How Culture Is Communicatively Constituted In Intercultural Healthcare Organizations: Leadership Sensegiving, Knowledge Sharing, And Employee Innovation

Ahmad Adeel; Ghulam Hussain; Ahmad Aziz Sheikh

doi:10.36923/jicc.v26i1.1409

Open Access Article Organizational Culture

Ahmad Adeel ⁽¹⁾ , Ghulam Hussain ⁽²⁾ , Ahmad Aziz Sheikh ⁽³⁾

1. Faculty of Business and Communications, INTI International University, Nilai, Negeri Sembilan, Malaysia.

2. Department of Management Sciences, COMSATS University Islamabad, Lahore-Campus, Pakistan

3. Department of Business Education, The University of Chenab, Gujrat, Pakistan

https://doi.org/10.36923/jicc.v26i1.1409

Issue
Vol. 26 No. 1 (2026)

Submitted
2026 January 4

Accepted
2026 February 8

Published
2026 February 22

Keywords:

Intercultural Communication, Cross-Cultural Leadership, Leadership Sense-Giving, Inclusive Organisational Culture, Knowledge Sharing Across Cultures, Sustainable Healthcare Organisations, Developing Countries, Process Innovation

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Abstract

Healthcare organisations are increasingly intercultural workplaces in which leadership, knowledge sharing, and innovation are shaped through ongoing communicative negotiation across cultural differences. However, much existing research treats culture as a static background condition and under-theorises how leadership communication constitutes organisational realities. Drawing on intercultural communication theory, the communicative constitution of organizations (CCO), and leadership sense-giving, this study examines how culture is communicatively constituted through cross-cultural leadership and how these cultural processes shape knowledge sharing and individual innovation in culturally diverse healthcare organizations. Using a sequential mixed-methods design, qualitative interviews were first conducted to explore how healthcare professionals interpret leaders’ sense-giving as cultural cues that define legitimacy and participation. A subsequent quantitative study tested a sequential mediation model. The results show that leadership sense-giving constitutes an inclusive organisational culture, which fosters knowledge sharing and enables individual innovation. By foregrounding culture as an emergent communicative process, this study advances intercultural communication research by explaining how leadership communication becomes consequential for innovation in healthcare contexts. Practically, the findings suggest that culturally inclusive leadership sensegiving can be enacted through everyday healthcare routines, such as team meetings, clinical handovers, and shared decision-making processes, to support knowledge sharing and innovation.

Article Highlights:

Leadership sense-giving communicatively constitutes inclusive organizational culture in intercultural healthcare settings.
Inclusive culture fosters knowledge sharing across cultural and professional boundaries.
Knowledge sharing enables the enactment of employee innovation.
Organizational culture and knowledge sharing sequentially mediate the leadership–innovation relationship.
Culture operates as an emergent communicative process rather than a static organizational variable.

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Authors

Ahmad Adeel

https://orcid.org/0000-0002-1853-9982

adeelleads@yahoo.com (Primary Contact)

Ghulam Hussain

Ahmad Aziz Sheikh

https://orcid.org/0009-0002-5392-412X

Author Biographies

Ahmad Adeel

Ahmad Adeel is an associate professor of research at the Faculty of Business and Communications, INTI International University, Persiaran Perdana BBN, Putra Nilai 71800 Nilai, Negeri Sembilan, Malaysia. He received his PhD in Business Administration from Huazhong University of Science and Technology, Wuhan, China. His research interests are: conflict management, motivation, and employee creativity.

Ghulam Hussain

Ghulam Hussain is an associate professor at the Department of Management Sciences, COMSATS University Islamabad, Lahore Campus. His research interests are: management, operations, supply chain, and employee behavior.

Ahmad Aziz Sheikh

Ahmad Aziz Sheikh is affiliated with the Department of Business Education, The University of Chenab, Gujrat, Pakistan.

Adeel, A., Hussain, G., & Sheikh, A. A. (2026). How Culture Is Communicatively Constituted In Intercultural Healthcare Organizations: Leadership Sensegiving, Knowledge Sharing, And Employee Innovation. Journal of Intercultural Communication, 26(1), 32-43. https://doi.org/10.36923/jicc.v26i1.1409

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Introduction

Healthcare organisations are increasingly intercultural, with everyday work unfolding through interactions among individuals that are shaped by diverse cultural, linguistic, and professional traditions (Gibson & Zhong, 2005). Workforce mobility and organisational diversity have increased cultural diversity within healthcare organisations, making intercultural communication a key feature of contemporary organisational life (Cieślak et al., 2024). In such organisations, culture is not just a background variable that influences the behaviour of their employees; it is enacted through communication and becomes consequential in how meanings are negotiated, authority is interpreted, and collaboration is achieved (Wang, Arshad, & Arshad, 2025). Consider the example of a morning clinical handover in a diverse hospital ward, where a nurse from a rural background briefs a team meeting, including doctors and staff from different cultural backgrounds. When the nurse shares observations using local dialect nuances, the team collaborates to better understand the patient's symptoms, resulting in a unified approach to patient care. Such exchanges illustrate how culture comes to life and matters in every interaction, affecting decisions and nurturing collaboration. Intercultural communication researchers have long emphasized that culture should be understood as a dynamic and interactional process rather than a fixed attribute attached to organizations or ethnic groups (Dervin, 2016; Holliday, 2021; Vasumathi, Vasudevan, Razak, & Mohammad, 2025).

Leaders play a vital role in contemporary organizations. With their legitimate power, they frame organizational realities, shape how things will be done, signal whose knowledge will be valued, whose creative ideas will be endorsed, which behaviors are acceptable, and shape the shared understanding of appropriate actions of the employees (Adeel & Batool, 2025b; Bagga, Gera, & Haque, 2023; Batool, Ibrahim, Adeel, Jiang, & Samad, 2024). Leaders' communication thus plays a crucial role in constituting the organizational culture (Hyde & Kullman, 2004; Willett, LaGree, Shin, Houston, & Duffy, 2023). However, much of the research on leadership in culturally diverse organizations continues to rely on two core assumptions of the functionalist perspective that limit our understanding. First, it conceptualizes cultures as a mere contextual factor, a static backdrop to organizational operations. Second, it views leadership as a set of styles or competencies that are mechanically adapted to cultural differences without acknowledging the dynamic, interactive nature of culture and leadership. Within this line of research, communication is often treated as an instrumental means of transmitting decisions or aligning behavior, rather than as a site where cultural meanings are produced and contested. By explicitly naming these limitations, we can sharpen our critique of the functionalist perspective and highlight the need for more nuanced explorations of leadership in a cross-cultural context.

Intercultural communication research offers an important correction by putting the culture first, and as an emergent and communicatively constituted phenomenon. From this cultural perspective, culture is expressed through communication, relational positioning, and symbolic practices that shape interpretation, participation, and power relations (Detert & Burris, 2007; Holliday, 2021). Despite this theoretical view, empirical research that explicitly examined how leader communication constitutes organizational culture and how this culture, in turn, shapes knowledge sharing and employee innovation remains limited. This gap in the literature is significant: intercultural communication research has predominantly focused on patient-provider encounters, leaving internal organizational communication and leadership practices comparatively underexplored (McDaniel Jr, Driebe, & Lanham, 2013). Healthcare organizations are not only culturally diverse but also operate in high-stakes environments where communication failures can affect patient safety, ethical practices, and organizational learning. For instance, a breakdown in communication during a critical patient handover might lead to misinterpretation of medical conditions and incorrect treatment paths, endangering patient outcomes. This gap is particularly consequential because internal leadership communication shapes how cultural differences are negotiated among healthcare professionals, yet remains comparatively underexamined in intercultural communication research.

Cultural assumptions embedded in leadership communication research have often led scholars to treat organizational culture as a static explanatory variable, limiting our understanding of how cultural dynamics emerge and evolve in organizational practices (Johansson et al., 2014). In simple terms, the communicative constitution of organizations (CCO) is a theoretical approach that views organizations as entities created and continually shaped by communication among people. This perspective views organizations not as fixed structures but as ongoing accomplishments achieved through communication (Putnam & Maydan Nicotera, 2010). From the CCO perspective, organizational culture is not merely a background condition, but an evolving form of communicative behavior through which meanings, roles, and expectations are continuously negotiated and stabilized (Cooren et al., 2011). Leadership, accordingly, is also understood as an interpersonal communicative process through which meanings are authorized, coordinated, and stabilized (Mayfield et al., 2021).

Leadership sense-giving further reinforces this cultural perspective by focusing on how leaders frame situations, articulate priorities, and offer interpretive cues to subordinates that guide collective understanding, particularly under conditions of ambiguity (Marshall, 2018; Weick, Sutcliffe, & Obstfeld, 2005; Adeel, Kee, & Qasim, 2022). Sense-giving in a leadership context is, by nature, cultural because it depends on shared symbols and understandings while also reshaping them. In culturally diverse healthcare organizations, leadership sense-giving will become an important site where multiple cultural perspectives converge, shaping how knowledge is interpreted and how employee innovation emerges (Rom & Eyal, 2019). Despite the theoretical relevance, only a few researchers have integrated CCO and leadership sense-giving to examine how culture is formed through interactions and leadership practices in healthcare organizations, and how these cultural processes shape knowledge sharing and employee innovation. Through repeated sense-giving episodes, leaders' communicative cues can become taken-for-granted reference points that shape how employees interpret situations, evaluate knowledge, and judge the legitimacy of innovative ideas.

While prior research informed by the communicative constitution of organisations has emphasised leadership as a process of meaning construction and coordination, it has paid comparatively less attention to how leadership communication becomes stabilised as shared cultural expectations over time. Existing studies typically examine leadership sensemaking or knowledge processes in isolation, offering limited insight into how leaders’ sensegiving practices crystallise into organisational norms that shape participation, legitimacy, and innovation. Building on this literature, the present study does not position theoretical integration as its primary contribution. Instead, this research advances intercultural communication research by specifying a sequential communicative process through which leadership sensegiving contributes to the constitution of organisational culture, which in turn fosters knowledge sharing and enables employees to innovate in culturally diverse healthcare environments.

From the process-oriented perspective, this research employs a sequential mixed-methods design. The qualitative part of this research explores how healthcare professionals interpret leadership communications as culturally consequential in their routine, everyday work; however, the quantitative part examines how these interpretations are patterned across individuals using a sequential mediation model. This approach allows this research to link lived communicative experiences to broader relational patterns without reducing culture to a static organisational attribute.

From the process-oriented perspective, this research employs a sequential mixed-methods design. The qualitative part of this research explores how the healthcare professionals interpret leadership communications as culturally consequential in their routine, everyday work. As one participant described, "When our leader explains the reasons behind decisions and acknowledges our diverse perspectives, it makes us feel respected and willing to share our viewpoints." The quantitative part of this research examines how these interpretations of employees are patterned across individuals through a sequential mediation model. This approach allows this research to link lived communicative experiences to broader relational patterns without reducing culture to a static organizational attribute.

Theoretical Framework and Hypotheses Development

Culture as a Communicative and Constitutive Process in Organizations

Intercultural communication research conceptualizes organizational culture not just as a stable set of shared values or traits, but as a meaning system that is shaped and negotiated through communication (Piller, 2012). From this perspective, culture becomes visible in how individuals frame issues, interpret authority, manage conflicts, and legitimate employees’ knowledge and creative exchanges (Dervin, 2016; Hall & Swaine, 1976; Holliday, 2021). The communicative constitution of organizations (CCO) perspective provides a foundational framework for understanding how communicative processes are reproduced, challenged, or transformed by cultural assumptions. CCO researchers have found that organizations do not just precede communication; their structures, routines, and cultures also emerge through workplace communication (Cooren et al., 2011). This perspective emphasizes that culture is not merely an external context that influences organizational actions; it is an outcome of communicative practices that define what is meaningful, appropriate, and legitimate in workplaces (McPhee & Zaug, 2009).

In healthcare organizations, communication is particularly important for fostering a diverse culture. Professionals from diverse cultural backgrounds and linguistic repertoires work together across hierarchical structures and high-stakes institutional environments. These workplace conditions enhance the significance of leaders’ communication and are a central mechanism through which the organizational cultures are endorsed (Terkamo‐Moisio, Karki, Kangasniemi, Lammintakanen, & Häggman‐Laitila, 2022). So, leadership practices that involve attributing to subordinates, interpreting and framing, evaluating, and endorsing subordinates’ input become increasingly important in shaping how subordinates view, experience, manage, and mobilize cultural diversity in everyday life. In such contexts, leadership communication becomes a primary site through which cultural meanings are reinforced, negotiated, or challenged in everyday organizational practice.

Cross-Cultural Leadership: Sense-giving and Organizational Culture

Leadership sense-giving refers to the communicative processes through which leaders shape how others understand the organizational environment by framing situations, setting priorities, and offering interpretive cues (Gioia & Chittipeddi, 1991). Sense-giving, by its essence, is consequential in contexts characterized by ambiguity, complexity, and change, where shared understanding cannot be taken for granted (Polanyi, 1967; Schultz, Chaney, & Debenedetti, 2016). Sense-giving is an important part of organizational life, but it is not a neutral activity; it is deeply embedded in cultural assumptions about authority, voice, and meaning. From an intercultural communication perspective, leadership sense-giving is inherently cultural because it draws on culturally embedded symbols, narratives, and expectations that simultaneously shape them (Grisham, 2006). Subordinates read the winds according to the communicative choices the leader made and attribute importance to what is important when it is safe to voice their ideas (Ahmad, Thurasamy, Adeel, & Alam, 2023). Moreover, these attributions are reflected in their behaviors that signal cultural norms regarding participation, expertise, and legitimacy at workplaces.

In culturally diverse healthcare organizations, leadership sense-giving functions as a central communicative mechanism through which organizational culture is constituted rather than merely influenced. From a CCO perspective, repeated sense-giving episodes enable particular interpretations of "how things are done" to become stabilized through interaction, endorsement, and institutional reinforcement (Detert & Burris, 2007). Over time, these stabilized interpretations form shared cultural expectations that define participation, legitimacy, and acceptable behavior, while simultaneously marginalizing alternative meanings. In intercultural settings, leadership sense-giving can therefore either foster inclusive cultural norms that accommodate diversity or reinforce dominant frames that constrain voice and engagement. Over time, these patterns become institutionalized as an organizational culture. In intercultural settings, the leadership sense-giving can either foster inclusive cultural meanings that accommodate diversity or reinforce the dominant cultural frames that constrain participation. Thus, we predict here:

Hypothesis 1: Cross-cultural leaders’ sense-giving practices are positively related to the development of an inclusive organizational culture in culturally diverse healthcare organizations.

Organizational Culture and Knowledge Sharing Across Cultures

Knowledge exchange and employee innovation research across cultures also reflects some similar limitations. Cultural diversity has been found by the researchers as a catalyst for enhancing creative potential of employees, a lot of research has explained this outcome as a structural arrangement or due to the individual attitude, giving less attention to the communicative processes through which the knowledge is considered legitimate, shareable, or actionable (Nonaka et al., 1996; Okatta et al., 2024). Also, knowledge as an organizational resource is primarily considered as an objective resource that can flow across cultural boundaries, and innovation as an outcome of employees' efforts that follows the diverse organizational culture under favorable conditions (Adeel & Batool, 2025a; Adeel et al., 2023). This framing in the literature has overlooked the significant cultural role in determining whose ideas are recognized as knowledge, who is heard, and how the novelty of ideas is interpreted in intercultural settings. Employee knowledge sharing in interculturally diverse organizations cannot be understood independently of the organizational culture. Knowledge is not just information and its exchange that circulates within organisational systems; employee knowledge sharing is culturally situated and communicatively constructed (Batool, Ibrahim, & Adeel, 2024). What is considered as a reliable and valid knowledge, which employee is perceived as a credible knowledge holder, and when the knowledge is considered appropriate by the employees and when to share knowledge are all shaped by the cultural norms and the communicative expectations (Nonaka et al., 1996). For instance, employees might judge the legitimacy of knowledge based on the cultural compatibility of the ideas presented or the hierarchical status of the knowledge holder, which assumes that authority often correlates with credibility in certain cultural contexts.

The Intercultural communication research has highlighted that cultural differences influence how individuals interpret workplace authority, manage uncertainty at work, and engage in interpersonal interactions. In healthcare organizations, where professional hierarchies intersect with cultural diversity, these perspectives and the dynamics are particularly important. Cultural assumptions are embedded in organizational cultures and may either encourage employees to engage in open exchange or reinforce silence, especially among employees from different cultural or professional groups (Assoratgoon & Kantabutra, 2023). Thus, employee knowledge sharing emerges not simply from the employees’ willingness to exchange but also from the culturally constituted communicative environments. These dynamics are especially salient in healthcare organizations, where hierarchical authority and professional status intersect with cultural diversity to shape communication patterns.

From the perspective of CCO, organizational culture provides the interpersonal conditions under which employee knowledge sharing becomes possible in workplaces. Cultures characterized by inclusivity, interpretive openness, and mutual recognition enable knowledge to circulate across organizational cultural boundaries (J. Zhang, Jehangir, Yang, Tahir, & Tabasum, 2025). Conversely, cultures that privilege the dominant voices of employees or narrow definitions of expertise restrict knowledge exchange among employees. Leadership sense-giving plays a vital role in shaping these cultural conditions by framing employee knowledge sharing as legitimate, valued, and safe. Thus, we predict here:

Hypothesis 2: An inclusive organizational culture is positively related to knowledge sharing among culturally diverse healthcare professionals.

Knowledge Sharing as a Cultural Foundation for Innovation

Employee innovation in intercultural organizations is not solely the result of structural diversity or individual creativity (AlEssa & Durugbo, 2022; Amoozegar et al., 2025; Song et al., 2025). Employee innovation is culturally understood through communicative practices. Innovation requires not only the generation of novel and valuable ideas but also their recognition, interpretation, and integration into organizational practice. These recognition, interpretation, and integration processes depend heavily on shared cultural meanings and communicative alignment. In this research, employee innovation is conceptualized as the behavioral enactment of employees' creative ideas, rather than as their creative potential or as organizational-level outcomes. Innovation refers to employees’ implementation of new ideas, practices, or solutions in their work roles that emerge from culturally constituted knowledge-sharing environments (Y. Zhang, Xi, & Xu, 2022; Zhou & Shalley, 2011). For instance, consider a nurse introducing a new protocol for patient check-ins to a culturally diverse team. By integrating colleagues' feedback on cultural considerations and emphasizing collaborative decision-making, the nurse implements a system that improves patient interactions and care outcomes. This example illustrates employee innovation as an observable action shaped by communicative and cultural processes, rather than as an underlying orientation or an abstract organizational performance indicator (Zeleke, Guyo, & Moronge, 2025).

Intercultural communication researchers have suggested that cultural diversity enhances employees' innovative potential only when workplace communication conditions allow the meaningful exchange of knowledge, the recombination and accumulation of diverse perspectives, and the meaningful exchange of knowledge. Knowledge sharing is an important cultural mechanism through which employees exchange and recombine knowledge. In healthcare organizations, employee innovation often arises from collaborative problem-solving across professional and cultural boundaries, making communicative openness essential (Gibson & Zhong, 2005). Within a CCO framework, employee innovation is constituted by communicative processes that link employee knowledge sharing to collective action. When organizational culture legitimizes employees’ diverse knowledge contributions and the leadership sense-giving reinforces interpretive openness, knowledge sharing of employees becomes a pathway through which innovation is enacted (J. Zhang et al., 2025). Without such cultural support, diversity may instead lead to fragmentation or defensive communication, constraining innovation. Thus, we predict here:

Hypothesis 3: Employee knowledge sharing is positively related with employee innovation in culturally diverse healthcare organizations.

The Mediating Role of Organizational Culture and Knowledge Sharing

Combining all the above discussions, leadership sense-giving, organizational culture, employee knowledge sharing, and employee innovation form a sequential cultural process. Leaders’ sense-giving is associated with the development of a vibrant organizational culture, which, in turn, shapes the communicative conditions for employees' knowledge sharing (Mehreen, Clegg, & Rammal, 2025). Employee knowledge sharing then enables innovation by facilitating the integration of the knowledge gained and diverse cultural perspectives into organizational practice. This process-oriented view aligns with intercultural communication theory by emphasizing how culture operates through communication rather than as an external variable. It also extends CCO research by linking leadership communication to innovation through culturally constituted knowledge processes. In healthcare organizations, where cultural misalignment can have significant consequences, understanding this sequence is particularly important. From an interpretive perspective, this sequential mediation represents patterned sensemaking rather than deterministic causality. The statistical model is therefore used as an analytical representation of communicatively constituted processes, consistent with a constructivist understanding of organizational communication. Thus, we predict:

Hypothesis 4: Organizational culture and employee knowledge sharing sequentially mediate the relationship between cross-cultural leadership sense-giving and employee innovation.

Figure 1. Illustrates the proposed theoretical framework

Methodology

Research Design

In this research, we used a sequential mixed-methods design to explain how cross-cultural leadership sense-giving communicatively creates organizational culture, knowledge sharing, and innovation in culturally diverse health care organizations. A mixed-methods approach was used in this research, as it was appropriate for understanding the current proposed model in a process-oriented view of culture as an emergent communicative phenomenon. Using both qualitative and quantitative methods in this research enabled us to capture both the deeper explanations of intercultural communication processes and the stable relationship patterns among the key variables (Creswell & Plano Clark, 2023).

Consistent with the communicative constitution of organizations (CCO) perspective, the qualitative phase served as the primary interpretive foundation, examining how participants experienced and interpreted leadership communication across cultural differences. Insights from this phase informed the conceptual refinement of key constructs and clarified the sequential logic linking leadership sense-giving, organizational culture, knowledge sharing, and innovation. The subsequent quantitative phase was designed to examine whether these interpretive patterns were systematically reflected across a larger sample, allowing the study to explore patterned relationships without treating culture as a static organizational attribute.

In cultural studies, organizational culture is often conceptualized as a collective- or organizational-level construct; however, in this research, we examined culture at the individual level, namely the individual’s experience and the interpretation of organizational members. Consistent with previous research on intercultural communication and CCO perspectives, culture is measured through individuals’ sense-making of leadership communication and everyday interactional practices. The operationalization of individual-level culture represents culture as lived and enacted, rather than as an aggregated or objective organizational identity. Therefore, it was appropriate to examine how intercultural meanings shape knowledge sharing and individual innovation. To mitigate potential common-method bias, we incorporated multiple data sources and used both qualitative interviews and quantitative surveys across different study phases. This approach reduces the likelihood of bias and strengthens the credibility of our findings by offering a more comprehensive view of the cultural processes involved.

Epistemological Positioning and Analytical Strategy

This study adopts an interpretive-constructivist epistemological stance consistent with intercultural communication research and the communicative constitution of organizations perspective. Culture is not treated as an objective or measurable attribute of organizations, but as a socially constructed and communicatively enacted phenomenon that emerges through interaction. Accordingly, leadership, organizational culture, employee knowledge sharing, and employee innovation are examined as meanings and practices experienced and enacted by individuals rather than as fixed structural properties. This positioning allows the study to foreground participants’ interpretations of leadership communication as culturally consequential while remaining analytically consistent with a process-oriented view of communication. To align methodological choices with this epistemological stance, thematic analysis was employed in the qualitative phase to interpret participants' narratives. At the same time, SEM was utilized in the quantitative phase to test the relationships among constructs as experienced by individuals, ensuring coherence between the epistemological and analytical frameworks.

Table 1.Descriptive Statistics and Reliability
Construct	Mean	SD	Cronbach’s α	CR	AVE
Leadership Sense-giving	3.74	0.62	0.89	0.91	0.62
Organizational Culture	3.68	0.58	0.87	0.89	0.60
Knowledge Sharing	3.59	0.65	0.85	0.88	0.59
Employee Innovation	3.51	0.61	0.83	0.86	0.56

Note. N=347; CR = composite reliability; AVE = average variance extracted. All reliability values exceed recommended thresholds. Source: Author’s own work

Treatment of Control Variables

In this research, we adopted a theory-driven, process-oriented analytical approach. As the focus was on the communicative and cultural mechanisms through which the leadership sense-giving establishes organizational culture, knowledge sharing, and individual innovation, the control variables were not central to the theoretical model. Therefore, consistent with research on intercultural communication, this analysis prioritizes meaning-making processes over individual attributes. Also, the additional analyses that included basic demographic variables did not significantly change the patterns of the results; thus, they were not reported. Consistent with this approach, demographic variables were examined in supplementary analyses and did not substantively alter the estimated relationships, supporting the robustness of the reported findings.

Research Context and Participants

In this research, data were collected from culturally diverse health care organizations, including both public and private hospitals that employed healthcare professionals from multiple cultural, ethnic, linguistic, and professional backgrounds. The healthcare sector was selected for this research because it is a high-stakes institutional environment where intercultural communication, leadership, and knowledge exchange are closely linked to ethical responsibility and organizational performance. The participants in this study included both formal leaders (e.g., department heads, clinical supervisors, senior administrators) and healthcare professionals (e.g., physicians, nurses, allied health staff). Those who worked in culturally diverse teams and regularly interacted with their bosses across cultural or professional boundaries were approached for data collection. This ensured that participants had sustained exposure to intercultural leadership communication. The context of this research was intercultural. The participants worked in culturally diverse health care organizations characterized by daily interactions among individuals from different cultures, linguistic, ethnic, and professional backgrounds. Instead of treating culture as a fixed categorical variable, this research conceptualized it as a condition of ongoing communicative engagement across difference.

Table 2.Descriptive Statistics and Reliability
Construct	Mean	SD	Cronbach’s α	CR	AVE
Leadership Sense-giving	3.74	0.62	0.89	0.91	0.62
Organizational Culture	3.68	0.58	0.87	0.89	0.60
Knowledge Sharing	3.59	0.65	0.85	0.88	0.59
Employee Innovation	3.51	0.61	0.83	0.86	0.56

Note. N=347; CR = composite reliability; AVE = average variance extracted. All reliability values exceed recommended thresholds. Source: Author’s own work

Table 3.Confirmatory Factor Analysis Results
Fit Index	Recommended	Observed
χ²/df	< 3.00	2.31
CFI	≥ 0.90	0.94
TLI	≥ 0.90	0.93
RMSEA	≤ 0.08	0.056
SRMR	≤ 0.08	0.048

Note. N=347; Model fit indices indicate good measurement model fit. Source: Author’s own work.

Qualitative Phase: Data Collection and Analysis

Data Collection

In this research, for the qualitative part, we used semi-structured interviews with healthcare professionals and their supervisors (leaders). The primary focus of these interviews was on the experience of the participants of leadership communication in the intercultural context, with significant attention on how their leaders framed the organizational priorities, encouraged them, or constrained their voice, and recognized their knowledge contributions. These open-ended questions allowed the participants to explain the solid interactional episodes that involve leadership communications, knowledge sharing, and their innovation. Interviews were conducted in their local language, with a focus on linguistic sensitivity and, where necessary, clarification of meaning. The duration of each interview was approximately 45–60 minutes, and all interviews were audio-recorded with the consent. Data collection continued until theoretical saturation was reached, meaning that during the interviews, no substantively new cultural or communicative themes emerged (n=36). Before data collection, formal approval was obtained from management. The purpose and significance of the research were explained to management in a formal meeting, and then formal approval was granted for data collection. Given the sensitivity of intercultural and hierarchical dynamics in healthcare organizations, particular care was also taken to anonymize the data and ensure that participation posed no professional risks to the respondents.

Data Analysis

Interview data were then analyzed using thematic analysis (Braun & Clarke, 2006). We read the transcripts iteratively across multiple stages to identify recurring communicative patterns related to the leaders’ sense-giving, cultural interpretation, knowledge legitimacy, and innovation. In the second stage, we inductively assigned the initially developed codes while staying close to the participants’ language and meanings. In the third stage, the codes were refined and clustered into higher-order themes that reflected culturally constituted communicative processes. Throughout this analysis, special attention was given to how the participants described the cultural dimensions of the communication; this also included their assumptions about authority, participation, and expertise. Reflexive memos were also maintained to document analytic decisions and address the researchers’ positionality. Findings from the qualitative phase were then used to refine construct definitions and inform the design of the quantitative survey instrument. (n=36). Notably, the qualitative analyses also revealed that tensions and asymmetries in leadership communication, including moments when leadership sense-giving is constrained by participation or reinforces hierarchical boundaries, informed the interpretation of the quantitative results rather than serving as confirmatory evidence.

Quantitative Phase: Data Collection and Measures

Survey Design and Data Collection

A cross-sectional survey was used in this research for a large sample of healthcare professionals working in culturally diverse teams. In this research, we adapted the survey items based on validated scales, with minor tweaks to the wording to reflect insights from the qualitative phase and to ensure cultural and contextual appropriateness. The survey was distributed electronically, and participation in the survey was voluntary and anonymous. To assess clarity, cultural sensitivity, and reliability before the entire administration, the survey was pilot-tested. Data was collected from healthcare professionals working in different hospitals in South Punjab, Pakistan. Initially, 1000 emails were sent to the registered healthcare professionals and administrators; after two weeks, 500 more emails were sent. The researchers wanted to receive as many responses as they could. Initially, 639 healthcare professionals and 48 administrators agreed to participate; 458 healthcare professionals and 24 supervisors provided data after several reminders. After deleting mismatched and incomplete data, our final sample included 347 healthcare professionals and 22 supervisors.

Table 4.Structural Model Results (Direct Effects)
Path	β	SE	t-value	Result
Leadership Sense-giving → Organizational Culture	0.48	0.05	9.60***	Supported
Organizational Culture → Knowledge Sharing	0.41	0.06	6.83***	Supported
Knowledge Sharing → Employee Innovation	0.36	0.06	6.00***	Supported
Leadership Sense-giving → Employee Innovation	0.09	0.05	1.80	Not supported

Note. N=347; *** p < .001. Source: Author’s own work

Table 5.Mediation Analysis (Bootstrapping, 5,000 Samples)
Indirect Path	β	95% CI	Mediation
Leadership Sense-giving → Organizational Culture → Knowledge Sharing → Employee Innovation	0.07	[0.04, 0.11]	Supported
Leadership Sense-giving → Organizational Culture → Employee Innovation	0.05	[0.02, 0.09]	Supported

Note. N=347; Confidence intervals do not include zero, indicating significant indirect effects. Source: Author’s own work

Measures

Cross-Cultural Leadership Sense-giving was measured using 6 items (Gioia & Chittipeddi, 1991) on a five-point Likert scale. Sample items include “My leader helps team members interpret organizational goals across cultural differences” and “My leader explains the meaning behind decisions in ways that make sense to people from different cultural backgrounds.” (α = .89). Organizational Culture was measured using five items (Cooren et al., 2011; Holliday, 2021) on a 5-point Likert scale. Sample items include “Different cultural perspectives are respected in my organization” and “Employees feel safe expressing culturally different viewpoints.” (α = .87). Knowledge Sharing was measured with five items on a five-point Likert scale. Consistent with the prior research, knowledge sharing was conceptualized as an enacted behavioral practice rather than a structural or technological process (Bock, Zmud, Kim, & Lee, 2005). Items assessed the extent to which the respondents voluntarily exchanged, explained, and built upon knowledge through interactions across cultural differences. Sample items include “I willingly share work-related knowledge with colleagues from different cultural backgrounds” and “I exchange ideas and experiences with culturally diverse colleagues to solve work-related problems” (α = .85). Individual Innovation was measured with 4 items on a five-point Likert scale. Consistent with prior research, innovation was conceptualized as an implementation-oriented behavior rather than as creative potential or organizational-level outcomes (Farr & Ford, 1990; Scott & Bruce, 1994). Sample items include “I implement new ideas in my work to improve existing practices” and “I contribute to putting new solutions or approaches into practice in my job.” (α = .83).

Data Analysis Strategy

Data was analyzed using structural equation modeling (SEM) with Mplus. SEM was selected for this research because it allows simultaneous estimation of multiple relationships and testing of mediation effects, consistent with this research’s process-oriented theoretical model. Bootstrapping procedures were used to assess the mediation model and to assess the indirect effects. Model fit indicators were used to evaluate the model using the comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR).

Integration of Qualitative and Quantitative Findings

Integration occurred at both the design and interpretive stages of the study. Qualitative findings informed construct clarification, the sequencing of the proposed model, and the interpretation of mediation pathways by highlighting how leadership communication was experienced as culturally enabling or constraining. Quantitative results were subsequently interpreted through these communicative patterns, allowing statistical relationships to be understood as manifestations of culturally constituted interactional processes rather than as isolated variable effects.

Table 6.Structural Model Fit Indices
Fit Index	Value
χ²/df	2.47
CFI	0.93
TLI	0.92
RMSEA	0.059
SRMR	0.051

Note. N=347; Overall structural model demonstrates acceptable fit. Source: Author’s own work

Results

Qualitative Results

Analysis of the interview data revealed recurring patterns in how healthcare professionals described leadership communication and its role in shaping everyday work interactions in culturally diverse settings. Participants of the qualitative part consistently identified leadership communication as an important reference point through which their expectations regarding authority, participation, and legitimacy were enacted in their daily routine organizational life.

Many participants described inclusive leadership communication practices, such as explaining the rationale behind decisions, acknowledging culturally and professionally diverse viewpoints, and inviting dialogue, as signals that shaped a shared sense of openness within their teams. These practices were frequently associated with participants’ perceptions that diverse perspectives were welcomed and that speaking up was appropriate in routine interactions. In contrast, participants also reported experiences of leadership communication characterized by implicit assumptions, limited explanation, or unidirectional messaging. Such practices were described as reinforcing hierarchical distance and narrowing the range of acceptable contributions, particularly for staff from minority cultural or professional backgrounds.

Knowledge sharing emerged in the interviews as a context-dependent activity rather than a routine organizational behavior. Participants indicated that their willingness to exchange knowledge was shaped by how leadership communication framed expertise and participation. In settings where leaders explicitly recognized different forms of knowledge and encouraged explanation across professional and cultural boundaries, participants reported more frequent exchanges of ideas and problem-solving information. Conversely, when leadership communication emphasized status, seniority, or culturally narrow definitions of expertise, participants described withholding knowledge or limiting exchanges to trusted in-group members.

Participants described innovation as emerging from collaborative interactions rather than from individual idea generation alone. Interviewees noted that implementing new ideas often depended on whether knowledge sharing across cultural and professional boundaries was normalized in everyday work practices. Participants emphasized that innovation was more likely to occur when leadership communication created space for experimentation, discussion, and adaptation. In contrast, environments characterized by restricted dialogue and rigid authority structures were described as limiting the enactment of new approaches.

Across interviews, these patterns highlighted variation in how leadership communication was experienced and how cultural expectations regarding participation, knowledge exchange, and change were enacted in practice. The qualitative findings, therefore, document consistent differences in communicative environments within culturally diverse healthcare organizations, as experienced by participants in their everyday work interactions.

Table 7.Qualitative Coding Structure and Emergent Themes
First-Order Codes	Second-Order Categories	Aggregate Cultural Themes
Explaining decisions across cultures	Meaning framing	Leadership sense-giving as cultural interpretation
Clarifying expectations explicitly	Interpretive guidance	Leadership sense-giving as cultural interpretation
Encouraging dialogue across differences	Voice legitimization	Leadership sense-giving as cultural interpretation
Feeling safe to speak up	Cultural safety	Inclusive organizational culture
Respect for diverse viewpoints	Cultural legitimacy	Inclusive organizational culture
Learning from culturally different colleagues	Knowledge exchange	Knowledge sharing across cultural boundaries
Adapting practices based on shared input	Knowledge integration	Knowledge sharing across cultural boundaries
Trying new approaches in daily work	Idea enactment	Employee innovation as cultural enactment
Implementing shared solutions	Practice innovation	Employee innovation as cultural enactment

Note. N=36; Coding followed an inductive-interpretive approach consistent with intercultural communication and CCO research. Source: Author’s own work

Table 8.Cultural Themes, Definitions, and Representative Quotes
Cultural Theme	Analytical Definition	Representative Quote
Leadership sense-giving as cultural interpretation	Leaders’ communicative framing that helps employees interpret meaning across cultural differences	When my supervisor explains why we do things, it helps everyone understand, even if we come from different backgrounds.
Inclusive organizational culture	A communicatively enacted environment where diverse cultural perspectives are recognized as legitimate	Here, different ways of thinking are accepted. You do not feel judged because of where you come from.
Knowledge sharing across cultural boundaries	Voluntary exchange and explanation of knowledge across cultural and professional differences	We openly share experiences, even when our training or culture differs.
Individual innovation as cultural enactment	Implementation of new ideas emerging from culturally inclusive communication	After discussing with colleagues from different backgrounds, I tried a new approach in my work.

Note. N=36; Quotes are anonymized and illustrative of recurring themes. Source: Author’s own work

Quantitative Results

Prior to the hypothesis testing, to assess the measurement model, confirmatory factor analysis (CFA) was performed. The four-factor model demonstrated a good fit to the collected data: χ²/df = 2.31, CFI = 0.94, TLI = 0.93, RMSEA = 0.056, and SRMR = 0.048. All the factor loadings were significant (p < .001) and exceeded 0.65, indicating a satisfactory convergent validity. Composite reliability values and average variance extracted (AVE) values also exceeded the recommended thresholds for all the constructs. Discriminant validity was also established as the square root of AVE. The hypothesized structural model was then tested using structural equation modeling with maximum likelihood estimation. The overall model demonstrated the acceptable fit: χ²/df = 2.47, CFI = .93, TLI = .92, RMSEA = .059, and SRMR = .051. All the path coefficients are reported as the standardized estimates.

We regressed organizational culture on leadership sense-giving; the result revealed a positive relationship between leadership sense-giving and organizational culture (β = .48, p < .001), supporting hypothesis 1 of this research. We then regressed knowledge sharing on organizational culture; the result revealed a positive relationship between organizational culture and knowledge sharing (β = .41, p < .001), supporting hypothesis 2 of this research. We regressed individual innovation on knowledge sharing. The results revealed a positive relationship between knowledge sharing and individual innovation, supporting hypothesis 3 of this research (β = .36, p < .001).

To confirm mediation, a bootstrapping analysis with 5,000 resamples was performed, and the results indicated a significant indirect effect (β = .07, 95% CI [.04, .11]), providing support for the proposed sequential mediation and supporting hypothesis 4 of this research. Further, the direct effect of leadership sense-giving on innovation became non-significant when the mediators were included in the equation (β = .09, p > .05), suggesting a complete mediation.

Table 9.Linking Qualitative Themes to the Sequential Mediation Model
Model Component	Supporting Qualitative Insight
Leadership sense-giving → Organizational Culture	Leadership framing defined cultural norms of participation and meaning
Organizational Culture → Knowledge sharing	An inclusive culture enabled open exchange across differences
Knowledge sharing → Employee Innovation	Shared knowledge translated into enacted improvements
Sequential process	Innovation emerged after shared understanding and exchange

Note. N=36; This table illustrates how qualitative findings substantively support the proposed sequential mediation model. Source: Author’s own work

Qualitative Findings

Analysis of the qualitative interview data revealed consistent patterns illustrating how culture was communicatively constituted through leadership sense-giving, and how these cultural processes shaped knowledge sharing and innovation. Participants of the qualitative study described the leadership communication as a central space where cultural expectations regarding authority, voice, and legitimacy were enacted. Leaders' framing of organizational goals, openness to dialogue, and responsiveness to culturally diverse perspectives were repeatedly cited as signals that shaped how organizational culture was understood and experienced.

The Participants emphasized that inclusive sense-giving practices, such as acknowledging diverse professional and cultural viewpoints, explaining the rationale behind decisions, and inviting interpretation rather than imposing meaning, fostered a shared cultural understanding that encouraged participation. Conversely, leadership communication that relied on implicit assumptions, culturally narrow norms of authority, or unidirectional messaging was described as reinforcing exclusion and discouraging engagement. These communicative patterns were not just interpreted as leadership behaviors but also as cultural signals that define “how things are done” within their organization.

Employee knowledge sharing also emerged as a culturally underlying mechanism and process rather than a routine activity. The participants also noted that willingness to share knowledge depended on whether the organizational culture, as constituted through the leadership communication process, recognized diverse forms of expertise and provided culturally safe spaces for beneficial exchanges. Employee innovation, consequently, was described as an emerging phenomenon when employee knowledge sharing across cultural and professional boundaries was normalized and legitimized. These qualitative findings provided strong support for the proposed sequential model linking leadership sense-giving, organizational culture, knowledge sharing, and innovation.

Discussion

This research examined intercultural leadership communication in healthcare organizations by foregrounding culture as a communicatively constituted and power-laden process rather than a static contextual variable. Throughout qualitative and quantitative analyses, leadership sense-giving emerged as a central communicative mechanism through which meanings about authority, employee voice, and legitimacy at work were negotiated in everyday interactions between employees and their supervisors. The findings from both analyses revealed that sense-giving workplace practices were not perceived as welcoming by everyone. Qualitative results highlighted moments where leadership communication enabled participation by explaining decisions, acknowledging diverse expertise, and inviting dialogue, as well as moments where implicit norms, hierarchical assumptions, or culturally narrow frames constrained engagement. These tensions also illustrated that intercultural communication in healthcare operates through uneven and asymmetrical communicative practices, shaping which knowledge is recognized and whose ideas gain traction.

The quantitative results were interpreted in the light of these communicative tensions. While leadership sense-giving was positively related to workplace organizational culture, employee knowledge sharing, and employee innovation through a sequential process, the qualitative findings indicated that these relationships depend on how culture is enacted through communication at organizations. Inclusive sense-giving practices were associated with communicative environments that normalized knowledge exchange across cultural and professional boundaries, thereby enabling innovation as an enacted behavior rather than a latent capacity. On the other hand, leader sense-giving that reinforced hierarchy or ambiguity was experienced as reducing knowledge sharing and limiting their innovation. Taken together, these findings suggest that innovation in intercultural healthcare settings does not simply follow from diversity or leadership presence, but depends on whether communicative conditions allow cultural differences to be translated into shared understanding and coordinated action within specific institutional and cultural contexts.

This study advances intercultural communication research by specifying how leadership, culture, and innovation are constituted through ongoing communicative processes rather than treated as static attributes or contextual variables. By conceptualizing cross-cultural leadership sense-giving as a culturally embedded communicative practice, the study extends leadership research beyond trait- or competency-based models and demonstrates how leadership communication contributes to the stabilization of shared cultural expectations in everyday organizational life. The findings of this research further confirmed knowledge sharing and employee innovation as culturally constituted workplace practices that emerge through communicative sensemaking, rather than as outcomes of structural diversity or individual creativity alone. In this way, this research explains the role of organizational culture as a process providing mechanisms through which leadership communication shapes participation, legitimacy, and action across cultural differences. Finally, this research contributes to the communicative constitution of organizations research by empirically demonstrating how the intercultural leadership sequential communications links to micro-level sense-giving practices at work and to meso-level organizational phenomena, culture, and innovation, thereby contributing to CCO research. In this way, this research bridges interactional and organizational research and reinforces the importance of meaningful contributions to the communicative constitution as a framework for investigating culturally complex contexts.

Practical Implications

The findings of this research suggest that leadership development in culturally diverse healthcare organizations should move beyond cultural competence checklists toward cultivating leaders’ capacity for culturally reflexive sense-giving in everyday work practices. Instead of focusing solely on the formal policies or diversity indicators, leaders in the workplace can develop inclusive organizational cultures through their routine communicative practices, such as explaining the rationale behind clinical and administrative decisions, inviting multiple interpretations during team meetings, and explicitly acknowledging diverse forms of professional and cultural expertise during handovers and case discussions. The results further indicate that innovation is more likely to emerge when organizations create communicative spaces where intercultural dialogue is normalized and where knowledge exchange is framed as legitimate and safe, rather than relying solely on structural diversity or formal knowledge systems. Attention to how meetings are structured, how disagreement is managed, and how authority is communicated can help ensure that cultural diversity becomes a resource for learning and innovation rather than a source of silence or fragmentation. These findings underscore that intercultural leadership communication is not a peripheral soft skill, but a core organizational practice with direct implications for knowledge sharing, adaptation, and innovation in healthcare settings.

Limitations and Future Research Directions

This research has several limitations that point toward directions for future research. First, although the mixed-methods design of this research enhanced interpretive depth, the quantitative component relied on cross-sectional data, which limits the model's ability to capture how leadership sense-giving and organizational culture evolve. Future research could use a longitudinal design, dividing the data collection process into multiple time points, to provide greater insight into the temporal workplace dynamics through which communicative practices become stabilized or contested in culturally diverse organizations. Second, this research was conducted in healthcare organizations in South Punjab, where, due to high power distance in professional hierarchies, institutional authority, and culturally embedded norms, communication is shaped in context-specific ways. While the organizational context of this research was theoretically meaningful, future research should collect data from other sectors to examine whether similar communicative processes operate in other organizational and cultural contexts. Finally, although this research foregrounds culture as communicatively constituted, it does not explicitly disentangle the roles of language dominance, institutional hierarchy, or power asymmetries associated with professional status or migration background. Future studies could build on this work by examining how these dynamics intersect with leadership communication to enable or constrain participation, knowledge sharing, and innovation in intercultural organizational settings.

Conclusions

This research examined how intercultural leadership communication operates within healthcare organizations by treating culture as a communicatively constituted and evolving process. The findings of this research suggested that leadership sense-giving shapes organizational culture and, in turn, this influences employee knowledge sharing and the enactment of employee innovation, rather than employee innovation emerging automatically from the diversity or structural organizational arrangements. By combining qualitative results with quantitative analysis, this research highlighted how everyday communicative workplace practices regulate participation, legitimacy, and action in culturally diverse healthcare organizations. The results of this research also emphasized that these organizational processes are context-dependent and are closely tied to institutional hierarchies and cultural norms. Overall, this research reinforces the importance of understanding leadership, culture, and innovation as interconnected communicative accomplishments in intercultural organizational life.

Acknowledgement Statement: The authors would like to thank the healthcare professionals and organizational members who generously shared their time and experiences for this study. We are also grateful to colleagues and reviewers whose constructive feedback helped refine the theoretical framing and clarity of this work. Any remaining errors or omissions are solely the responsibility of the authors.

Conflicts of interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Authors' contribution statements: Author 1 contributed to the Conceptualization, Methodology, Formal Analysis, Validation, Data Curation, Investigation, Writing – Review & Editing, Supervision, and Project Administration; Author 2 contributed to Software, Validation, and Data Curation; Author 3 contributed to Validation, Investigation, and Resources.

Funding statements: There is no funding to report. This research was conducted without ﬁnancial support from any public, commercial, or non-proﬁt funding agencies. The authors aﬃrm that the study was independently designed, executed, and reported. The views, interpretations, and conclusions expressed in this article are solely those of the authors and do not necessarily reflect the views of the participating healthcare organizations or any affiliated institutions. All methodological decisions, analyses, and interpretations were made by the authors without external inﬂuence. Any simulated replication datasets used in this study were generated exclusively for transparency, verification, and methodological illustration purposes and do not represent the original empirical data collected from participants.

Data availability statement: The data supporting the findings of this study are available from the corresponding author upon reasonable request. To support transparency and replicability, simulated replication datasets that mirror the statistical properties of the empirical data have been generated and are available for verification and methodological purposes. Due to ethical considerations and confidentiality agreements with participating healthcare organizations, the original interview transcripts and raw survey data are not publicly available.

Ethical consideration statement: This study was approved by the Ethical Committee of the University of Chenab, Pakistan. The Ethical Clearance Number is 98BE25.

Disclaimer: The views and opinions expressed in this article are those of the author(s) and contributor(s) and do not necessarily reflect JICC's or editors' official policy or position. All liability for harm done to individuals or property as a result of any ideas, methods, instructions, or products mentioned in the content is expressly disclaimed.

Declaration of generative AI and AI-assisted technologies in the writing process: During the preparation of this work, the author(s) used ChatGPT for copy-editing. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

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How Culture Is Communicatively Constituted In Intercultural Healthcare Organizations: Leadership Sensegiving, Knowledge Sharing, And Employee Innovation

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