41-55.

Hall ET. (1959)The Silent Language. New York: Doubleday.

Hammer MR, Gudykunst WB, Wiseman RL (1978). Dimensions of intercultural effectiveness: an exploratory study. Int J Intercultural Rel.;2:382-393.

Lonner WJ. (1990). The search for psychological universals. In: Triandis HC, Lamber WW, eds. Handbook of Cross-Cultural Psychology. vol. 1. Boston: Allyn & Bacon; :143-204.

O'Mara AO.(1995). Communicating with other health professionals. In: Arnold A, Boggs K, eds. Professional Communication Skills for Nurses. 2nd ed. Philadelphia: W. B. Saunders Company; :513-541.

Rakich J, Longest BB, Darr K. (1992). Managing Health Service Organizations. 3rd ed. Baltimore: Heath Professions Press .

Spitzberg BH, Cupach WR. (1984). Interpersonal Communication Competence. Beverly Hills: Sage Publications.


Table 1. Means and Standard Deviations for Scores Measured

Scale Mean Standard Deviation
Word error score 4.48 6.03
ICA score 2.21 0.71
Defensive communication score 66.13 15.43
Supportive communication score 38.39 14.57

Table 2. Correlations Among Scores and Intercultural Communication Competence (ICC)

Scale High ICC Low ICC
Word error score Low High
ICA score Low High
Defensive communication score High Low
Supportive communication score Low High


Table 3. Correlations Between Predictors and Word Error Score

Scale r(107) value
ICA score 0.34**
Defensive communication score -0.25*
Supportive communication score 0.36**

*p<0.01; **p<0.001


Table 4. Correlations Between Predictors and Low ICA Scores

Scale r(107) value
Word error score 0.346*
Defensive communication score -0.50
Supportive communication score 0.77



back to the top