A cross-sectional design was used for this study. The research was conducted in a private hospital situated in the Eastern region of Saudi Arabia. Registered nurses from various clinical units, including emergency, intensive care, medical-surgical, and outpatient departments, were invited to participate. These diverse clinical settings offered a suitable context for investigating DHL, cultural intelligence, and cultural competence within the framework of routine nursing practice. This study constitutes an in-depth analysis of an existing dataset previously used to test a structural model of culturally competent behavior. In the current analysis, a multiple regression approach was used to examine the individual predictive effects of DHL, cultural intelligence, and demographic variables on cultural competence behavior.

A convenience sampling method was used to recruit eligible registered nurses. The inclusion criteria specified that participants must be registered nurses engaged in direct patient care with a minimum of 6 months of clinical experience. Nurses occupying primarily administrative or managerial positions were excluded from the study due to their limited direct patient interaction. An a priori power analysis conducted using G*Power (Heinrich Heine University Düsseldorf) determined that a minimum sample size of 222 participants was necessary to identify a small-to-moderate effect size (f²=0.05) at a significance level of α=.05, with 80% statistical power in a multivariable regression model.

DHL was evaluated using the eHealth Literacy Scale, an 8-item instrument designed to measure individuals’ perceived capacity to locate, assess, and apply online health information. Each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) [21].

Cultural intelligence was measured using the 20-item Cultural Intelligence Scale, which encompasses metacognitive, cognitive, motivational, and behavioral domains. Responses were recorded on a 7-point Likert scale, with values ranging from 1 (strongly disagree) to 7 (strongly agree) [22].

Cultural competence was assessed through an 8-item behavioral scale derived from established instruments measuring cultural competence. The items targeted observable culturally responsive nursing behaviors and were rated on a 5-point scale, where 1 indicated “never” and 5 indicated “always” [23]. In the present study, all instruments exhibited excellent internal consistency reliability, with Cronbach α exceeding 0.95.

Demographic data included age, gender, marital status, education level (diploma vs Bachelor of Science [BSc] in Nursing), specialty, years of experience, and nationality. In Saudi Arabia, a nursing diploma is conferred upon completion of a 2‐ to 3-year program at a health institute, whereas a BSc in Nursing requires successful completion of a 4- to 5-year university degree.

The survey was administered using QuestionPro (QuestionPro Inc) in February 2026. Access was restricted to invited participants via a unique link. Nurses were invited through hospital nursing departments via email and WhatsApp. Of the 411 nurses who viewed the survey, 296 completed it (participation rate of 72.0%). IP address checking and cookies were enabled to prevent duplicate submissions. Incomplete questionnaires were excluded from analysis. Responses completed in less than 1 minute were excluded to ensure data quality.

Ethical approval was secured from the Institutional Review Board of the participating hospital, Dr Sulaiman Al Habib Medical Group (RC26.02.08). Participation in the study was voluntary, and informed consent was obtained prior to the commencement of data collection. No identifiable information was gathered and all responses were treated with confidentiality. Data were stored securely and were accessible solely to the research team. The study complied with the ethical principles delineated in the Declaration of Helsinki.

Data were analyzed using SPSS (version 22; IBM Corp). Descriptive statistics were computed for demographic variables and study constructs. Categorical variables were summarized using frequencies and percentages, while continuous variables were reported as means and SDs.

Levels of cultural competence, cultural intelligence, and DHL were categorized using percentile-based cutoffs for descriptive purposes. Categories were established as low, moderate, and high through visual binning based on percentile distribution in SPSS. This methodology facilitated the empirical derivation of cutoffs, reflecting the natural distribution of scores within the sample and enabling meaningful interpretation and comparative analysis across constructs.

Independent samples t tests were used to explore differences in competence across various demographic groups. Pearson correlation analysis was performed to investigate relationships among the primary study variables. Hierarchical multiple linear regression was conducted to identify predictors of cultural competence. Demographic variables were entered in the first block, cultural intelligence in the second block, and DHL in the final block. Statistical significance was established at P<.05.

Prior to regression analysis, all assumptions were rigorously tested. Normality of residuals was assessed using the Shapiro-Wilk test and visual inspection of P-P plots. Linearity was confirmed through scatterplots of standardized residuals against predicted values. Homoscedasticity was assessed via visual inspection of residual plots, and independence of errors was confirmed using the Durbin-Watson statistic, which fell within an acceptable range. All assumptions were met. Multicollinearity was assessed using tolerance values. All tolerance values exceeded 0.10 (ranging from 0.511 to 0.944), indicating no serious multicollinearity among predictors.

This study examined predictors of cultural competence among nurses, focusing on DHL and cultural intelligence, and explored associations with demographic factors and competence levels. Cultural intelligence was identified at a moderate level. In contrast, over half of the participants demonstrated low DHL. Most nurses (n=195; 65.9%) displayed moderate cultural competence. Education was the only demographic factor significantly associated with cultural competence, with BSc holders scoring higher than diploma holders. Cultural intelligence and DHL were positively correlated with competence, and hierarchical regression revealed that both significantly predicted cultural competence, explaining a substantial portion of its variance.

The results showed that nurses’ cultural intelligence was moderate. This finding is consistent with previous studies reporting moderate levels of cultural intelligence among nursing students and health care professionals [9,10]. Higher levels have been observed among nurse educators, suggesting that professional experience and continuous professional development may enhance cultural intelligence [16]. The moderate levels observed in this study are likely due to a lack of formal education in cultural intelligence and limited opportunities for structured intercultural learning. In Saudi Arabia, nurses are often exposed to culturally diverse patients, which can lay the foundation for intercultural interactions; however, this exposure alone may not be sufficient to develop advanced cultural intelligence without targeted educational programs [1].

More than half of the participants had low DHL, suggesting difficulties accessing, appraising, and applying digital health information. This finding is consistent with previous studies reporting inadequate DHL among nursing students and nurses [7,8]. Other studies have also highlighted considerable variability in DHL and emphasized the need for systematic educational interventions [13]. Conversely, higher levels of DHL have been reported among nurses with higher educational qualifications and professional positions, indicating that educational and workplace factors can positively influence digital competency [14]. Low DHL levels in the current study may be explained by a lack of training in using digital platforms, limited institutional support, and factors such as low confidence, restricted access, and the rapid pace of technological change [15].

Most nurses had moderate levels of cultural competence, consistent with previous studies among practicing nurses and nursing students in Saudi Arabia [1,5]. Moderate levels of cultural competence have commonly been reported in settings with limited formal transcultural nursing education, whereas greater professional experience has been associated with higher levels of competence [6,16]. The findings of this study may be due to a combination of theoretical knowledge gained through education and practical experience with different patients. However, the absence of continuous, structured programs for cultural competence may limit further development toward higher levels of competence [11,12].

Among the demographic variables, education was the only factor that significantly predicted cultural competence, with BSc holders outperforming diploma holders. This finding supports previous evidence suggesting that higher educational attainment is associated with stronger professional and cultural competencies [6,14]. However, previous research has also indicated that clinical experience and continuing professional education may enhance cultural competence regardless of initial educational preparation [1]. The current study’s results are likely a reflection of the fact that BSc courses involve more transcultural topics, evidence-based practice, intercultural communication, and digital literacy, which, when combined, improve cultural competence [7,9].

Both cultural intelligence and DHL were positively correlated with cultural competence, suggesting that nurses with high adaptability to diverse cultural settings and strong digital literacy skills exhibit greater cultural competence. This finding is consistent with previous research demonstrating that cognitive-cultural capabilities and digital competencies jointly contribute to culturally responsive nursing practice [9,10,13]. Conceptually, cultural intelligence and DHL represent complementary competencies. Cultural intelligence enables nurses to understand, interpret, and adapt to patients’ cultural beliefs, values, and communication styles, whereas DHL equips nurses to locate, evaluate, and apply culturally appropriate health information and digital resources. Together, these competencies facilitate informed clinical decision-making, individualized patient care, and effective communication across diverse cultural contexts. Although technological competence is important, previous studies suggest that digital skills alone are insufficient to ensure culturally competent practice without the motivation and ability to adapt to patients’ cultural needs [15]. The results therefore indicate that nurses with high cultural intelligence can decode patients’ cultural messages and respond appropriately, while those with high DHL can effectively use digital resources to support culturally competent care [7,8].

Hierarchical regression analysis also showed that cultural intelligence and DHL were significant predictors of cultural competence, accounting for a large proportion of the variance in scores. This finding reinforces previous evidence that cognitive-cultural capabilities and digital competencies are both important determinants of culturally competent nursing practice [9,16]. More importantly, the results support the multidimensional nature of cultural competence, demonstrating that effective culturally competent care depends on both interpersonal adaptability and technology-related competencies. Cultural intelligence facilitates adaptive cross-cultural interactions, whereas DHL enables nurses to integrate evidence-based digital resources into culturally responsive care. Their combined contribution suggests that neither competency alone is sufficient; rather, culturally competent nursing practice emerges from integrating both human-centered and digital capabilities. Nurses with adaptive cultural intelligence and DHL are therefore more likely to implement evidence-based, culturally responsive interventions that improve the quality of patient care [12]. Although these individual competencies explained a substantial proportion of cultural competence, organizational factors such as leadership support, access to culturally appropriate digital resources, and continuing professional development may further strengthen culturally competent practice. Future research should examine these organizational influences using longitudinal and theory-driven study designs [1].

Based on the results of this study, the following recommendations can be made. Nursing education programs should integrate cultural intelligence and DHL into undergraduate curricula and continuing professional development to strengthen nurses’ ability to deliver culturally competent care. Simulation-based intercultural communication training and workshops focusing on culturally sensitive digital health services should also be incorporated to enhance both cultural adaptability and effective use of digital health technologies. Additionally, health care organizations should establish institutional policies that promote equitable access to culturally appropriate digital resources, provide ongoing technical and educational support, and foster culturally inclusive work environments through leadership initiatives. Efforts should also be directed toward improving digital accessibility by addressing barriers such as limited technological confidence, inadequate access to digital resources, and unavailability of linguistically and culturally appropriate digital health information for diverse patient populations.

As AI and digital health technologies become increasingly integrated into health care, future educational and organizational initiatives should explore their role in supporting culturally competent nursing practice, including clinical decision support, culturally tailored patient education, and communication across multicultural health care settings. Strengthening these competencies has the potential to improve health care quality, patient safety, and patient satisfaction. For future studies, longitudinal and mixed-methods research is recommended to provide a more comprehensive understanding of the development of cultural competence over time. Future studies should also investigate additional individual and organizational factors, such as leadership support, organizational culture, digital infrastructure, and access to professional development, which may influence cultural intelligence, DHL, and cultural competence among nurses in Saudi Arabia.

Although this study identified significant predictors of cultural competence among nurses, it has some limitations. Data were collected from a single private setting, limiting generalizability, and the cross-sectional design prevents causal inferences. Additionally, reliance on self-reported questionnaires may introduce response bias. Future studies should use larger, more diverse samples, longitudinal designs, and objective measures to strengthen the findings.

This study identified DHL and cultural intelligence as key predictors of nurses’ cultural competence. While cultural intelligence was moderate, over half of the participants had low DHL, and most showed moderate competence. Education was the only significant demographic factor, with BSc holders scoring higher. Both cultural intelligence and DHL significantly predicted competence, highlighting the need for health care institutions to provide supportive environments with culturally appropriate resources and technology to enhance culturally competent care.