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Abstract

Introduction

Patient safety issues have become a priority in health policy and health systems governance. This priority has drawn attention to health professionals’ licensing and effectiveness of the nursing curriculum in preparing students with the appropriate patient safety competencies. Despite their crucial role, there is a notable gap in the literature regarding the comprehension and competency of nursing students in patient safety within Iran.

Objective

This multicenter cross-sectional correlational study aimed to investigate the relationship between cultural competence, patient safety culture, and safe nursing care (SNC) among nursing students in southern Iran.

Methods

A total of 238 nursing students enrolled in clinical internship courses between November 2024 and February 2025 at three medical universities in Fars Province, Iran, were recruited using a census sampling approach. Data were collected through four instruments: (a) a demographic questionnaire; (b) the Hospital Survey on Patient Safety Culture, which measures perceptions of safety culture; (c) the Inventory for Assessing the Process of Cultural Competence, which evaluates cultural competence across five domains; and (d) the SNC tool, which assesses nursing performance in clinical skills, teamwork, and patient safety.

Results

The students reported moderate to high levels of cultural competence (75.73 ± 17.2), moderate perceptions of patient safety culture (116.02 ± 21.25), and moderate to good performance in SNC (245.29 ± 59.16). Correlational analysis revealed statistically significant and positive associations among the three constructs, with patient safety culture strongly correlated with SNC (r = 0.68, p < .001) and moderately correlated with cultural competence (r = 0.50, p < .001). In the SNC model (Adjusted R² = 0.46), academic year remained the strongest predictor (B = 44.536, 95% CI [33.201, 55.870], p < .001), highlighting the critical role of academic progression in enhancing safe care performance.

Conclusion

These findings underscore the need to integrate structured cultural competence and patient safety education into nursing curricula while expanding clinical learning opportunities in diverse healthcare environments. Furthermore, experiential training in multicultural settings may foster a deeper understanding of cultural and safety principles, thereby improving the quality of care at both individual and organizational levels.

Keywords

cultural competence patient safety safe nursing care nursing students

Introduction

In clinical settings, patients have the right to receive culturally congruent care, which in turn requires nurses to possess the cultural competence needed to deliver care that reflects each patient's cultural background (Khachian et al., 2020; Kianian et al., 2024). This requirement is particularly salient in multicultural clinical environments, where cultural diversity among patients may increase the risk of miscommunication, erode trust, and adversely affect health outcomes if cultural needs are not adequately addressed (Jeffreys, 2015; Mohammadi et al., 2020)

Cultural competence refers to the ability to recognize and respond appropriately to the values, attitudes, beliefs, and customs of patients from diverse cultural and ethnic backgrounds (Antón-Solanas et al., 2021; Lee et al., 2020). Recent studies show that cultural competence contributes to more effective provider–patient communication, stronger trust, improved patient satisfaction, and better adherence to treatment, thereby leading to enhanced health outcomes (Mary & Fatuma, 2024). Cultural competence is widely understood as a continuous, measurable process that enables effective communication with patients regardless of their cultural background (Mahmoodi et al., 2017; Riley et al., 2012). This process can be monitored using structured assessment tools and self-evaluation methods (Campinha-Bacote & Sayings, 2010; Tran, 2024). Evidence further indicates that hospitals with higher cultural competence exhibit a stronger safety culture, which is associated with improved patient safety outcomes (Upadhyay et al., 2022).

The cultural competence movement, initiated approximately two decades ago, has been advanced as a strategy to bridge cultural divides between patients and care providers; it aligns efforts to improve care quality, enhance health outcomes, and reduce ethnic disparities within healthcare systems (Majda et al., 2021; Okoro et al., 2012). This movement has also influenced nursing education and clinical practice by embedding cultural competence training into curricula and promoting culturally responsive approaches to care in clinical settings (Kaihlanen et al., 2019). Recent international research indicates not only that cultural competence reduces ethnic disparities but also that it directly contributes to patient safety and the delivery of safe nursing care (SNC) (Brach et al., 2019; Upadhyay et al., 2022). Conversely, when nurses lack cultural competence, miscommunication and misunderstanding can lead to errors in diagnosis and medication administration, which can have detrimental effects on overall safety outcomes (Osmancevic et al., 2023).

This study is theoretically grounded in Campinha-Bacote's model of cultural competence (2002), which conceptualizes cultural competence as a dynamic and continuous process comprising five interrelated constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. According to this model, effective and SNC emerges when healthcare professionals actively engage in ongoing self-assessment, systematic knowledge acquisition, and meaningful cross-cultural interactions that enhance both communication and clinical decision-making (Campinha-Bacote, 2002). Within this theoretical framework, cultural competence functions as a critical antecedent to the development of a positive patient safety culture, as nurses who acknowledge and respect cultural diversity are more inclined to foster open communication, reduce misunderstandings, and mitigate safety risks. Accordingly, this study investigates the interrelationship among cultural competence, patient safety culture, and SNC through the lens of this model, seeking to offer an empirically grounded understanding of the ways in which cultural processes shape safety outcomes.

Cultural competence and patient safety culture should therefore be regarded as conceptually interlinked dimensions of safe nursing practice rather than discrete domains. The capacity to provide care that aligns with patients’ cultural expectations is fundamental to nurses’ communication skills, firmly embedded in educational programs and clinical practice, and closely tied to the knowledge, skills, and preparedness required for effective care delivery (Antón-Solanas et al., 2021; Kaihlanen et al., 2019). Such culturally competent care is closely associated with a robust patient safety culture, because nurses who recognize and respond to cultural needs help create safer clinical environments and reduce the risk of adverse events (Seo & Lee, 2024). Nurses are therefore expected not only to provide holistic care and cultivate therapeutic relationships with patients but also to remain attentive to their cultural needs. Failure to meet those needs may result in miscommunication, diminished patient satisfaction, and poorer health outcomes (Kianian et al., 2024). Corroborating this perspective, evidence from Saudi Arabia shows that nursing students with higher levels of cultural competence also demonstrate stronger safety-related attitudes, suggesting that these competencies begin to shape patient safety culture early in training (Cruz et al., 2017).

Review of Literature

What is central to meeting patients’ diverse needs is cultural competence, which enables nurses to deliver care that advances health outcomes (Chae et al., 2020; Tosun et al., 2021). Internationally, the literature demonstrates that cultural competence training improves interpersonal communication and patient safety outcomes; however, studies frequently treat these domains in isolation, leaving their integrated relationship insufficiently explored (Juntunen et al., 2024; Osmancevic et al., 2023). Not only does cultural competence enhance provider–patient communication and strengthen trust, but it also improves patient satisfaction and adherence to treatment, thereby contributing to superior clinical outcomes. Equally critical to promoting patient health is the prevention of harm and the assurance of safety during care delivery. In contemporary healthcare systems, patient safety has emerged as a principal concern in efforts to improve the quality of care (Alshammari et al., 2019; Asadi et al., 2020). At the heart of patient safety lies safety culture, which encapsulates the shared norms, attitudes, and perceptions of healthcare staff regarding safety and is manifest in their behaviors. Safety culture signals the extent to which safety is prioritized and valued by healthcare teams (Tavares et al., 2018; Vierendeels et al., 2018), and it is shaped by numerous visible and latent factors at both individual and organizational levels.

In clinical contexts, the growing complexity of patient conditions and treatment processes elevates the risk of medical error and adverse events; such occurrences adversely affect patients, undermine staff well-being, and can diminish perceived professional competence among nursing students (Patel & Wu, 2016). Baseline assessments in Iran, as in many middle-income countries, indicate that patient safety culture remains underdeveloped in several hospital settings (Hafezi et al., 2022; Mohammadpour et al., 2024). These findings underscore the imperative to understand how students—future nurses—develop safety attitudes in tandem with cultural competencies, since these formative attitudes may influence the safety of care delivered in coming decades.

When safety protocols are not followed or care is delivered unsafely, the consequences for patients and families can be profound, producing psychological distress and financial hardship and imposing broader burdens on the healthcare system. As scientific and technological advances continue to reshape clinical practice, the imperative to create and maintain safe care environments has become a global priority. Empirical studies have reported that many dimensions of patient safety culture remain insufficiently developed within hospitals (Motazedi et al., 2019), and therefore, the establishment of robust systems to safeguard health, optimize safety, and prevent environmental and clinical risks is essential. In recent years, the promotion of a strong patient safety culture has, accordingly, become a key indicator of service quality in healthcare institutions. Cultural competence directly supports SNC by reducing communication errors, strengthening trust, and improving shared decision-making between patients and providers (Teixeira et al., 2024). Given this interdependence, cultural competence, patient safety culture, and SNC should be understood as mutually reinforcing elements that together determine the quality and safety of nursing outcomes. Addressing these challenges requires not only identifying root causes but also implementing practical, evidence-based solutions. Given Iran's longstanding cultural, ethnic, linguistic, and religious diversity, it is essential to examine the factors that shape cultural competence among healthcare providers, particularly nurses, so that they can meet the needs of an increasingly heterogeneous population. Despite its importance, this topic has received limited scholarly attention within the Iranian context.

Concurrently, the rising prevalence of medical errors and adverse events underscores the imperative of ensuring SNC. Safe nursing care, which constitutes the foundation of patient safety and healthcare quality, seeks to reduce preventable harm, limit medical errors, and enhance patient satisfaction. This objective is especially pertinent in settings where patient populations are culturally, linguistically, and religiously diverse, since it is nurses’ cultural competence that becomes central to the delivery of effective and safe care. A deep understanding of patients’ beliefs, values, and cultural needs facilitates clear communication, reduces misunderstandings, and supports culturally appropriate clinical decision-making. Conversely, the absence of cultural competence may precipitate diagnostic and treatment errors that compromise patient safety. Integrating culturally competent practice with established safety procedures not only elevates the quality of nursing services but also fosters an environment that is respectful, inclusive, and responsive to patients’ diverse needs (Teixeira et al., 2024). Accordingly, this multicenter cross-sectional correlational study aimed to investigate the relationship between cultural competence, patient safety culture, and SNC among nursing students in southern Iran.

Methods

Design

This multicenter cross-sectional study was conducted among 238 nursing students enrolled in clinical internship courses from November 2024 to February 2025 at three medical universities in Fars Province, southern Iran, based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, which is a checklist for observational research (Von et al., 2007) (Supplementary file: STROBE checklist). The selected universities were chosen because they serve demographically diverse student populations and provide comprehensive clinical training programs; consequently, the study setting reflects the varied educational and clinical realities of the region and offers reliable insight into cultural competence and patient safety.

Inclusion/Exclusion Criteria

The inclusion criteria were being a bachelor's-degree nursing student and willingness to participate in the study. The exclusion criterion was unwillingness to continue participating in the study. For sampling, the first author attended the school of nursing affiliated with a university of medical sciences in the Fars Province, southern Iran, and asked the nursing students who met the inclusion criteria to complete the questionnaires.

Participants and Sampling

Participants were invited using a census (complete enumeration) sampling method; that is, all eligible nursing students undertaking clinical internships during the study period were approached and invited to participate. In a census, data are collected from all members of the target population rather than from a subset; put differently, instead of selecting a sample, all individuals or units of interest are examined (Carrillo et al., 2022).

Having employed census sampling to include all eligible nursing students across the three participating universities, the study nonetheless warrants cautious interpretation with respect to external validity. What limits generalizability is that the sample was confined to a single province in southern Iran; consequently, the findings may not be representative of nursing students in other regions or educational contexts. To strengthen external validity, future multicenter investigations should be undertaken, involving broader geographic coverage, varied institutional types, and diverse educational settings. Such studies would help ascertain whether the observed relationships hold across different populations and contexts (Heidari et al., 2025; Majnoon et al., 2023).

After receiving approval for the research protocol from the university's Research Ethics Committee, the study objectives were explained to all potential participants, and written informed consent was obtained from each student prior to data collection. Because questionnaires were administered only once, there were no dropouts or refusals during data collection.

Data Collection

Demographic survey. Demographic information collected included age, gender, marital status, and academic semester. In addition, data were gathered on participants’ work experience in their current unit, total clinical experience, and average weekly working hours.

Safe Nursing Care Questionnaire. The SNC Questionnaire, developed and psychometrically validated in Iran by Rashvand et al. (2017), was employed to assess safe nursing practice. Having been culturally adapted for use with Iranian nursing students, the instrument underwent expert-panel review, which confirmed content validity index (CVI = 0.92). Construct validity was further supported by exploratory factor analysis, which corroborated the questionnaire's four-domain structure; internal consistency was excellent in previous research (Cronbach's α = 0.97) and remained high in the present study (Cronbach's α = 0.95). This level of internal consistency supports the instrument's capacity to yield stable and reproducible measurements across respondents (Azizi et al., 2024).

The tool comprises 32 items organized into four domains: nursing skills (16 items), patients’ psychological safety (4 items), physical safety (7 items), and teamwork in nursing care (5 items). Responses are recorded on a 5-point Likert scale: Never (1), Rarely (2), Sometimes (3), Often (4), and Always (5). Each item is weighted in the scoring process. Total scores are interpreted as follows: 73–170, poor performance; 171–267, moderate performance; and 268–365, good performance. In this study, the Cronbach's α value was 0.88, which is considered a high level of reliability for the scale.

Hospital Survey on Patient Safety Culture

To evaluate patient safety culture, the Hospital Survey on Patient Safety Culture (HSOPSC), developed in 2004 by the Agency for Healthcare Research and Quality (AHRQ), was employed (El-Jardali et al., 2010). This validated instrument was developed using multiple data sources, cognitive testing, and factor analysis; it is designed to capture hospital staff perceptions of patient safety culture. The questionnaire is particularly appropriate for respondents with clinical experience and, in the present study, was administered to nursing students who had completed at least two semesters of clinical training.

The HSOPSC comprises two principal sections. The first elicits personal and professional information, including educational qualifications, current workplace, years of hospital experience and years in the current unit, weekly working hours, and job position. The second section contains 45 items distributed across multiple safety dimensions, including overall perceptions of patient safety (4 items), teamwork within units (4 items), staffing (4 items), nonpunitive response to error (3 items), supervisor/manager expectations and actions to promote safety (4 items), hospital management support for patient safety (3 items), teamwork across units (4 items), handoffs and transitions (4 items), communication openness (4 items), feedback and communication about error (3 items), frequency of event reporting (3 items), and patient involvement and rights (3 items).

The survey is self-administered, employing a 5-point Likert scale: Strongly Agree (5), Agree (4), Neutral (3), Disagree (2), and Strongly Disagree (1). According to the instrument's scoring guidelines, domain scores of 169 and above (≥75%) are classified as strong; scores between 113 and 168 (50–74%) denote acceptable performance; and scores of 112 or below (<50%) identify areas requiring improvement. The Persian version of the HSOPSC has been validated in Iran, including by Arab (2013), and has been translated and reviewed by experts at the Ministry of Health and Medical Education. In an Iranian study, Faryabi et al. (2015) reported a Cronbach's alpha of 0.83, confirming acceptable internal consistency for the Persian instrument. The Persian version of the HSOPSC has demonstrated robust validity across several Iranian and international investigations. What previous studies have shown is that content and construct validity were confirmed by Arab (2013) and Faryabi et al. (2015) through expert-panel review and confirmatory factor analysis, which in turn verified a multidimensional factor structure consistent with the original AHRQ model. In the present study, Cronbach's α was 0.87, indicating a high level of internal consistency for the scale.

Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals, Revised

The Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals, Revised (IAPCC-R), developed by Campinha-Bacote (2002), was also used to assess participants’ cultural competence (Ho & Lee, 2007). It was Campinha-Bacote (2002) who established the instrument's construct validity through confirmatory factor analysis, which confirmed its alignment with the five conceptual domains of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.

The instrument comprises 25 items rated on a 4-point Likert scale and operationalizes five core constructs: Cultural Desire, defined as the voluntary motivation to engage in cross-cultural encounters; Cultural Awareness, denoting recognition of one's own biases and cultural sensitivity; Cultural Knowledge, referring to the acquisition of cultural information through formal and informal education; Cultural Skill, indicating the ability to obtain culturally relevant clinical data in a respectful and sensitive manner; and Cultural Encounters, which capture direct interactions with individuals from diverse backgrounds to advance cultural understanding.

Each construct consists of five items, yielding a total score range of 25–100. Score interpretations are as follows: 25–50, cultural incompetence; 51–74, cultural awareness; 75–90, cultural competence; and 91–100, cultural proficiency. The Persian version of the IAPCC-R has been culturally adapted and psychometrically evaluated for use in Iran; Khanbabayi et al. (2017) reported a Cronbach's alpha of 0.91, indicating excellent internal consistency. Given its robust psychometric properties and its cultural adaptation for Iranian populations, the IAPCC-R was judged appropriate for assessing the cultural competence of nursing students in the present study. Khanbabayi et al. (2017) established the content and construct validity of the Persian version of the instrument through expert review and factor-analytic procedures, reporting a CVI (0.90) and strong item-factor loadings (>0.60). In the present study, Cronbach's α was 0.92, indicating a high level of internal consistency and demonstrating the scale's reliability for assessing cultural competence.

Statistical Analysis

Data were analyzed using SPSS version 23.0. The normality of continuous variables was assessed with the Kolmogorov–Smirnov test, confirming that the data were normally distributed. Parametric statistical methods, including independent-samples t-tests, one-way ANOVA, Pearson correlation, and multiple linear regression, were applied to examine relationships among variables. Categorical variables were analyzed using the Chi-square test. A p-value of less than .05 was considered indicative of statistical significance.

Ethical Considerations

This study was conducted in accordance with the revised Declaration of Helsinki, which provides ethical guidelines for research involving human participants. Written informed consent was obtained from each participant after a thorough explanation of the study's objectives, procedures, and potential implications. All data were collected anonymously, with no personally identifiable information recorded. Participants were explicitly informed of their right to withdraw from the study at any stage without penalty, and this assurance was clearly stated in the questionnaire documentation. Confidentiality was rigorously maintained throughout the study. The research protocol received formal approval from the Institutional Research Ethics Committee of University of Medical Sciences (ethical code: IR.FUMS.REC.1403.062).

Results

As presented in Table 1, a total of 238 nursing students participated in the study, of whom 101 (42.4%) were male. The majority of participants (62.6%) were enrolled in their fourth academic year. The mean age of the students was 22.47 years (SD = 1.98), with a calculated variance of 2.86.

Table 1.

The Demographic Characteristics of Participants (N = 238).

		Frequency	Percent
Gender	Male	101	42.4
Gender	Female	137	57.6
Academic year	2	10	4.2
	3	79	33.2
	4	149	62.6
		Mean	SD
Age (year)		21.79	1.69

According to the data presented in Tables 2 and 3, the mean score for patient safety culture was 116.02 (SD = 21.25), reflecting a moderate to favorable level of awareness among participants regarding fundamental principles of safety culture. A substantial majority of students, exceeding 70%, rated patient safety culture as acceptable, approximately 28% identified areas requiring improvement, and only a small proportion (1.7%) perceived it as exceptionally strong. In the domain of SNC, the mean score was 245.29 (SD = 59.16). More than 38% of respondents evaluated their performance as good, half reported it as average, and fewer than 12% assessed it as poor. These findings indicate considerable potential for improving the quality of nursing care, underscoring the necessity of sustained efforts toward continuous enhancement.

Table 2.

The Scores of Patient Safety Culture, Safe Nursing Care, and Cultural Competence.

Variable	Minimum	Maximum	Mean	SD
Patient safety culture	57	162	116.02	21.25
Safe nursing care	73	365	245.29	59.16
Cultural competence	25	100	75.73	17.2

Table 3.

Percentage Distribution of Different Levels Within Patient Safety Culture, Safe Nursing Care, and Cultural Competence.

Variable		Frequency	Percent
Patient safety culture	Needs improvement	67	28.2
	Acceptable	167	70.2
	Strong	4	1.7
Safe nursing care	Poor performance	28	11.8
	Average performance	119	50.0
	Good performance	91	38.2
Cultural competence	Cultural incompetence	28	11.8
	Cultural awareness	77	32.4
	Cultural qualification	83	34.9
	Cultural proficiency	50	21.0

With respect to cultural competence, the mean score was 75.73 (SD = 17.2), indicating a moderate to high level of competence among respondents. Approximately 56% of students fell into the higher proficiency categories, comprising cultural competence (34.9%) and cultural proficiency (21%), whereas 44% were placed in the lower tiers, including cultural awareness (32.4%) and cultural incompetence (11.8%). These results emphasize the urgent need for the development and implementation of targeted educational strategies designed to systematically enhance cultural competence across all proficiency levels.

As reported in Tables 4 and 5, statistically significant relationships were observed among the principal variables. No significant gender-based differences were identified in patient safety culture (p = .514, Cohen's d = 0.086) or cultural competence (p = .296, Cohen's d = 0.260), with both effect sizes indicating negligible to small practical differences. However, a significant gender difference emerged in SNC scores (p = .049), favoring female students; the effect size was small (Cohen's d = 0.137), suggesting limited practical impact despite statistical significance. Academic year demonstrated a strong and statistically significant association with all three variables (p < .001), with substantial effect sizes (η² = 0.343 for patient safety culture, η² = 0.263 for SNC, and η² = 0.362 for cultural competence), indicating that academic progression accounts for a large proportion of variance in these outcomes. Notably, fourth-year students consistently achieved the highest mean scores across patient safety culture, SNC, and cultural competence, reflecting progressive enhancement in safety awareness, clinical performance, and cultural adaptability as students advance academically.

Table 4.

The Relationship Between Patient Safety Culture, Safe Nursing Care, and Cultural Competence with Demographic Variables.

Variables		Patient Safety Culture	Safe Nursing Care	Cultural Competence
Gender	Male	114.98 ± 21.91	240.62 ± 60.88	73.17 ± 17.10
	Female	116.80 ± 20.80	248.74 ± 57.84	77.61 ± 17.09
	p-value	0.514	0.049	0.296
	Cohen's d	.086	.137	.260
Academic year	Year2	87.30 ± 16.32	145.50 ± 48.15	49.00 ± 15.57
	Year3	102.05 ± 17.64	209.35 ± 42.12	67.38 ± 12.91
	Year4	125.37.± 17.18	271.05 ± 49.98	81.95 ± 15.70
	p-value	<0.001	<0.001	<0.001
	η²	.343	.263	.362

Table 5.

The Correlations Between Patient Safety Culture, Safe Nursing Care, and Cultural Competence.

Variable		Patient Safety Culture	Safe Nursing Care	Cultural Competence
Patient safety culture	p	1	–	–
	p-value	–	–	–
	CI	–	–	–
Safe nursing care	p	.68	1	–
	p-value	<.001	–	–
	CI	(0.58,0.76)	–	–
Cultural competence	p	.50	.57	1
	p-value	<.001	<.001	–
	CI	(0.40,0.59)	(0.46,0.68)	–

P = Pearson Correlation; CI = confidence Interval.

Correlational analysis (Table 5) revealed statistically significant and positive associations among all three core constructs. Patient safety culture was strongly correlated with SNC (r = 0.68, p < .001, 95% CI [0.58, 0.76]) and moderately correlated with cultural competence (r = 0.50, p < .001, 95% CI [0.40, 0.59]). Although the correlation between cultural competence and patient safety culture was statistically significant (r = 0.50, p < .001), the strength of this association was moderate, suggesting that these constructs, while interrelated, are also shaped by distinct contextual and individual determinants. Potential confounding variables, including academic year, type of clinical exposure, prior safety training, and differences in workload, may have contributed to the observed relationship. Likewise, SNC demonstrated a moderate and significant correlation with cultural competence (r = 0.57, p < .001, 95% CI [0.46, 0.68]). These findings underscore the intrinsically interconnected nature of safety awareness, care quality, and cultural competence in clinical practice. The strength of these associations suggests that improvements in one domain, particularly through well-structured educational interventions, may exert a positive and reinforcing effect on the others, thereby fostering a more comprehensive enhancement of nursing competencies.

Multivariate Linear Regression Analysis

As shown in Tables 6 and 7, multivariate linear regression analyses were conducted to identify significant predictors of patient safety culture and SNC. The adjusted R² values of 0.39 and 0.46, respectively, indicate that the predictor variables collectively accounted for a moderate proportion of the variance in these outcomes. Prior to interpreting the regression results, key assumptions were rigorously evaluated. Homogeneity of variance (homoscedasticity) was assessed using the Breusch–Pagan test, yielding nonsignificant results for both outcomes (p = .78 for SNC; p = .57 for patient safety culture), thereby confirming that the variance of residuals remained constant across levels of the predictors. Normality of residuals was also examined and confirmed, supporting the assumption that residuals were approximately normally distributed and ensuring the validity of parameter estimates and associated inferences.

Table 6.

Factors Predicting Patient Safety Culture (Adjusted R² = 0.39).

	Unstandardized coefficients		t	Sig.	95.0% Confidence Interval for B		Collinearity Statistics
Variable	B	SE of B	t	Sig.	Lower bound	Upper bound	Tolerance	VIF
Age (year)	−.619	.641	−.966	.335	−1.883	.644	.984	1.017
Gender	1.074	2.195	.489	.625	−3.250	5.399	.982	1.018
Cultural competence	.347	.074	4.710	.000	.202	.493	.722	1.384
Academic year	16.441	2.202	7.467	.000	12.103	20.779	.729	1.371

B = Regression coefficient; SE of B = standard error of B.

Table 7.

Factors Predicting Safe Nursing Care (Adjusted R Square = 0.46).

	B	SE of B	t	Sig.	Lower bound	Upper bound	Tolerance	VIF
	Unstandardized Coefficients		t	Sig.	95.0% Confidence Interval for B		Collinearity Statistics
Age (year)	−3.988	1.676	−2.380	.018	−7.289	−.686	.984	1.017
Gender	.679	5.735	.118	.906	−10.620	11.978	.982	1.018
Cultural competence	1.203	.193	6.244	.000	.823	1.582	.722	1.384
Academic year	44.536	5.753	7.741	.000	33.201	55.870	.729	1.371

B = Regression coefficient; SE of B = standard error of B.

Multicollinearity diagnostics indicated that all independent variables exhibited acceptable tolerance values (>0.70) and variance inflation factor (VIF) values well below the critical threshold (<10), with VIFs ranging from 1.017 to 1.384 and tolerance values ranging from 0.72 to 0.98. These findings confirm the absence of multicollinearity among predictors, ensuring the stability and interpretability of the regression coefficients.

In the patient safety culture model (adjusted R² = 0.39), academic year emerged as the most influential predictor (B = 16.44, 95% CI [12.103, 20.77], p < .001), indicating that students in higher academic years reported significantly greater perceptions of patient safety culture. Cultural competence also demonstrated a significant positive effect (B = 0.347, 95% CI [0.202, 0.493], p < .001), suggesting that higher levels of intercultural capability are associated with stronger safety-related attitudes and practices. Conversely, age (B = −0.619, 95% CI [−1.883, 0.644], p = .335) and gender (B = 1.074, 95% CI [−3.250, 5.399], p = .625) did not significantly predict patient safety culture.

In the SNC model (Adjusted R² = 0.46), academic year remained the strongest predictor (B = 44.536, 95% CI [33.201,55.870], p < .001), highlighting the critical role of academic progression in enhancing safe care performance. Cultural competence retained a significant positive association (B = 1.203, 95% CI [0.823, 1.582], p < .001), reinforcing its influence on safe nursing practice behaviors. Interestingly, age was inversely associated with safe care scores (B = −3.988, 95% CI [−7.289, −0.686], p = .018), indicating that older students reported lower performance levels. Gender, however, did not significantly predict SNC (B = 0.679, 95% CI [−10.620, 11.978], p = .906).

Taken together, these findings emphasize that academic progression and cultural competence are consistent and robust predictors of both patient safety culture and SNC. The positive influence of cultural competence across both models underscores the necessity of embedding structured educational and clinical interventions aimed at fostering intercultural sensitivity and competence within nursing curricula. Moreover, the inverse relationship between age and safe care performance warrants further investigation into factors such as workload management, adaptability, and fatigue among older students.

Discussion

The present study aimed to examine the associations among cultural competence, patient safety culture, and SNC within a sample of nursing students. Our findings revealed a statistically significant positive relationship between cultural competence and patient safety culture, indicating that students who demonstrated higher levels of cultural competence also reported stronger perceptions of patient safety culture. This result aligns with the work of Upadhyay et al., who found that hospitals characterized by higher cultural competence exhibited a more robust safety culture in patient care (Upadhyay et al., 2022). Collectively, these convergent findings suggest that cultural competence represents a critical resource for fostering a resilient patient safety culture and for delivering safe care to patients from diverse and minority backgrounds.

The present study's findings revealed a significant positive correlation between cultural competence and patient safety culture, yet the magnitude of this relationship was moderate (r = 0.50). This pattern implies that, although students demonstrating higher levels of cultural competence tend to exhibit stronger safety awareness, various contextual and organizational factors may influence or attenuate this association. Existing evidence indicates that patient safety culture is determined by a constellation of factors extending beyond individual competencies—among them, institutional leadership, communication climate, staffing adequacy, and the presence of a nonpunitive approach to error reporting (Hafezi et al., 2022; Seo & Lee, 2024). Moreover, disparities in how cultural competence and patient safety education are integrated into nursing curricula may constrain the degree to which these domains reinforce one another (Majda et al., 2021).

Additional factors—such as excessive clinical workload, occupational stress, hierarchical communication patterns, and limited interprofessional collaboration—may also weaken the direct influence of cultural competence on safety culture perceptions (Shopo et al., 2025; Upadhyay et al., 2022). Accordingly, the moderate correlation observed in this study likely reflects the multifactorial and system-level nature of safety culture, which transcends individual cultural sensitivity and encompasses broader organizational and contextual dynamics.

In contrast, Lee and colleagues assessed patient safety culture and cultural competence among final-year undergraduate nursing students and reported no statistically significant association between the two constructs (Lee et al., 2020). In their study, participants indicated that patient safety and cultural competence were primarily addressed through classroom instruction rather than via laboratory simulations or clinical placements. This discrepancy underscores the necessity of integrating cultural competence explicitly into clinical education, ensuring that students acquire the practical skills required to provide safe, culturally congruent care. Our analysis also demonstrated that greater educational experience was associated with stronger endorsement of patient safety culture, such that each additional academic year increased the likelihood of reporting a stronger safety culture. Similarly, Bressan et al. reported that nursing students’ competencies in patient safety improved over successive academic years, even when measured knowledge remained relatively stable (Bressan et al., 2021). These observations corroborate our findings and suggest that experiential learning plays a pivotal role in consolidating safety-related competencies.

By contrast, Ramírez-Torres and colleagues found that fourth-year students expressed lower perceptions of patient safety culture than first-year students (Ramírez-Torres et al., 2023). Although this result diverges from our findings, it nonetheless emphasizes that practical experience and formal education enhance students’ awareness of the elements necessary to practice safely. Taken together, these studies indicate that the combination of theoretical instruction, progressive clinical exposure, and authentic engagement with healthcare services enhances experiential learning and reinforces professional accountability in maintaining a patient safety culture. Consequently, strengthening nursing students’ safety culture is likely to improve the quality of care and elevate safety standards (Huang et al., 2020).

In the present study, gender emerged as a significant factor influencing attitudes and perceptions of patient safety culture. This finding aligns with prior research reporting gender-related differences in safety perceptions. For instance, Alzahrani et al. observed that female healthcare workers consistently scored higher across domains of patient safety culture, particularly in teamwork, open communication, and error reporting. They attributed these differences to potential variations in communication style and risk perception, suggesting that women may be more collaborative and risk-averse, traits that reinforce a safety culture (Alzahrani et al., 2019). However, other investigations, such as that by Sorra and Nieva, found minimal or inconsistent gender differences across most dimensions of patient safety culture in a large sample of U.S. hospitals, highlighting the context-dependent nature of these effects (Sorra & Nieva, 2004).

These divergences across studies likely reflect contextual, cultural, and methodological differences. Cultural context, in particular, exerts a substantial influence on how gender roles are enacted within professional settings; in highly gendered healthcare environments, men and women may experience authority, communication, and accountability differently, thereby shaping their perceptions of patient safety.

The researchers also identified a robust positive association between cultural competence and SNC, such that students exhibiting higher levels of cultural competence were significantly less likely to deliver unsafe or substandard nursing care compared with those demonstrating lower competence. Carberry et al. have argued that a core tenet of the competency-based approach lies in its capacity to ensure safe care for the patients and communities served by nurses. At the same time, they emphasize that the competency framework presents both conceptual and practical challenges in nursing. Integrating this framework into advanced practice necessitates acknowledging its limitations to enable critical evaluation of prevailing interpretations and applications and to challenge them where appropriate. A focused analysis of cultural competence thus illuminates difficulties associated with implementing a competency model in professional nursing practice and identifies issues whose resolution is essential for safeguarding professional standards (Carberry, 1998). Accordingly, pedagogical strategies that equip nursing students to achieve cultural competence in clinical practice are likely to enhance the overall quality of nursing care. Nurses must cultivate effective interpersonal relationships and respect patients’ value systems and lived experiences to protect patients’ rights and avoid stereotypical generalizations about specific cultural groups; the expertise of qualified nurses from diverse cultural backgrounds can substantially facilitate this process (Chenoweth et al., 2006).

The researchers further examined predictors of perceived SNC, with particular attention to academic progression. Notably, academic year did not emerge as a significant predictor of perceived SNC in our regression model. This finding suggests that progression through successive academic years, in isolation, does not necessarily translate into enhanced competence or elevated safety-related perceptions. Tanaka et al. reported minimal differences in perceived clinical safety competence between third- and fourth-year students and concluded that mere accumulation of theoretical coursework or the passage of time may be insufficient to develop the critical competencies required for safe practice; without sufficient depth and quality of practical clinical exposure, academic advancement may yield only modest improvements in safety-related perceptions and skills (Tanaka et al., 2023).

In contrast, Lee and Kim documented a positive association between academic year and improvements in safety-related attitudes and behaviors in a longitudinal study of Korean nursing students. They attributed this progression to the cumulative effects of repeated clinical rotations and structured mentoring programs embedded within the curriculum, both of which progressively shape students’ understanding of safety protocols and clinical decision-making (Lee et al., 2020). Similarly, Solgajová et al. reported statistically significant increases in SNC across academic years (Solgajová et al., 2024). These findings suggest that, with increasing seniority and the cumulative accumulation of theoretical knowledge and clinical experience, nursing students acquire the capabilities necessary to provide safer care and to commit fewer care-related errors than in earlier stages of their training.

Differences in findings across studies may be attributed to variability in the quality and structure of nursing education programs. Although academic progression theoretically entails greater exposure to clinical learning, the depth of that exposure, the quality of supervision, and the integration of reflective practice differ markedly between institutions. Our results indicate that, in the absence of targeted educational interventions, progression through successive academic years alone may be insufficient to cultivate the competencies required for SNC.

The present study revealed a statistically significant gender difference in SNC scores among nursing students, with female students reporting higher levels of safe-care performance. This finding suggests that gender may influence the formation of attitudes, behaviors, and competencies associated with the delivery of safe care in clinical settings. This observation is consistent with Altmiller and Armstrong, who reported that female nursing students achieved significantly higher scores on patient-safety competency measures, particularly in the domains of communication, teamwork, and situational awareness. They attributed these differences to gendered socialization processes that foster nurturing behaviors and attentiveness in female students, traits closely aligned with the principles of safe nursing practice (Altmiller & Armstrong, 2017).

By contrast, Barton et al. reported findings that diverge from ours, observing no statistically significant gender differences in students’ self-reported patient-safety skills. They argued that the growing emphasis on standardized clinical education and competency-based assessment, which provides equitable exposure and evaluation for all students regardless of gender, has likely attenuated gender-based disparities (Barton et al., 2020). Collectively, these studies indicate that cultural and educational contexts may moderate the influence of gender on clinical performance.

In the Iranian context, nursing has traditionally been regarded as a predominantly female profession, a cultural framing that may bolster both confidence and perceived performance among female students. Conversely, educational environments that explicitly promote gender-neutral skill development may exhibit smaller gender-related variance in performance. It is also essential to consider the potential impact of social desirability bias in self-reported measures: female students may be more inclined, whether due to internalized professional expectations or heightened sensitivity to safety-related behaviors, to report higher performance, whereas male students may underreport their capabilities owing to differing self-assessment norms or confidence levels. This interpretive perspective suggests that observed gender differences may reflect not only genuine competency differentials but also variations in self-concept and reporting behavior.

The present study further examined the relationship between gender and cultural competence, finding no statistically significant differences. In our sample, gender did not appear to determine individual levels of cultural competence. This result aligns with Choi and Kim's cross-sectional study of undergraduate nursing students in South Korea, which reported no significant gender differences in cultural-competence scores and concluded that exposure to intercultural education and experiential learning predicts competence more strongly than demographic characteristics such as gender (Choi & Kim, 2018). Similarly, Halter et al. reported comparable levels of cultural awareness and sensitivity among male and female nursing students after controlling for academic standing and clinical experience (Halter et al., 2015). Nevertheless,our findings are also concordant with reports by Urbanavičė and colleagues, who observed that women scored significantly higher on measures of cultural knowledge and skills, proposing that social gender norms may predispose women to develop stronger interpersonal competencies relevant to cross-cultural interactions (Urbanavičė et al., 2025). Overall, these findings underscore the importance of assessing cultural competence through a multifaceted lens that incorporates not only demographic variables such as gender but also contextual and experiential determinants, including intercultural education, international exposure, and curriculum design.

Furthermore, academic year emerged as a significant predictor of cultural competence. This finding underscores the pivotal role of clinical experience and professional socialization in shaping these competencies. As nursing students’ progress through their academic programs, they acquire greater exposure to diverse patient populations, interprofessional communication, and real-world safety challenges, thereby enhancing both cultural sensitivity and situational awareness. This developmental trajectory aligns with Benner's novice-to-expert framework, which posits that competence evolves through experiential learning and reflective practice (Benner, 1984; Lin et al., 2015).

Senior students are also more likely to have participated in patient safety and cultural competence courses, as well as simulation-based training, all of which have been shown to strengthen the integration of safety principles into clinical judgment (Jung et al., 2023). The stronger predictive role of academic year may therefore reflect cumulative educational exposure and the internalization of professional norms that emphasize patient-centered, culturally safe care. Nonetheless, this finding suggests a need to embed structured cultural competence and patient safety education earlier in the nursing curriculum, ensuring that students’ at all academic levels develop these essential competencies in a consistent and systematic manner. Nurse educators should also design tiered and contextually relevant curricula that address learners’ specific developmental needs, thereby maximizing the effectiveness of educational interventions aimed at fostering cultural competence and safety-oriented professional practice.

Strengths and Limitations

The present study provides valuable empirical evidence linking these constructs in an understudied context, offering a meaningful contribution to the body of knowledge informing nursing education and practice in Iran and comparable settings. Several limitations should be acknowledged when interpreting the findings of this study. First, although a census sampling method was employed to include all eligible nursing students from the three participating medical universities, the research was conducted exclusively in Fars Province, southern Iran. Consequently, the results may not be fully generalizable to nursing students in other provinces or institutional contexts with differing cultural, organizational, or educational characteristics. To enhance external validity, future multicenter studies involving universities from diverse geographic and sociocultural regions of Iran are recommended. Second, the cross-sectional design precludes causal inference regarding the observed relationships among cultural competence, patient safety culture, and SNC. Longitudinal or interventional research designs would be better suited to examine how these constructs evolve and interact over time. Third, data collection relied on self-report instruments, which may have introduced potential response biases such as social desirability or recall bias. Although census sampling increased internal representativeness, the inclusion of participants from only a limited number of universities may have restricted the diversity of educational and clinical experiences captured. Moreover, qualitative or mixed-methods approaches could yield deeper insights into the mechanisms and contextual factors shaping cultural competence, patient safety culture, and SNC.

Implications for Practice

The findings of this study point to several practical implications for strengthening nursing education in Iran. First, cultural competence and patient safety content should be systematically integrated across both theoretical and clinical courses rather than taught in isolation. For instance, simulation-based learning that merges intercultural communication scenarios with patient safety challenges can help students develop the capacity to manage complex, high-risk situations in a controlled environment. Second, incorporating multicultural clinical placements, such as community-based rotations in ethnically diverse regions, can expose students to a range of cultural norms and patient expectations, thereby fostering empathy, adaptability, and situational awareness. Third, dedicated patient safety modules emphasizing teamwork, transparent error disclosure, and culturally sensitive communication should be introduced early in the curriculum. Structured reflection sessions and debriefings following these experiences can further facilitate the internalization of professional values and ethical safety practices. Collectively, these curricular strategies can cultivate a dual-competence framework—cultural and safety-oriented—that equips nursing graduates to deliver safe, patient-centered, and culturally congruent care in Iran's increasingly diverse healthcare landscape.

Conclusion

The findings of this study indicate that higher levels of cultural competence are positively associated with improved performance in SNC and more favorable perceptions of patient safety culture among nursing students, though causal inferences cannot be drawn due to the cross-sectional design. Notably, advanced statistical analyses suggest that cultural competence alone may not fully account for positive perceptions of patient safety; in some instances, heightened cultural sensitivity may increase students’ awareness of deficiencies within clinical settings. To address this, educators should integrate scenario-based learning activities and case studies into the curriculum, enabling students to apply cultural competence in practical situations and reflect on strategies for managing identified challenges.

Footnotes

Acknowledgments

The authors would like to appreciate Fasa University of Medical Sciences & Clinical Research Development Unit of Fasa Valiasr hospital for financially supporting this research.

ORCID iD

Mostafa Bijani

Ethical Statement

All the participants gave written informed consent to participate in the study. This study was conducted based on the principles of the revised Declaration of Helsinki, which is a statement of ethical principles used to guide medical researchers who investigate human subjects. The subjects were assured of their anonymity and confidentiality of their information. Furthermore, this study was approved by the Institutional Research Ethics Committee of Fasa University of Medical Sciences, Fasa, Iran (ethical code: IR.FUMS.REC.1403.062).

Informed Consent

Written informed consent was obtained from all subjects before the study.

Consent for Publication

All authors have read and approved the final manuscript.

Authors’ Contributions

Mostafa Bijani and Zahra Mohebi contributed to writing—review & editing, writing—original draft, visualization, validation, supervision, project administration, methodology, data curation, and conceptualization. Maryam Talebi moghaddam and Sorur Javanmardifard contributed to writing—original draft, data curation, and conceptualization. Ali Taghinezhad contributed to writing—review & editing, methodology, and conceptualization.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.

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Investigating the Relationship Between Cultural Competence,Patient Safety Culture,and Safe Nursing Care Among Nursing Students: A Multicenter Cross-Sectional Correlational Study in Iran

Abstract

Introduction

Objective

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

Methods

Design

Inclusion/Exclusion Criteria

Participants and Sampling

Data Collection

Hospital Survey on Patient Safety Culture

Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals, Revised

Statistical Analysis

Ethical Considerations

Results

Multivariate Linear Regression Analysis

Discussion

Strengths and Limitations

Implications for Practice

Conclusion

Footnotes

Acknowledgments

ORCID iD

Ethical Statement

Informed Consent

Consent for Publication

Authors’ Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References