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The Significance of Cultural Intelligence in Nurse Leadership Angela Richard-Eaglin, DNP, MSN, FNP-BC, CNE, FAANP

Cultural intelligence (CQ), which is the ability to efficiently traverse multicultural environments and interactions, can have a profound impact on cultural literacy and fluency. It is foundational in the embodiment of cultural awareness, sensitivity, humility, and competence, and in decreasing biased decision-making. Evidence shows that bias, attitudes, and behaviors of health care providers negatively impact health outcomes for marginalized and stigmatized populations. The role of the nurse leader transcends multiple venues, including academia, clinical practice, and corporate and settings; therefore, CQ development and role modeling is essential in influencing health professions clinicians, faculty, and students to deliver bias-free care.

ealth care is a dynamic, multicultural, and global industry that requires fluidity of lead-

H ership strategies that prioritize culture as an

integral component of effective leadership. Many concepts are used to describe cultural influences and interactions: awareness, competence, humility, sensi- tivity, and more recently, cultural intelligence (CQ). Acquisition of CQ provides foundational knowledge and skills that facilitate awareness, humility, sensitivity, and competency with regard to culture. These concepts are important to leaders across organizations because they improve cultural literacy and fluency, and they also guide practices that encourage and support diversity, equity, inclusion, and belonging (DEIB). Diversity, in a broad sense, includes differences in thoughts, cultural norms among organizational

KEY POINTS

� Cultural intelligence provides a foundation that encourages practices that support diversity, equity, inclusion, and belonging.

� There is an urgent need for initiatives that discourage bias-influenced health care and leadership practices.

� Nurse leaders across various settings have a pivotal role in prioritizing bias-free practices that support optimal and equitable outcomes for all organizational stakeholders, including patients, students, clinicians, and faculty.

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departments, communication styles and preferences, value systems, and work styles. It is important that leaders embody and endorse diversity from this broad perspective in an effort to adequately advance cultur- ally inclusive initiatives.

Leadership practices should include creating an environment that emits not only a sense of inclusivity, but also a true sense of belonging for everyone. This is how a “culture” is created. Leaders should recognize and acknowledge that the antithesis of inclusion is exclusion. For example, hiring someone and allowing them the opportunity to be on a committee but then denying them an actual participative voice is a demonstration of exclusionary inclusion. Simply hiring individuals from minority or marginalized groups does not satisfy the criteria for fostering a diverse, equitable, and inclusive environment. Exclusionary practices lead to organizational imbalances such as dissension and increased turnover, and from a health care perspective, breed health inequities.1-3

Executives across organizations have identified the following outcomes to validate the importance of CQ: creating diverse markets and a multicultural workforce, recruiting and retaining the most talented individuals, and achieving financial success through reduced costs and increased profitability.4 In a systematic review of meta-analyses and other largescale diversity studies, the authors reported evidence that people are attracted to diverse organizations; creativity and innovation are greater in diverse organizations; and financial out- comes are better for organizations where diversity is apparent.5 To that end, intentionality in executing

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initiatives that ensure DEIB in recruitment and reten- tion of a multicultural workforce and multicultural student recruitment/enrollment is important in affecting successful organizational outcomes. Cultural intelligence can be foundational in these efforts.

There is an urgency for cultivating organizational communities that recognize the significance of culture and actualize the core value statements that embody DEIB.Organizations that convey acceptance, inclusivity, and belonging increase employee productivity and long- term commitment.4 Leadership through a broad lens with intentional application of CQ principles directly enhances the impact on outcomes that contribute to organizational stability, including improved job satisfac- tion and performance, as well as increased long-term commitment.5,6 The purpose of this paper is to demon- strate the use of CQ as a foundational framework for enhancing leadership in nursing and ultimately, decreasing bias-influenced decisions and outcomes.

UNDERSTANDING CQ Cultural intelligence is defined as the ability to function efficiently in culturally diverse environments.4,7,8 Cul- tural intelligence can have a profound impact on cul- tural literacy and fluency, and ultimately on removing cultural and structural barriers. Cultural intelligence may also decrease biased decision-making and conse- quently, improve outcomes for all stakeholders within an organization.4 Individual comfort levels during cross- cultural interactions and a vested interest in active participation in multicultural interactions are funda- mental in developing CQ.4

There are 4 CQ factors: drive/motivation, cogni- tion/knowledge, metacognition/strategy, and behavior/ action.4,7 Cultural intelligence drive/motivation involves interest and confidence during cross-cultural in- teractions.4,7 Acquiring CQ requires a continuous desire to successfully interact in and circumnavigate different cultures. Cognition/knowledge involves not only knowing, but also understanding cultural likenesses and differences.4,7 Metacognitive CQ or strategy, refers to cultural awareness and the ability to plan for multicul- tural interactions.4,7 Preparation for cultural exchanges, while also allowing space for embracing uniqueness within cultures, allows for more robust multicultural in- teractions. Behavioral CQ, or action, refers to adapt- ability within multicultural contexts.4,7 This allows adjustment of thoughts and flexibility in developing be- haviors that assist with effective cross-cultural in- teractions.4,7 Proficiency in developing each of these skills separately and the ability to use them collectively constitutes a person’s level of CQ.4,6

Cognizance of one’s cultural values preferences and their potential to influence bias is another pre- cursor for developing CQ.4 Cultural values are per- sonal preferences that influence ways of being and ways of

doing.9-11 Cultural values are based on individual

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preferences and are not right or wrong. Individual cul- tural value orientations impact interpersonal in- teractions, communication styles and preferences, preparation/planning, negotiation, and task perfor- mance.9 In addition to awareness of personal cultural values, knowledge and acceptance of dissimilar per- spectives is necessary to invoke understanding and tolerance and enable healthier relationships. Culturally intelligent leaders use differences to facilitate an appreciation for diversity of thought and alternative processes.

There are 3 levels of CQ: low, moderate, and high.12 Individuals with low CQ exhibit the following behaviors: react to extrinsic stimuli in unfamiliar cul- tural environments, use their own cultural contexts to draw conclusions, and may view cultural differences as insignificant.12 With moderate CQ, individuals accommodate cultural norms into thoughts and be- haviors, and have a desire to know more about cultural differences but may focus more on commonalities.12

High CQ catalyzes a broader purview of culture and diversity that builds innovative, productive teams.4

People with high CQ consistently demonstrate the following attributes:

� Flexibility in modifying thoughts and behaviors to- ward other cultural norms

� Application of cultural differences to facilitate innovations

� Subconscious interrelation within cross-cultural contexts

� Ability to identify diversity within cultures and treat each multicultural interaction as unique12

Successful attainment of CQ is enhanced when individuals have at least a moderate level of emotional intelligence (EI).13,14 Emotional intelligence measures individual awareness, control, and expression of emo- tions, as well as the ability to empathetically manage reactions to the others’emotions.13,14 The synergism of EI and CQ increases ability to gain confidence to engage in multicultural experiences, enhances mind- fulness, and consequently, improves ability to manage bias.4,13,14 This holds true for all individuals and could assist nurse leaders in role modeling CQ and creating culturally intelligent, cohesive, and innovative teams.4

IMPACT OF LOW CQ ON HEALTH EQUITY AND ORGANIZATIONAL OUTCOMES Ethnocentrism, a concept that refers to individuals whose judgments and decisions are informed by their own cultural context, is prevalent among those with low CQ.12 Bias, attitudes, and behaviors of health care providers negatively impact health outcomes for marginalized and stigmatized populations.15-18 The Institute of Medicine’s report Unequal Treatment: Con-

fronting Racial and Ethnic Disparities in Health Care19

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suggests that provider implicit bias toward racial and ethnic minority populations leads to lower quality health care as compared to white patients. This report prompted acknowledgment and examination of the role of implicit bias among health care providers in contributing to health inequity and poor health out- comes for marginalized populations.20 By acknowl- edging biases, leaders can limit judgments and stereotypes that are based on their individual cultural preferences.21 Therefore, it is incumbent upon nurse leaders to develop pragmatic strategies and best prac- tices such as CQ and implicit bias training that pro- mote organizational wellness, as well as those that translate to social justice and health equity.

In a systematic review of studies related to implicit bias in health care professionals, results showed that physicians and nurses displayed bias on the basis of race/ethnicity, weight, socioeconomic status, social circumstances, mental health conditions, gender, and various diagnoses.22 Evidence also suggests that im- plicit biases toward patients places them at a disad- vantage, as the standards of care are lower for these patients (for example, they receive less interaction time with health care professionals and fewer tests are or- dered), compounding the health disparities that already exist among marginalized and stigmatized pop- ulations.22 Additionally, evidence shows that academi- cians in health care professions and experienced health care providers may perpetuate stigmatization and promote bias through language used in verbal and written communications with students and novice clinicians.23

These findings amplify the need for urgency in implementation of initiatives that discourage bias- influenced health care and leadership practices. Reparation begins with acknowledging the existence of personal biases, followed by motivation to change, strategy development, and action. Cultural intelligence provides a framework for reparation, thereby increasing the likelihood of bias management, leading to equitable organizational and health outcomes. Evi- dence suggests that as the level CQ increases, biased decision-making decreases.24

Throughout my years as a health care professional, patients have entrusted sharing their experiences of bias-influenced health care with me. More times than not, those experiences were likely a result of provider biases. Evidence supports the notion that individuals are able to detect bias-influenced interactions with health care providers.16,17,25,26 As an African Amer- ican female, I have experienced the deleterious effects of bias in health care, not only directly as a patient, but also indirectly through the experiences of my family members. My passion for and commitment to patient advocacy and health equity is further fueled by bias- induced discrepancies that contribute to health disparities.

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Nurse leaders in health systems settings have a pivotal role in guiding health care professionals to deliver bias-free care that prioritizes optimal and equitable health outcomes for every patient. As it pertains to having a positive effect on improving pa- tient outcomes, nurse leaders should charge clinicians with application of CQ to practice, holding them accountable for delivering culturally responsible and relevant, patient-centered care.

CULTURAL INTELLIGENCE APPLICATION IN NURSE LEADERSHIP Organizations in which executive leaders demonstrate higher levels of CQ contributes to a reputation of dignity, respect, and social concern.4 Specific to CQ in health care settings and academic nursing education programs, reputation guides recruitment and retention of employees, patients, and students. The role of the nurse leader transcends multiple venues, including academia, clinical practice, and corporate and settings; therefore, CQ development and role modeling is essential. The first step in CQ application to leadership is awareness of what informs and influences the orga- nizational culture, coupled with knowledge and un- derstanding of individual cultural influences among team members.

Actualization of any change begins with self- awareness; therefore, the nurse leader must be introspec- tive to effectively inspire change among the individuals whom they lead. Examples of critical self-awareness for applying CQ include knowledge of personal cultural preferences that personally affect leadership, awareness and acknowledgement of whether personal biases are affecting leadership methods, and personal interest in gaining skills and confidence to function within multicul- tural contexts.4Cultural intelligence provides a framework for transcending awareness to strategic application of culturally evident and bias-free leadership practices among nurse leaders and clinicians.

An example of broad application of CQ in nurse leadership is to establish organizational cultural norms that support diversity beyond hiring individuals based on external traits such as race and ethnicity, gender/ gender identification, age, etc. Everyone wants to feel valued for their intellectual capacity and ability to perform well within their professional roles rather than being hired solely because of those traits. Nurse leaders who approach hiring using the CQ framework have the ability to ensure that the organizational culture is represented in such a way that people know that they are hired into a culturally intelligent institution that recognizes the value of multicultural teams beyond extrinsic features. Subsequent to hiring, nurse leaders should also ensure implementation of effective men- toring and evaluation processes that are based on objective performance measures that include CQ levels

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among themselves and members of the team. High levels of CQ can guide those leadership practices.

Application of CQ requires alignment with the 4 capabilities of CQ: motivation/drive to develop cross- cultural navigation skills, acquiring knowledge about multicultural norms, developing strategies for adapting to cultural differences, and accommodating cultural differences through actions.4 An example of CQ drive includes developing and implementing initiatives that suggest a strong commitment to DEIB. The nurse leader can demonstrate this by developing core values and a broad strategic plan that boldly and clearly communicates the organization’s commitment. The second CQ capability, acquiring knowledge, includes pursuing opportunities that allow the leader and members of the team to learn more about individual cultural values preferences, individual cultural norms, and about cultural norms and behaviors of others, particularly of those with whom the organization em- ploys and serves. The benefit of gaining cross-cultural knowledge is that it creates a mutual understanding that can serve to improve relationships and, therefore, increase organizational cohesion, increase innovations, and contribute to successful outcomes.4

Application of the third function of CQ, strate- gizing, includes developing a detailed strategic plan with realistic and dedicated timelines. The strategic plan should align with the organization’s core values, mission, vision, and cultural norms. In addition, the strategic plan should include accountability processes that are clearly communicated and strictly and consistently enforced. Nurse leaders can meet the fourth CQ capability, action, by scheduling CQ, di- versity, bias, microaggressions, and other applicable training, along with ongoing follow-up and coaching for themselves and the rest of the organization. In ac- ademic settings, nurse leaders have the professional responsibility to personally develop the skills necessary to effectively promote and implement initiatives that demonstrate and support DEIB in such a way that the faculty and student body are representative of a global and multicultural population. Cultural intelligence provides fundamental knowledge and strategies that the nurse leader can implement to achieve measurable outcomes that can be applied across settings.

CONCLUSION Awareness implores accountability and accountability implores responsibility. Creating an environment that demonstrates a commitment to DEIB can start with nurse leaders at every level acquiring CQ training and facilitating training for all other members within the organization, and ensuring ongoing follow up and coaching as needed. Combatting bias and the in- equities that are by-products of bias requires consistent attention to organizational norms, ongoing coaching, and resources. It is critical that leadership approaches

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are equitable and free from bias in all spaces, including clinical, academic, and policy development. Nurse leaders bear a responsibility for role modeling behav- iors that support and encourage CQ and the other related cultural concepts such as: awareness, sensitivity, humility, and competence. Cultural intelligence is a journey, congruent with the embodiment of the lifelong learning philosophies that are integral within health care professions. Nurse leaders should be consistent and deliberate in making sure that CQ and DEIB initiatives become the norm within their organizations. Maintaining a high level of CQ requires consistent re- evaluation of personal motivation, strategy develop- ment, and consistent actualization of cross-cultural best practices. It is incumbent upon nurse leaders to hold themselves and members of the organization account- able for sustaining CQ. Refusing to be a part of the solution is choosing to be a part of the problem.

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Angela Richard-Eaglin, DNP, MSN, FNP-BC, CNE, FAANP, is assistant professor at Duke University School of Nursing in Durham, North Carolina. She is a Certified Professional Cultural Intelligence I&II Facilitator and Coach. She can be reached at angela.richard-eaglin@ duke.edu.

1541-4612/2021/$ See front matter Copyright 2020 by Elsevier Inc.

All rights reserved. https://doi.org/10.1016/j.mnl.2020.07.009

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