Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for giving me the opportunity to review this article and help improve it through my comments.

1. It is true that correlations and regressions contribute within the study, thanks to which a protective relationship is suggested. Now I think it would be a very valuable contribution to include a mediation analysis to see if cultural competence moderates the effect of the work environment on anxiety.
2. The study is limited to a single "Medical City". It would be necessary to discuss in a more in-depth way how the internal policies of this institution may have influenced the high levels of competition.
3. The study finds a weak negative correlation with nationality. An in-depth study on this data would be necessary, is there any difference between the competence of national nurses and those who come from outside?
4. In table 1, I find it difficult to square the results due to the centering of its rows, I think that if you use a justification on the left and compress the table a little, the results would be more readable, on the other hand the word Philbin, if it refers to Filipino, wouldn't it be used otherwise?, it may be an error of knowledge of the current language reviewer, in case it is not so.

Author Response

Comment: It is true that correlations and regressions contribute within the study, thanks to which a protective relationship is suggested. Now I think it would be a very valuable contribution to include a mediation analysis to see if cultural competence moderates the effect of the work environment on anxiety. 
Response: Thank you for this important comment. To further explore the 'protective' nature of cultural competence, we have performed both mediation and moderation analyses (see Tables 7). Our results confirm that cultural competence significantly moderates the relationship between work environment demands and anxiety (B = -0.215, p = .005), suggesting a robust buffering effect. Furthermore, it serves as a significant mediator, explaining a substantial portion of the relationship between environmental stressors and psychological outcomes. We have added these findings to the Results and Discussion sections of the revised manuscript. 
Comment: The study is limited to a single "Medical City". It would be necessary to discuss in a more in-depth way how the internal policies of this institution may have influenced the high levels of competition. 
Response: We thank the reviewer for this insightful observation. We agree that the specific institutional environment of Qassim University Medical City likely played a key role in the high cultural competence scores. We have expanded the Discussion section to detail how institutional factors—including mandatory accreditation standards (CBAHI/JCI), the inherently multicultural composition of the workforce, and the availability of Continuing Nursing Education (CNE) workshops—likely fostered a high-competency environment. These internal policies mandate cultural sensitivity not only as a clinical skill but as a requirement for patient safety and organizational accreditation. 
Comment: The study finds a weak negative correlation with nationality. An in-depth study on this data would be necessary, is there any difference between the competence of national nurses and those who come from outside? 
Response: Thank you for this important comment. In our data, nationality showed only a weak negative correlation with the cultural competence dimensions, whereas education level, attendance at multicultural workshops, and self-perceived cultural competence were much stronger correlates. Therefore, the present study does not support a strong inference that national and expatriate nurses differ meaningfully in overall cultural competence. Rather, the association appears to reflect broader educational and experiential factors that may vary across groups. 
Comment: In table 1, I find it difficult to square the results due to the centering of its rows, I think that if you use a justification on the left and compress the table a little, the results would be more readable, on the other hand the word Philbin, if it refers to Filipino, wouldn't it be used otherwise?, it may be an error of knowledge of the current language reviewer, in case it is not so. 
Response: Thank you for this helpful comment. We agree that the presentation of Table 1 can be improved for readability, and we revised the table layout by left-aligning the text and adjusting the width/spacing to make the results easier to follow. In addition, we appreciate the observation regarding the term “Philbin.” This appears to be a typographical error, and the correct term should be “Filipino.” It was modified. 

Reviewer 2 Report

Comments and Suggestions for Authors

This is a multiple regression study seeking to understand the role of cultural competence on loneliness. The use of the subscales to measure the observable variables is appropriate

While correlation alone or path analysis are additional means of testing for a relationship between the variables, multiple regression is an appropriate choice. The literature support for each of the two variables is appropriate. No modifications are needed.

The sample size is adequate for multiple regression.

The analyses were conducted appropriately, and the results align with the literature. No changes needed.

The discussion adequately presents the logical connection of the two variables and points out that loneliness still occurs among nurses. 

Perhaps a follow-up qualitative study seeking to understand feelings of loneliness and the causes might contribute to a deeper understanding of the causes of loneliness.

Author Response

Comment: While correlation alone or path analysis are additional means of testing for a relationship between the variables, multiple regression is an appropriate choice. The literature support for each of the two variables is appropriate. No modifications are needed. 
Response: Thank you for your positive and constructive feedback. We appreciate your acknowledgment that multiple regression is an appropriate analytical approach for examining the relationships among the study variables, and that the supporting literature for the variables is adequate. 
Comment: The sample size is adequate for multiple regression. 
Response: Thank you for your positive evaluation. We appreciate your acknowledgment that the sample size is adequate for conducting multiple regression analysis. 
Comment: The analyses were conducted appropriately, and the results align with the literature. No changes needed. 
Response: Thank you for your positive and encouraging feedback. We appreciate your recognition that the analyses were conducted appropriately and that the results are consistent with the existing literature. 
Comment: The discussion adequately presents the logical connection of the two variables and points out that loneliness still occurs among nurses. 
Response: Thank you for your thoughtful and positive feedback. We appreciate your recognition that the Discussion section clearly presents the logical relationship between the study variables and appropriately highlights that loneliness remains a relevant issue among nurses. 
Comment: Perhaps a follow-up qualitative study seeking to understand feelings of loneliness and the causes might contribute to a deeper understanding of the causes of loneliness. 
Response: Thank you for this valuable and insightful suggestion. We agree that a qualitative approach could provide a deeper understanding of nurses’ experiences of loneliness and the underlying factors contributing to it. In response, we have incorporated this recommendation into the revised manuscript by highlighting the need for future qualitative research to explore nurses’ subjective experiences, perceptions, and contextual factors influencing loneliness. Such approaches may offer richer insights into the causes and help inform more targeted interventions. 

Reviewer 3 Report

Comments and Suggestions for Authors

The abstract should be presented in a structured format, divided into background, objective, methods, results, and conclusion, as this will make it easier for the reader to follow. The objective is formulated in an overly vague manner (“This study explores the relationship…”), which reduces scientific precision. It would be more appropriate to clearly specify the population, context, and type of analysis, for example: “This study aimed to examine the relationship between cultural competence and loneliness among nurses working at a university medical city in Saudi Arabia, and to identify associated demographic and psychological factors.”

At the level of methods, the description is insufficient, as it does not specify the sampling technique, the data collection period, or the main statistical tests used. A more robust formulation would be: “A descriptive cross-sectional study was conducted using a convenience sample of 168 nurses. Data were collected via an online questionnaire between April and May 2024 and analyzed using descriptive statistics, Spearman correlation, and multiple linear regression.”

Regarding the results, the abstract presents excessive and poorly structured information, including multiple correlations and secondary variables, which compromises clarity. In a scientific abstract, only the main findings should be prioritized. Additionally, there is an important issue of interpretation, namely the use of causal language in a cross-sectional study, such as “suggesting that increased cultural competence is linked to lower loneliness.” This type of formulation is incorrect and should be replaced with associative language, for example: “is associated with lower levels of loneliness.” The conclusion is also too generic and lacks critical depth, and could be improved with a more specific formulation aligned with the results, such as: “These findings highlight the potential role of cultural competence in reducing loneliness and psychological distress among nurses, suggesting the need for targeted training interventions.”

Regarding the introduction, it demonstrates a good literature review and presents relevant definitions of cultural competence, but lacks focus and a clear argumentative line. There is a tendency to extensively describe well-established concepts, with repetition of ideas (e.g., components of cultural competence), without a logical progression leading to the research problem. Ideally, the introduction should be reorganized into clear sections: background of cultural competence, its relevance in nursing, introduction of the loneliness variable, and finally identification of the research gap. One of the main problems is precisely the weak integration of the “loneliness” variable, which appears late and without a solid theoretical justification. It would be important to introduce it earlier and explain its possible relationship with cultural competence, for example: “Despite growing evidence on cultural competence in nursing, its potential relationship with psychosocial outcomes such as loneliness remains underexplored.”

Additionally, the introduction does not clearly state the research gap, which weakens the relevance of the study. A more appropriate formulation would be: “Although previous studies have examined cultural competence and stress among nurses, few have explored its association with loneliness, particularly in multicultural healthcare settings such as Saudi Arabia.” The study objective, as presented, is overly descriptive (“aimed to assess…”), and should better reflect the analytical nature of the research, for example: “This study aimed to examine the relationship between cultural competence and loneliness and to identify demographic and psychological predictors among nurses.” The research questions are also underdeveloped and could be reformulated in a more analytical way, such as: “What is the relationship between cultural competence and loneliness among nurses?” and “Which demographic and psychological factors predict cultural competence and loneliness?”

With regard to the methods, this is the section with the most critical issues. First, there is a major inconsistency in the sample size: the abstract refers to 168 participants, whereas the tables present 184. This discrepancy undermines the credibility of the study and must be rigorously corrected. The sample size calculation is also presented in a confusing way, with poorly formatted formulas and inconsistent results, making it difficult to understand and reproduce. A simpler and clearer explanation would be preferable, such as: “The sample size was calculated using a 95% confidence level and a 5% margin of error, resulting in a minimum required sample of 184 participants.”

Another relevant issue is the lack of a clear description of the sampling method. It is not specified whether the sampling was convenience-based, random, or otherwise, which constitutes an important methodological limitation. This should be explicitly stated, for example: “A convenience sampling technique was used.” In the description of participants, there is also a conceptual error referring to “students’ age,” when the study population consists of nurses, indicating a lack of careful revision.

The instruments section is generally well described but contains issues related to language and scientific rigor. Expressions such as “vehemently disagreement” should be corrected to “strongly disagree,” and statements such as “The CCS is a statistically significant scale” are incorrect and should be replaced with descriptions of validity and reliability, for example: “The scale has demonstrated good validity and reliability.” The description of the pilot study also raises methodological concerns, particularly the inclusion of pilot participants in the final sample, which is not recommended practice. It should be clarified that they were excluded: “Pilot participants were excluded from the final analysis.”

In the data collection process, the use of online questionnaires distributed via email and WhatsApp is described as a way to reduce selection bias, which is not accurate. This approach may, in fact, introduce selection bias, so the wording should be more cautious: “This approach may have introduced selection bias.” Finally, the statistical analysis lacks clarity, particularly in defining dependent and independent variables and explaining the use of linear regression. A more appropriate formulation would be: “Multiple linear regression was used to examine predictors of loneliness, with cultural competence dimensions as independent variables.”

Regarding the results, these are presented in considerable detail and include descriptive statistics, correlations, and regression models, which is a strength. The tables are informative and help to understand variable distributions and relationships. However, important issues remain. The inconsistency in sample size (n = 184 in the tables) persists and does not match other sections, which compromises the overall reliability of the study and must be corrected before interpretation.

Furthermore, the results section is sometimes overly descriptive and lacks synthesis. For example, the detailed description of each item of the loneliness scale (such as “Feel isolated from others” or “Feel part of a group of friends”) is unnecessary in a scientific article and should be replaced with a summary of key global indicators. Instead, emphasis should be placed on the main findings, such as overall levels of cultural competence and loneliness, and statistically significant associations.

Another important issue concerns the interpretation of correlations. The article classifies correlation strength using predefined intervals (e.g., “strong” for values above 0.75), but does not critically discuss very high values, such as r = 0.978 between cultural competence dimensions. Such high correlations may indicate redundancy between variables or multicollinearity issues, which should be examined and discussed, particularly given the use of linear regression. Indicators such as the Variance Inflation Factor (VIF) should be included to assess this.

In the regression analysis, although models are presented, there is a lack of clarity regarding what was included in each model and the theoretical justification for these choices. For example, when different dimensions of cultural competence are used as predictors of loneliness, it would be important to justify their inclusion and discuss possible interdependencies. Additionally, results presentation could be improved by including confidence intervals, not just B and p values.

With regard to the discussion, it presents some interpretations consistent with the results but has several important limitations. First, there is a tendency to repeat results rather than critically interpret them. For example, the negative association between cultural competence and loneliness is reiterated but not explored in depth, and no theoretical mechanisms are provided to explain this relationship.

Additionally, the discussion frequently uses causal language, which is inappropriate for a cross-sectional study. Statements suggesting that cultural competence “reduces” loneliness or anxiety should be reformulated to reflect associations only. For example: “These findings suggest that higher cultural competence is associated with lower levels of loneliness and psychological distress.”

Another critical issue is the lack of consistent integration with existing literature. Although some studies are cited, the discussion does not establish a meaningful dialogue between the findings and previous research. It would be important to compare results with similar studies, identify similarities and differences, and discuss possible explanations such as cultural context, sample characteristics, or measurement tools.

The discussion also fails to adequately address study limitations. Aspects such as the cross-sectional design, the use of self-report questionnaires, selection bias from online data collection, and the single-institution setting should be explicitly acknowledged. For example: “This study is limited by its cross-sectional design, which precludes causal inferences, and by the use of self-reported data, which may be subject to response bias.”

On the other hand, greater emphasis on the practical implications of the findings would be desirable. Although the article mentions the importance of cultural competence training, it does not sufficiently develop concrete recommendations for clinical practice, hospital management, or training policies. For example, it could suggest structured intercultural training programs or interventions aimed at reducing social isolation among professionals.

Finally, regarding the conclusion, it adequately summarizes the general idea of the study but is too generic and lacks critical depth. It merely reiterates the importance of cultural competence without adding new insights or clear implications. Moreover, as in the discussion, it uses language that may be interpreted as causal, which should be avoided.

A more robust conclusion should integrate three elements: a summary of the main findings, practical implications, and suggestions for future research. For example: “In conclusion, this study found that higher levels of cultural competence were significantly associated with lower levels of loneliness and psychological distress among nurses. These findings highlight the potential value of integrating cultural competence training into professional development programs. Future longitudinal studies are needed to explore causal relationships and to assess the effectiveness of such interventions.”

Author Response

Comment: The abstract should be presented in a structured format, divided into background, objective, methods, results, and conclusion, as this will make it easier for the reader to follow. The objective is formulated in an overly vague manner (“This study explores the relationship…”), which reduces scientific precision. It would be more appropriate to clearly specify the population, context, and type of analysis, for example: “This study aimed to examine the relationship between cultural competence and loneliness among nurses working at a university medical city in Saudi Arabia, and to identify associated demographic and psychological factors.” 
Response: We sincerely thank the reviewer for this constructive suggestion. We agree that structuring the abstract into clear sections, Background, Objective, Methods, Results, and Conclusion, enhances readability and clarity. In response, we have revised the abstract to follow a structured format and have refined the Objective section to specify the study population, setting, and analytical focus. 
Comment: At the level of methods, the description is insufficient, as it does not specify the sampling technique, the data collection period, or the main statistical tests used. A more robust formulation would be: “A descriptive cross-sectional study was conducted using a convenience sample of 168 nurses. Data were collected via an online questionnaire between April and May 2024 and analyzed using descriptive statistics, Spearman correlation, and multiple linear regression.” 
Response: We sincerely thank the reviewer for this constructive feedback. We agree that providing more detailed information in the Methods section enhances clarity and transparency. In response, we have revised the Methods section to specify the sampling technique, the data collection period, and the main statistical analyses. 
Comment: Regarding the results, the abstract presents excessive and poorly structured information, including multiple correlations and secondary variables, which compromises clarity. In a scientific abstract, only the main findings should be prioritized. Additionally, there is an important issue of interpretation, namely the use of causal language in a cross-sectional study, such as “suggesting that increased cultural competence is linked to lower loneliness.” This type of formulation is incorrect and should be replaced with associative language, for example: “is associated with lower levels of loneliness.” The conclusion is also too generic and lacks critical depth, and could be improved with a more specific formulation aligned with the results, such as: “These findings highlight the potential role of cultural competence in reducing loneliness and psychological distress among nurses, suggesting the need for targeted training interventions.” 
Response: We sincerely thank the reviewer for this valuable feedback regarding the Results section of the abstract. We agree that excessive detail and the use of causal language can reduce clarity and scientific accuracy, particularly in cross-sectional studies. In response, we have revised the Results section to prioritize only the main findings and replaced causal wording with appropriate associative language. We sincerely thank the reviewer for this insightful suggestion. We agree that the original Conclusion was overly generic and did not fully reflect the study findings. In response, we have revised the Conclusion to better align with the main results and to provide a clearer, more specific interpretation. 
Comment: Regarding the introduction, it demonstrates a good literature review and presents relevant definitions of cultural competence, but lacks focus and a clear argumentative line. There is a tendency to extensively describe well-established concepts, with repetition of ideas (e.g., components of cultural competence), without a logical progression leading to the research problem. Ideally, the introduction should be reorganized into clear sections: background of cultural competence, its relevance in nursing, introduction of the loneliness variable, and finally identification of the research gap. One of the main problems is precisely the weak integration of the “loneliness” variable, which appears late and without a solid theoretical justification. It would be important to introduce it earlier and explain its possible relationship with cultural competence, for example: “Despite growing evidence on cultural competence in nursing, its potential relationship with psychosocial outcomes such as loneliness remains underexplored.” 
Response: We sincerely thank the reviewer for this detailed and constructive feedback regarding the Introduction. We agree that the original text included extensive descriptions of well-established concepts and some repetition, which obscured the logical progression toward the research problem. In response, we have reorganized the Introduction into clear, cohesive sections to improve readability and argumentative flow. We sincerely thank the reviewer for highlighting the need to better integrate the “loneliness” variable in the Introduction. In response, we have revised the manuscript to introduce loneliness earlier in the text and provide a conceptual rationale for its relationship with cultural competence. 
Comment: Additionally, the introduction does not clearly state the research gap, which weakens the relevance of the study. A more appropriate formulation would be: “Although previous studies have examined cultural competence and stress among nurses, few have explored its association with loneliness, particularly in multicultural healthcare settings such as Saudi Arabia.” 
Response: We sincerely thank the reviewer for this insightful and constructive comment. We agree that the initial version of the Introduction did not sufficiently integrate the concept of loneliness or clearly articulate the research gap. In response, we have revised the Introduction to introduce loneliness earlier in the text and provide a clearer conceptual link between cultural competence and psychosocial outcomes. 
Comment: The study objective, as presented, is overly descriptive (“aimed to assess…”), and should better reflect the analytical nature of the research, for example: “This study aimed to examine the relationship between cultural competence and loneliness and to identify demographic and psychological predictors among nurses.” 
Response: We sincerely thank the reviewer for this insightful comment. We agree that the original study objective was overly descriptive and did not fully convey the analytical focus of the research. In response, we have revised the objective to reflect both the relational and predictive aims of the study. 
Comment: The research questions are also underdeveloped and could be reformulated in a more analytical way, such as: “What is the relationship between cultural competence and loneliness among nurses?” and “Which demographic and psychological factors predict cultural competence and loneliness?” 
Response: We sincerely thank the reviewer for this constructive feedback. We agree that the original research questions were overly broad and lacked analytical precision. In response, we have revised the research questions to be more focused and aligned with the study objectives. 
Comment: With regard to the methods, this is the section with the most critical issues. First, there is a major inconsistency in the sample size: the abstract refers to 168 participants, whereas the tables present 184. This discrepancy undermines the credibility of the study and must be rigorously corrected. 
Response: We sincerely thank the reviewer for carefully noting the inconsistency in the reported sample size. We apologize for this oversight. In response, we have carefully reviewed the manuscript and confirmed that the correct final sample size is 184 participants, as presented in the tables. 
Comment: The sample size calculation is also presented in a confusing way, with poorly formatted formulas and inconsistent results, making it difficult to understand and reproduce. A simpler and clearer explanation would be preferable, such as: “The sample size was calculated using a 95% confidence level and a 5% margin of error, resulting in a minimum required sample of 184 participants.” 
Response: We sincerely thank the reviewer for this valuable comment. We acknowledge that the initial presentation of the sample size calculation was unclear, with formatting issues and unnecessary complexity that may have affected its readability and reproducibility. In response, we have revised the Methods section to provide a clearer and more concise description of the sample size calculation. 
Comment: Another relevant issue is the lack of a clear description of the sampling method. It is not specified whether the sampling was convenience-based, random, or otherwise, which constitutes an important methodological limitation. This should be explicitly stated, for example: “A convenience sampling technique was used.” In the description of participants, there is also a conceptual error referring to “students’ age,” when the study population consists of nurses, indicating a lack of careful revision. Response: We sincerely thank the reviewer for these important observations. We agree that the lack of clarity regarding the sampling method and the wording inconsistency in the description of participants required correction. In response, we have revised the Methods section to explicitly state the sampling approach. Additionally, we have corrected the wording error in the participant description by replacing “students’ age” with “nurses’ age.” 
Comment: The instruments section is generally well described but contains issues related to language and scientific rigor. Expressions such as “vehemently disagreement” should be corrected to “strongly disagree,” and statements such as “The CCS is a statistically significant scale” are incorrect and should be replaced with descriptions of validity and reliability, for example: “The scale has demonstrated good validity and reliability.” The description of the pilot study also raises methodological concerns, particularly the inclusion of pilot participants in the final sample, which is not recommended practice. It should be clarified that they were excluded: “Pilot participants were excluded from the final analysis.” 
Response: We thank the reviewer for this important feedback regarding the Instruments section. All language issues have been corrected for scientific rigor (e.g., “strongly disagree”). Statements such as “The CCS is a statistically significant scale” have been replaced with precise methodological phrasing regarding validity and reliability. The pilot study section has been corrected to explicitly state that pilot participants were excluded from the final analysis. 
Comment: In the data collection process, the use of online questionnaires distributed via email and WhatsApp is described as a way to reduce selection bias, which is not accurate. This approach may, in fact, introduce selection bias, so the wording should be more cautious: “This approach may have introduced selection bias.” Finally, the statistical analysis lacks clarity, particularly in defining dependent and independent variables and explaining the use of linear regression. A more appropriate formulation would be: “Multiple linear regression was used to examine predictors of loneliness, with cultural competence dimensions as independent variables.” 
Response: We thank the reviewer for these insightful comments. The description of the online questionnaire distribution has been updated to acknowledge that this approach may have introduced selection bias. The statistical analysis section has been clarified; dependent and independent variables are now explicitly defined, and the use of regression analysis is properly described. 
Comment: Regarding the results, these are presented in considerable detail and include descriptive statistics, correlations, and regression models, which is a strength. The tables are informative and help to understand variable distributions and relationships. However, important issues remain. The inconsistency in sample size (n = 184 in the tables) persists and does not match other sections, which compromises the overall reliability of the study and must be corrected before interpretation. 
Response: We thank the reviewer for highlighting this important issue. The manuscript has been carefully revised to ensure consistency in reporting the sample size. All sections, including the Abstract, Methods, Results, and Tables, now consistently report n = 184 participants. 
Comment: Furthermore, the results section is sometimes overly descriptive and lacks synthesis. For example, the detailed description of each item of the loneliness scale (such as “Feel isolated from others” or “Feel part of a group of friends”) is unnecessary in a scientific article and should be replaced with a summary of key global indicators. Instead, emphasis should be placed on the main findings, such as overall levels of cultural competence and loneliness, and statistically significant associations. Response: Thank you for this valuable comment. The Results section has been revised to improve clarity and synthesis. Specifically, detailed item-level descriptions of the loneliness scale have been removed, and the presentation now focuses on key global indicators, including total and subscale scores. 
Comment: Another important issue concerns the interpretation of correlations. The article classifies correlation strength using predefined intervals (e.g., “strong” for values above 0.75), but does not critically discuss very high values, such as r = 0.978 between cultural competence dimensions. Such high correlations may indicate redundancy between variables or multicollinearity issues, which should be examined and discussed, particularly given the use of linear regression. Indicators such as the Variance Inflation Factor (VIF) should be included to assess this. 
Response: Thank you for this insightful comment. We agree that the very high correlations observed among the cultural competence dimensions may indicate substantial overlap between variables and potential multicollinearity in the regression models. In the revised manuscript, we have added a discussion of this issue and report multicollinearity diagnostics, including VIF and tolerance values. 
Comment: In the regression analysis, although models are presented, there is a lack of clarity regarding what was included in each model and the theoretical justification for these choices. For example, when different dimensions of cultural competence are used as predictors of loneliness, it would be important to justify their inclusion and discuss possible interdependencies. Additionally, results presentation could be improved by including confidence intervals, not just B and p values. 
Response: We have revised the regression section to specify clearly which variables were included in each model and to provide the theoretical rationale for selecting the cultural competence dimensions as predictors of loneliness. We also acknowledge that these dimensions are interrelated, and we discussed their potential overlap and interdependence more explicitly. 
Comment: With regard to the discussion, it presents some interpretations consistent with the results but has several important limitations. First, there is a tendency to repeat results rather than critically interpret them. For example, the negative association between cultural competence and loneliness is reiterated but not explored in depth, and no theoretical mechanisms are provided to explain this relationship. 
Response: We agree that the discussion should provide deeper theoretical interpretation rather than merely restating results. In the revised manuscript, we have substantially expanded our analysis of the cultural competence-loneliness relationship by explicitly linking it to stress-buffering mechanisms, improved social integration, and workplace belonging. 
Comment: Additionally, the discussion frequently uses causal language, which is inappropriate for a cross-sectional study. Statements suggesting that cultural competence “reduces” loneliness or anxiety should be reformulated to reflect associations only. For example: “These findings suggest that higher cultural competence is associated with lower levels of loneliness and psychological distress.” 
Response: Thank you for this important observation. We agree that causal language is not appropriate given the cross-sectional design of the study. Accordingly, we have carefully revised the Discussion section to avoid causal interpretations. 
Comment: Another critical issue is the lack of consistent integration with existing literature. Although some studies are cited, the discussion does not establish a meaningful dialogue between the findings and previous research. It would be important to compare results with similar studies, identify similarities and differences, and discuss possible explanations such as cultural context, sample characteristics, or measurement tools. 
Response: Thank you for this valuable feedback. In the revised manuscript, we have expanded comparisons with similar studies, explicitly identifying similarities and differences. We now discuss potential explanations including cultural context, sample characteristics (85% expatriate workforce), and institutional factors, thereby situating our results within the broader literature. 
Comment: The discussion also fails to adequately address study limitations. Aspects such as the cross-sectional design, the use of self-report questionnaires, selection bias from online data collection, and the single-institution setting should be explicitly acknowledged. 
Response: We have expanded and modified the limitations section to address all these comments, including the cross-sectional design and the use of self-reported data. 
Comment: On the other hand, greater emphasis on the practical implications of the findings would be desirable. Although the article mentions the importance of cultural competence training, it does not sufficiently develop concrete recommendations for clinical practice, hospital management, or training policies. 
Response: Thank you for this constructive suggestion. We have significantly expanded the practical implications and recommendations sections to provide concrete, actionable guidance, such as structured intercultural training programs and peer-support groups. 
Comment: Finally, regarding the conclusion, it adequately summarizes the general idea of the study but is too generic and lacks critical depth. It merely reiterates the importance of cultural competence without adding new insights or clear implications. Moreover, as in the discussion, it uses language that may be interpreted as causal, which should be avoided. 
Response: Thank you for this constructive feedback. We have completely rewritten the conclusion in the revised manuscript to provide critical depth, eliminate causal language, and articulate specific implications. 
Comment: A more robust conclusion should integrate three elements: a summary of the main findings, practical implications, and suggestions for future research. 
Response: We have completely restructured the conclusion in the revised manuscript to integrate all three recommended elements. 

Reviewer 4 Report

Comments and Suggestions for Authors

1. Although the paper explores the relationship between cultural competence and loneliness, the manuscript does not clearly define its specific contribution to knowledge, apart from what has already been established in prior studies. The authors should have placed their paper within current knowledge and clearly identified its specific contribution to knowledge.
2. The manuscript does not have a theoretical or conceptual framework to support cultural competence and its relationship to loneliness and mental health outcomes. A model to support hypothesized relationships is desirable.
3. Inconsistency is found in the sample size used in the study, where the abstract used 168 while the tables/results used 184.
4. While the limitations are recognized, they are not discussed sufficiently. This is particularly important because the correlations found are strong, as evidenced by the high correlations found in the study (e.g., r = -0.777). The authors must not only recognize the limitations but also discuss the findings as association rather than causation.
5. While the study used self-report measures, there is the potential for social desirability bias, particularly with the measures used in the study such as cultural competence.
6. The manuscript includes several correlations and regression results, yet there is no discussion of issues related to multicollinearity, assumptions of regression analysis, and interpreting effect sizes. Given the high level of correlations (e.g., greater than 0.8), there may be issues of redundancy in the variables.
7. The discussion seems to infer that cultural competence can lead directly to a decrease in loneliness and mental health problems. This should be tempered in light of the methodology.
8. The manuscript should be edited by a professional editor. There are grammatical problems, as well as some redundancy and poor phrasing in several places (e.g., in the discussion of cultural competence dimensions).

Author Response

Comment: Although the paper explores the relationship between cultural competence and loneliness, the manuscript does not clearly define its specific contribution to knowledge, apart from what has already been established in prior studies. 
Response: Thank you for this important observation. In the revised version, we have clearly positioned this study as the first to examine the relationship between cultural competence and loneliness among nurses in Saudi Arabia's highly multicultural healthcare workforce. 
Comment: The manuscript does not have a theoretical or conceptual framework to support cultural competence and its relationship to loneliness and mental health outcomes. A model to support hypothesized relationships is desirable. 
Response: Thank you for this important suggestion. We agree that the manuscript benefits from an explicit theoretical foundation. Accordingly, we have added a conceptual framework based on a stress-buffering perspective to explain how cultural competence may be associated with loneliness and mental health outcomes among nurses. 
Comment: Inconsistency is found in the sample size used in the study, where the abstract used 168 while the tables/results used 184. 
Response: We sincerely thank the reviewer for carefully noting the inconsistency in the reported sample size. We apologize for this oversight. In response, we have confirmed that the correct final sample size is 184 participants. 
Comment: While the limitations are recognized, they are not discussed sufficiently. This is particularly important because the correlations found are strong (e.g., r = -0.777). The authors must not only recognize the limitations but also discuss the findings as association rather than causation. 
Response: Thank you for this important feedback. We have substantially expanded the limitations section to provide more comprehensive discussion, particularly emphasizing that the strong correlations observed represent associations rather than evidence of causation. 
Comment: While the study used self-report measures, there is the potential for social desirability bias, particularly with the measures used in the study such as cultural competence. 
Response: In the revised manuscript, we have expanded our discussion of this limitation, noting that participants may have provided socially desirable responses due to professional expectations in a multicultural setting. 
Comment: The manuscript includes several correlations and regression results, yet there is no discussion of issues related to multicollinearity, assumptions of regression analysis, and interpreting effect sizes. Given the high level of correlations (e.g., greater than 0.8), there may be issues of redundancy in the variables. 
Response: In the revised manuscript, we have added discussion of multicollinearity concerns, including VIF values and regression assumptions. We explicitly caution that the unique contributions of individual dimensions should be interpreted conservatively. 
Comment: The discussion seems to infer that cultural competence can lead directly to a decrease in loneliness and mental health problems. This should be tempered in light of the methodology. 
Response: Thank you for this important observation. We acknowledge that the cross-sectional methodology precludes causal inferences, and we have revised the discussion throughout to consistently use associative language. 
Comment: The manuscript should be edited by a professional editor. There are grammatical problems, as well as some redundancy and poor phrasing in several places. Response: All grammatical issues, redundancy, and awkward phrasing have been addressed.

 

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

I believe that the revisions carried out by the author have substantially improved the quality, clarity, and overall rigor of the manuscript. The concerns previously raised have been adequately addressed, and the paper now presents its contributions in a clear and coherent manner. In its current form, I consider the article to be suitable for acceptance and publication.

Author Response

Comment:I believe that the revisions carried out by the author have substantially improved the quality, clarity, and overall rigor of the manuscript. The concerns previously raised have been adequately addressed, and the paper now presents its contributions in a clear and coherent manner. In its current form, I consider the article to be suitable for acceptance and publication.     

Response: We sincerely thank the reviewer for their time and for the positive assessment of our revised manuscript. We are delighted to hear that the changes made have significantly improved the clarity and rigor of the paper.

Reviewer 4 Report

Comments and Suggestions for Authors

The revised manuscript shows clear improvements in conceptual framing and analysis, with only minor issues in sample size reporting and language needing correction.

The sample size reporting is inconsistent across sections and should be clarified to ensure alignment between the calculated, recruited, and analyzed sample.

 

Author Response

Comment: 

The revised manuscript shows clear improvements in conceptual framing and analysis, with only minor issues in sample size reporting and language needing correction.

The sample size reporting is inconsistent across sections and should be clarified to ensure alignment between the calculated, recruited, and analyzed sample.

Response: 

 

We sincerely thank the reviewer for this valuable comment. In response, we carefully reviewed and revised the sample size section and language to improve clarity and methodological transparency.

We have now standardized the sample size calculation by clearly presenting the formula, all parameters used (N, Z, d, p), and step-by-step computation to ensure reproducibility. In addition, we clarified the distinction between the calculated minimum sample size and the final analyzed sample.

We also confirmed that all eligible participants who completed the survey were included in the final analysis (n = 184), which is identical to the calculated minimum required sample size, ensuring full alignment across the manuscript.