Nurse leaders experiences of integrating culturally and linguistically diverse registered nurses into healthcare settings: An interview study

AIM: To describe nurse leaders' experiences of how culturally and linguistically diverse registered nurses integrate into healthcare settings

• Results of this study revealed that a nurse leaders knowledge management competence assists towards evaluation, support, and continuous development of a culturally and linguistically diverse nurse competence •The findings of this study show that nurse leaders formal leadership competence enables a leader towards adopting effective leadership style, use of competence and successful integration of culturally and linguistically diverse nurses

Background
Nurses constitute much of the global healthcare workforce (Debesay et al.,2022) but statistics show that, globally, there is a significant nursing shortage (Boniol et al.,2022). Further projections show that the future nursing human resource deficit will be exacerbated by high retirement rates among nurses and increased demand for care (Kamau et al.,2022). The Finnish healthcare system needs to plan strategies to increase human resources, as nursing is identified among the healthcare professions facing the highest shortage among different countries (WHO,2020). It is projected that, for example in Finland, by the year 2030, the nursing shortage will amount to thirty thousand (Finnish Institute of Health and Welfare, 2021), and the recruitment of culturally and linguistically diverse nurses is a key strategy to mitigate this trend, as the healthcare educational system itself will not be enough to fill this gap (Ministry of Economic Affairs and Employment, 2022). Similar strategies are also adopted in other countries: the UK National Healthcare System for example planned to recruit at least 50,000 nurses from abroad to specifically address the nurses shortage in the country (Department of Health and Social Care, 2022).
To meet the demand for more nurses, many healthcare systems have taken on an increased share of culturally and linguistically diverse (CALD) nurses who have either migrated or are locally edu-6 nity. The culturally and linguistically diverse nurses cover 3.3% of the overall Finnish nursing workforce (Finnish nurses association, 2020).
Globally, healthcare organizations are changing in response to cultural and linguistic demographic shifts in the diversity of healthcare employees, patients and clients (Egede-Nissen et al., 2019). The organizational changes brought about by an increasingly diverse workforce demand competent leadership, diversity management, work ethics, and skills (Egede-Nissen et al., 2019;García et al., 2020). Potential problems associated with diversity may include isolation, discrimination, communication breakdown, interpersonal conflicts, attrition, and poorer overall workforce performance. (Yadav & Lenka, 2020;Kamau et al. 2022). However, many studies have shown that diversity can enrich an organization by bringing on board a multitude of ideas, knowledge, and a mix of talents, which can be directly related to workplace creativity, innovation, enhanced productivity, and better outcomes (Hussain et al., 2020;Yadav & Lenka, 2020;Kamau et al., 2022). In healthcare, positive effects that result from organizational diversity, such as multilingualism and multiculturalism, are not only enjoyed within the nursing workforce, but trickle down to benefit the culturally and linguistically diverse patients and clients who interact with these organizations (Hussain et al., 2020;Debesay et al., 2022;Kamau et al., 2023).
In terms of leadership, managing diversity involves leading a heterogenous workforce that includes people of different genders, ages, and ethnicities and with varied cultural and linguistic backgrounds (Hussain et al., 2020;Yadav & Lenka, 2020). Maximising the potential of a diverse workforce is, however, dependent largely on how employees integrate into an organization (Jokisaari & Vuori, 2018).
Organizational socialization theory defines a process by which a newcomer overcomes organizational challenges and develops the necessary competencies to effectively adjust to a specific role (Van Maanen & Schein, 1977;Taormina, 2009). A positive organizational socialization process is also referred to as organizational integration, onboarding, or adaptation (Ramji et al., 2019: Slate et al., 2018Xu, 2008). An effective organizational socialization process improves professional identity, job satisfaction, and organizational well-being; moreover, it helps to develop essential work competencies, person-organization fit, and it reduces the intention to leave and the attrition rate (Tomietto et al.,2014;Kamau et al,2022).
For culturally and linguistically diverse nurses becoming socialized to the organization means gaining J o u r n a l P r e -p r o o f Journal Pre-proof a sense of belonging within the workforce, practicing nursing, and finding their place within the team and organizational environment Kamau et al., 2022). However, previous research has established that culturally and linguistically diverse nurses face challenges with integrating into Finnish healthcare organizations and the workforce (Kamau et al., 2023). These personal, team, ward, and organizational level challenges affect culturally and linguistically diverse nurses' professional identity, personal well-being, work engagement, care delivery, collegial relations, career development, and may also increase intention to leave the profession (Tomietto et al., 2019;Kamau et al., 2023).
Within strategies that organizations adopt to ensure the efficient organizational integration of culturally and linguistically diverse nurses, the nurse leaders' role has been found to be pivotal (Kamau et al., 2022). For instance, research in organizational socialization has established positive integration outcomes in instances where nurse leaders actively interact with newcomers, act as a source of feedback, and offer critical organizational and work-related support Kamau et al., 2022). Relationships between leaders and newcomers have also been found to affect integration and development within an organization (Jokisaari & Vuori, 2018). Leaders establish shared goals by motivating, supporting, and influencing their teams in pursuit of a common direction (Sulosaari et al., 2022).
The concept of leadership is multifaceted and reflects the specific scope of practice: thus, defining the roles and competencies of a leader may vary between professions (Orukwowu, 2022). Over time, studies of leadership have shifted from focusing on a leader's individual traits to other aspects that affect leadership (Sulosaari et al., 2022). For instance, organization-wide strategies and structures have been found to affect leaders' competence, decision-making, and choice of leadership style (Dağhan & Topçu, 2022).
First-line nurse leaders may have various titles, such as head nurse, nurse manager, or service manager (Dağhan &Topçu, 2022). They serve as heads of department within healthcare organizations (Nurmeksela et al.,2021) and occupy the role of first-line managers responsible for the leadership and management of nursing personnel who are involved in delivering care (Lehtonen et al.,2018).
However, we find that although previous research has largely established nurse leaders competencies (American Nurses Association,2015;García et al.,2020), roles and experiences of leadership (Lehtonen et al.,2018,) and the significance of the resources at a leader's disposal (Jokisaari & Vuori, 2018) there is a research gap regarding nurse leaders' experiences of how culturally and linguistically diverse nursing staff integrate into healthcare, particularly within care settings where the culturally and linguistically diverse nursing workforce is an emerging phenomenon.

Design
This study adopted a qualitative descriptive approach (Sandelowski,2010), a methodological approach which is well suited to understanding the lived experiences and perspectives of nurse leaders and establishing a structured understanding of the research phenomena. Naturalistic paradigm (Lincoln & Guba,1985) guided this research and hence nurse leaders' experiences were inquired within their natural settings. To ensure accuracy, reporting of this study was done against standards for reporting qualitative research, this enhanced transparency, quality and ensured complete data reporting (O'Brien et al., 2014).

Aim and research question
The aim of this study was to describe nurse leaders' experiences of how culturally and linguistically diverse registered nurses integrate into healthcare settings. Nurse leaders' experiences were described in response to the research question: How do nurse leaders experience the integration of culturally and linguistically diverse nurses into healthcare settings? J o u r n a l P r e -p r o o f Journal Pre-proof

Sample and context
A total of 13 nurse leaders were recruited from four primary and specialized healthcare organizations in central and northern parts of Finland during a period of five months, November 2021 to March 2022. Healthcare organizations were chosen for their proximity and accessibility to the researchers, having a known history of culturally and linguistically diverse nurses joining their workforce, and nurse leaders who met the inclusion criteria. Participant recruitment used a linear snowball sample approach (Bhardwaj,2019) which was initiated by two researchers (KS and KN) sending an email invitation to prospective nurse leaders, which included key information about the research purpose, aims, data collection methods, data management plan, and consent form. Leaders who agreed to participate were asked to refer the researchers to other leaders known to them, who met the inclusion criteria. The participant inclusion criteria were: 1) being a nurse leader occupying a first-line leadership position; 2) having experience of working with and leading culturally and linguistically diverse nurses; and 3) having more than one year's work experience as a leader. Participants demographic data were collected using a webropol electronic form.

Reflexivity
Data were collected by researcher (KS who is a nursing educator, doctoral student and KN who is a master's degree student), both were experienced in qualitative research and proficient in both Finnish and English languages. Research sample composed of participants who were not personally known to the researchers. Participants were not provided with the research questions prior to the interviews.

Data collection
Data were collected from all 13 nurse leaders who consented to participate, between November 2021 and March 2022. Due to the geographical distance between the research participants and the researcher's, individual, semi-structured interviews were conducted online in Teams (Microsoft Corporation Redmond, WA), by two researchers (KS &KN) and recorded in video and audio format.
Interviews lasted between 45 and 60 minutes. Preformulated interview themes were guided by the findings from a previous umbrella review, regarding integration strategies and models of culturally and linguistically diverse registered nurses into healthcare, three themes in the study were; intraorganizational, sociocultural, and professional development strategies and models (Kamau et al., 2022). For our study, two themes pertaining to nurse leaders' lived experiences of how CALD nurses J o u r n a l P r e -p r o o f Journal Pre-proof integrated and organizational processes, and strategies supporting integration, guided the formulation of interview questions (Supplementary table 1). Participants' expressions and responses were the basis for follow-up questions, and the researcher moderated the interview sessions to ensure that all key information was collected (Kallio et al.,2016). Three interviews were held in English and ten in Finnish. The first two interviews were used to pilot test the preformulated interview themes and questions: there were no notable discrepancies between these and the subsequent interviews, hence they were later included in the data analysis.

Data analysis
Data were transcribed verbatim (Halcomb & Davidson, 2006). This process produced 194 pages of raw data that were given special codes that ranged from 001 to 013 according to the sequence of interviews, allowing for easy data identification and concealing of participants' identities. Before analysis, researchers went through the transcribed data to ensure that it captured the content of recorded interviews (MacLean et al.,2004).
Data were analyzed using a three-step inductive content analysis process of data preparation, organization, and reporting (Elo & Kyngäs,2008;Kyngäs et al., 2019). A conventional content analysis approach (Hsieh & Shannon, 2005) was adopted to allow formation of categories and main categories that described nurse leaders' experiences to be formed from the transcribed data. The process of data analysis was guided by critical realism and the belief that individuals' experiences are captured through their senses, emotions, linguistic and cultural aspects (Lauzier-Jobin & Houle, 2021).
Data were analyzed using a three-step inductive content analysis process of data preparation, organization, and reporting (Elo & Kyngäs,2008;Kyngäs et al., 2019).
The content analysis process started with the researcher reading through transcribed data and making sense of nurse leaders' experiences. This was followed by mapping and manually recording meaning units in a coding sheet, during this process 474 meaning units, in sentence form, were mapped according to the research question. Meaning units were recorded in their original language to ensure that no meaning was lost, and this enhanced trustworthiness (Al-Amer et al., 2015).
During data abstraction and categorization, a total of 363 open codes and 279 subcategories were generated. In the final phase the subcategories were further merged into 24 categories and seven main categories which responded to the research question. Data were analyzed by the first author and cross-checked by all other co-authors, this minimized errors and enhanced credibility and confirmability (Cope,2014). Translation of data from Finnish to English during analysis was cross-J o u r n a l P r e -p r o o f Journal Pre-proof checked by the bilingual researchers, this ensured the accuracy, consistency, and trustworthiness of the analysis process (Al-Amer et al., 2015).

Ethical issues
All four participating healthcare organizations gave research permission as per Finnish ethical conduct regulations (Declaration of Helsinki, 2013). Participants data was anonymized using special codes ranging from 001-013. A data management practice (EU Commission, 2018) was applied when collecting, handling, and storing participants' data. In the participant invitation letter, participants were sufficiently provided with information regarding the research aim, data management, confidentiality, and anonymity and that they could withdraw their consent without any consequences.
Prior to participating in the interviews all participants read and signed a consent form, that also elaborated that participants could voluntarily withdraw their consent at any time (Declaration of Helsinki,2013).

Participant characteristics
The recruited participants were all front-line nurse leaders, all were Finnish, 11 were female and two male, and ages ranged from 38 to 63 year old with a mean age of 46. Participants' experience of working in a culturally diverse group ranged from one to twenty years, with an average of seven years. Three nurse leaders had experience living and working abroad, five were educated up to master's degree level, and all occupied either positions of ward manager (n=6) or service manager (n=7) within long term elderly care(n=5), home care (n=1), medical wards (n=5) and specialized care units (n=2). All participants who consented to participate were interviewed. Data saturation (Fusch & Ness,2015) was achieved by the thirteenth interview since no new data or themes were established.
Nurse leaders' experiences of how culturally and linguistically diverse registered nurses integrated into healthcare settings fell into seven main categories: leadership, organizational strategy and culture, support strategies, relationships and interactions, nurse competence requirements and development, language competence, cultural diversity, and the importance of competence development.

Leadership
Leadership related to the roles, experiences, competence, and leadership style of a nurse leader in providing integration support to culturally and linguistically diverse nurses. Nurse leaders' roles were vital within the work unit because they offered support to culturally and linguistically diverse nurses when they entered the workforce by reviewing their competence, aligning work roles to competence, and they supported workplace learning and competence development. Leaders arranged workplace education and learning opportunities and offered learning support. To improve culturally and linguistically diverse nurses' sense of professional identity and ease their work within the unit, leaders helped formulate workplace regulations and establish a conducive work culture. In instances where culturally and linguistically diverse nurses faced retaliation or racism from patients or families, leaders came to their defense through amicable conflict resolution mechanisms.
"There have been incidents of clear racism, from patients. And we tend to take that very seriously.
We don't allow it here" (participant 001) In fulfilling their roles leaders adopted various leadership approaches including ensuring equal treatment and justice towards all nurses, assuring native colleagues about the competence of culturally and linguistically diverse nurses, supporting professional independence, seeking, and utilizing culturally and linguistically diverse nurse feedback, and supporting outside-of-work social activities.
However, some of the interviewed leaders had experienced instances of leadership discrimination against and misperception about culturally and linguistically diverse nurses that significantly affected their hiring practices.
"I have seen that head nurses might, if it's an international name, and their language might not be that good, the head nurse might not even interview that person, which I find sad" (Participant 005) Leading a diverse workforce exposed nurse leaders to opportunities to acquire experience with culturally and linguistically diverse nurses, through orienting them to their work and the organization, meeting leadership expectations through feedback, and developing the cultural competence to manage diverse nurses. However, some leaders interviewed felt that other leaders sometimes lacked leadership education, suggesting a need for cultural and linguistic diversity training.
J o u r n a l P r e -p r o o f "We do need to see more education for our leaders as well and we need to encourage them more" (participant 002) "Training for the leaders, here in our ward we have a lot of international nurses, we have experience of them and are probably more skilled in handling them than others" (Participant 005) Leaders' competence with regards to supporting how culturally and linguistically diverse nurses integrate was found to vary, with those who had not experienced culturally and linguistically diverse nurses within their workforce being reluctant to employ a culturally and linguistically diverse nurse. Acknowledging the importance of culturally and linguistically diverse nurses to sustaining the workforce was an important incentive for employing and integrating them into healthcare organizations.
Leaders viewed culturally and linguistically diverse nurses as an important human resource and the future of the nursing workforce. culturally and linguistically diverse nurses not only increased the number of nurses, helping to meet workforce demand and address shortages, but they also enriched workplace and care culture, bringing diverse linguistic capabilities, and enhancing the care of culturally and linguistically diverse patients. The leaders interviewed experienced culturally and linguistically diverse nurses brought rich experiences and diverse views and being were able to perform similar roles and duties to other nurses. Leaders felt that organizations could have done more to attract culturally and linguistically diverse nurses into the workforce.

"If it is difficult for a culturally and linguistically diverse nurse to come and work for us, in these instances we must think what changes we need to make so that Finland can be attractive to culturally and linguistically diverse nurses "(Participant 004)
"They absolutely play a role, not just because we are in the middle of a pandemic, and a nursing shortage" (Participant 010) Nurse leaders experienced organizational structures affected how culturally and linguistically diverse nurses integrated. Positive organizational aspects included equality of roles, justice, equal access to opportunities, good treatment of nurse's, positive reception of culturally and linguistically diverse nurses and positive performance evaluation of their duties. Participating leaders expressed that their organizations generally lacked structured strategies for supporting culturally and linguistically diverse nurses or planning their integration. They also varied in how they assessed nurses' previous competence. Leaders felt that their organizations could have done more to match culturally and linguistically diverse nurses' competence to work demands, and to develop specialized ways of supporting how culturally and linguistically diverse nurses integrated into their workplaces.

"As an organization, we don't have Finnish classes for CALD nurses, but of course we encourage them
and I'm happy to tell them where they can take for example language courses, but they do it in their free time" (Participant 005)

Support strategies
Nurse leaders talked about their experience regarding strategies to support culturally and linguistically diverse nurse integration experiences. Structured strategies included workplace support, mentorship, induction. While more ad hoc strategies involved peer support and collegial support. Nurse leaders experienced that induction, oriented culturally and linguistically diverse nurses to the organization, work community, and roles, and enhanced their competence. The induction process was sometimes longer for culturally and linguistically diverse nurses, tailored to their previous competence and, on occasion, needs based. Nurse leaders experienced that although induction processes required resources, culturally and linguistically diverse nurses benefited from a prolonged induction that was tailored to their needs. During induction they were offered mentoring by a named experienced nurse, who guided the culturally and linguistically diverse nurse during the initial stages of their work. Participating leaders said organizations could enhance this form of support, as there was a felt need for mentorship during the integration process.

"I have noticed that when an international nurse comes aboard...it is the one who has been training them in the first place...who usually mentors them for quite a long time" (Participant 007)
Colleagues supported culturally and linguistically diverse nurses to settle in by offering teamwork support and creating a supportive work environment. Nurse leaders expressed that some colleagues also defended culturally and linguistically diverse nurses against hostile patients and during other negative experiences. Peer support was experienced on wards where there were several culturally and linguistically diverse nurses with similar backgrounds. These nurses were seen by nurse leaders to offer role modelling, shared experiences, and comfort within the work unit. Leaders expressed that organizations which already included culturally and linguistically diverse nurses within the workforce were attractive to other potential culturally and linguistically diverse nurse employees: "I have noticed that any ward that has nurses with an immigrant background in the workforce, they seem to attract more of them" (Participant 013) diverse nurse to prove their abilities. In contrast, positive collegial relations helped to establish friendships, supported cultural openness, and enhanced collegial support and workplace integration.
"I think the international nurses need to work harder in terms of proving to their colleagues that they are capable and able" (Participant, 009) Although collegial interaction was felt to establish understanding and social interaction between colleagues, there were instances of poor collegial interaction based on perceived differences which, at times, led to unrealistic expectations of culturally and linguistically diverse nurses by colleagues, and further hampered workplace social relationships: "It has been quite difficult in some cases because there are some misperceptions sometimes" (Participant 011) Culturally and linguistically diverse nurses' interactions with patients and family helped them to be accepted. Nurse leaders experienced that patients and their families were generally satisfied. They expressed that culturally and linguistically diverse nurses approached patients positively, offered culturally competent care, and increased patient satisfaction. In the instances where a patient interacted negatively with a culturally and linguistically diverse nurse this may have been due to cognitive challenges or racist beliefs on the part of the patient "Well, I just want to say that they increase patient satisfaction tremendously" (Participant, 005)

Nurse competence requirements and development
Nurse leaders experienced that both organizational and ward level competencies were demanded from culturally and linguistically diverse nurses. At the organizational level, like all nurses, they were required to have nursing competence, sufficient language skills, and be licensed to practice.
At the ward level additional competencies such as knowledge of care culture, care process, communication skills, positive personal skills, and an understanding of the organization were essential for integration into the work unit.
"We expect them to have the same kind of competence as any of our Finnish nurses" (Participant

007)
Organizational strategies for supporting culturally and linguistically diverse nurses to develop competence included rotations onto different wards, opportunities to obtain medication and safety licenses, and online courses focused on theoretical competence. In some cases, initial demands on J o u r n a l P r e -p r o o f culturally and linguistically diverse nurses were kept deliberately low, and continuous competence reviews allowed nurses to develop within an organization.
"We try to make them realize that we are really investing in them, getting them in permanent places, offering them more training" (Participant 004)

Language competence
Nurse leaders' experiences of culturally and linguistically diverse nurses' language competence related to ward level language requirements, language competence limitations, and language competence development. At the ward level, nurses are expected to be able to speak, read, write, and understand Finnish competently. However, the nurse leaders interviewed differed in how they experienced actual language competence expectations on different wards, as the acceptable level of language skills was variously described as good, sufficient, advanced, and in some cases even low.

"I think that first and foremost they need to have language skills. Ability to speak Finnish"001
Language limitations arose where a culturally and linguistically diverse nurse's language competence was below the expected level. It was felt that culturally and linguistically diverse nurses' scope of work was sometimes limited by language limitations as these created challenges to care delivery such as safety of care. Interactions with patients, families, and colleagues were also affected by language limitations. This frequently affected teamwork and, in more severe cases, prompted the mistreatment and unequal workplace treatment of culturally and linguistically diverse nurses. In some instances, this culminated in lower levels of development within the organization.

"If there are language challenges it makes it difficult at the beginning, and eventually affects integration into work community"002
and a lack of extra language support for culturally and linguistically diverse nurses. However, the organizational expectation was that culturally and linguistically diverse nurses were to be linguistically competent, and linguistic competence was a priority within many work communities. culturally and linguistically diverse nurses sought learning opportunities outside the organization to improve their language competence and, in some instances, received guidance from nurse leaders on where to access language courses.
"The nurses we have are highly skilled, highly competent, and as they are doing the job their language skills also get more proficient" 002

Cultural diversity and importance of competence development
In some instances, nurse leaders had experienced cultural diversity negatively influencing workflow, teamwork, and workplace interactions. Nurse leaders expressed that there was a need for mutual cultural adaptation and cultural discussions in the workplace to overcome such challenges. At the same time some workplaces were felt to enjoy positive cultural diversity and benefit from the presence of a culturally diverse workforce.

"I think the richness is that others bring new ways of working from other cultures" (Participant 012)
Nurse leaders felt that mutual cultural competence would have helped to develop positive cultural attitudes, understanding of work culture, and cultural interaction. Leaders' views on culturally competent care emphasized the need for culturally and linguistically diverse nurses to orient themselves to local care culture, overcome differences, and adapt to the workplace.
"Coming from other settings, another country and culture, even if they are already a nurse in their own home country, they might have a very different experience on nursing over there" (Participant

001)
The personal attitudes and motivation of culturally and linguistically diverse nurses also affected how they integrated. Nurse leaders experienced that attribute such as resilience, flexibility at work, courage to communicate, aspirations for career development, and a positive attitude helped integration. Nurse leaders further experienced that culturally and linguistically diverse nurses were hardworking and committed to their work, and this was valued by colleagues in the relevant work units.
J o u r n a l P r e -p r o o f "Sometimes it does come as a shock to them how hard this work is. But they are very resilient" (Participant 010)

Discussion
Our results show that the integration of culturally and linguistically diverse nurses into these healthcare organizations, as experienced by nurse leaders, is both a structured and a non-structured process. From our findings, we have established that a structured integration process is built into the healthcare organization and work unit. Within this structure, there are specific, known demands, development opportunities, and support mechanisms with regard to culturally and linguistically diverse nurses` competence. There are also structured organizational strategies to support integration, such as induction, mentorship, and workplace learning. Non-structured integration is more socially driven, comprising interpersonal workplace interactions, relationships, and friendships.
These findings corroborate organizational socialization theory (Van Maanen and Schein, 1977) and show the existence of both institutionalized and individualized socialization tactics.
Extensive research has established that institutionalized organizational socialization tactics are more efficient than individualized tactics . Our findings show that nurse leaders experienced their organizations as lacking such structured integration strategies, and approaches such as mentorship, prolonged induction, and language learning support were poorly supported. We, therefore, argue that culturally and linguistically diverse nurse integration support would be improved were healthcare organizations to structure, resource, and channel strategies for such integration within formal organizational structures (Kamau et al.,2022).
Our findings show that culturally and linguistically diverse nurses are perceived as competent by nurse leaders in many ways. These nurses possessed nursing competence and experience from various cultural, linguistic, and even practice backgrounds, and they enriched the workforce by contributing to the available nursing workforce and bringing their unique competencies. At the same time, they had needs with regard to competence development, for instance, competence in the Finnish language and local care culture. We also found that nurse leaders' knowledge of culturally and linguistically diverse nurses, appreciation of their competence, and even intention to employ them, was sometimes lacking. Nurse leaders' competence in knowledge management has been found to be essential to the efficient use, support, and development of nurse competencies (Karsikas et J o u r n a l P r e -p r o o f al.,2022). In our context, we have identified a need for more development in knowledge management competency among nurse leaders. This might help them develop essential skills for supporting the integration process and competence of culturally and linguistically diverse nurses, for instance formulating appropriate methods for competence assessment, continuous competence development, competence support, and utilization of culturally and linguistically diverse nurses' special competencies, such as linguistic and cultural competencies, within the organization.
Enabling organizations to support cultural awareness and competence among leaders and staff members has been found to be beneficial for care outcomes as well as organizational outcomes.
More specifically, cultural competence is associated with improved communication, higher satisfaction, adherence to educational interventions by patients, and empowered access to services and support (Cicolini et al., 2015). In this way, when organizational interventions are designed to enhance the cultural competence of leaders and staff members, it is possible to both improve culturally and linguistically diverse nurses' integration and patient care.
In this study we have also established that culturally and linguistically diverse nurses integrate through the support of and relationships with colleagues. These collegial relationships not only help in terms of professional growth, but also play a part in social networking and the formation of friendships that have been found to impact positively on integration (Kamau et al., 2022). However, we found that personal and cultural differences within the workforce can undermine collegial interaction, causing problems such as misperceptions, incivility, Inefficient use of staff members diverse skills, poor integration and, ultimately attrition. (Kaiser, 2017;Kamau et al., 2022).
Thus, creating strong social capital in the healthcare workforce can foster workplace collegiality, which is important for knowledge sharing and transfer (Materne, et al., 2017). Based on this finding we suggest that a nurse leaders' ability to support a strong nurse-to-nurse professional relationship (Kaiser,2017;Sulosaari et al.,2022) might further help towards building, sharing, and transferring knowledge, (Karsikas et al.,2022) and support a more cohesive, conducive, interactive, and supportive workforce context for the integration of culturally and linguistically diverse nurses.
Our results show nurse leaders experienced diversity within the workforce to challenge efficiency, relationships, and overall workplace atmosphere. On the positive side, nurse leaders stated that J o u r n a l P r e -p r o o f diversity enriched organizations through positive cultural outcomes. Harnessing the advantages of cultural diversity within the workforce involves overcoming the perceived constraints that it can impose; we find there is a need to further develop nurse leaders' diversity management competence. For instance, the American organization of nurse executives establishes that a nurse leader should possess diversity competence that would enable the creation of a workplace that is diversityfriendly and culturally competent (American Nurses Association, 2015). This ensures that the nurse leader can recognize various forms of diversity, including cultural and linguistic, within the workforce; incorporate cultural beliefs into care; develop organizational cultural competency; and formulate regulations and principles that support diversity (American Nurses Association, 2015). Cultural competence enhances human capital at the individual, team and organizational levels by bringing a broader perspective and culture of inclusion into nursing care. (Wang et al., 2022).
Our results highlight that some nurse leaders lacked formal leadership education, and this may have influenced their readiness to employ and lead culturally and linguistically diverse nurses as they Nurse leader competence has been associated with improved organizational performance and patient outcomes. Personal, interpersonal, human resource management, ethical, and leadership competencies are all essential to effective leadership (García et al., 2020). Moreover, understanding and adopting empowering approaches to nurse leadership, such as transformational and authentic leadership (Sulosaari et al., 2022), might help nurse leaders to maximize culturally and linguistically diverse nurses' competence within a team and organization, and empower, motivate, and build trust and cooperation between nurses.

Strengths and Limitations
The rigor of this study was enhanced by strictly adhering to established standards for reporting qualitative research (O'Brien et al., 2014). Transferability (Connelly,2016) was enhanced by having a representative sample of nurse leaders who represented both primary and specialized levels of J o u r n a l P r e -p r o o f healthcare, within two healthcare regions in Finland and provided rich data. Confirmability, credibility, and validity were enhanced by employing researcher triangulation through the entire research process (Noble & Heale,2019). The use of direct quotations increased authenticity in this research and strongly brought out participants voices (Eldh et al.,2020).
It was hard to recruit a research sample for this study hence the choice of snowball sample approach. However, there is a risk that our use of snowball sampling may have excluded some ideal participants. Moreover, our sample lacked nurse leaders from a culturally and linguistically diverse background themselves, hence such voices were missing from the research.
However, we note that this may be reflective of the research context as there might not be many nurse leaders of culturally and linguistically diverse background within Finnish healthcare institutions. Generalizability of our results to the entire population of nurse leaders may be limited due to the use of snowball sampling and participant self-selection during recruitment (Sharma, 2017). We however find that leaders who chose to participate may have had strong experience with culturally and linguistically diverse nurses.

Conclusions
This study has established unique findings with regard to Finnish nurse leaders' experiences of how CALD nurses integrate into healthcare workplaces in Finland. We have found that, in this context, nurse leaders may lack sufficient knowledge and expertise to manage the process of culturally and linguistically diverse nurses' integration. This is due to a lack of formal leadership and managerial readiness, and limited leadership competence in knowledge management and diversity management.
Integrating diversity leadership competence into formal nurse leadership and management educa-