Sacrifices from relocation to a foreign land: Multifaceted challenges experienced by self-initiated expatriate female nurses during cross-cultural adjustment

The purpose of this exploratory study is to understand the nature and multidimensional challenges of cross-cultural adjustment as experienced by female Malaysian self-initiated expatriates (SIE) working as registered nurses (RNs) in Saudi Arabia. In-depth interviews with twenty-two Malaysian SIE RNs provided rich data on their adjustment experiences. The resulting data were subjected to a qualitative content analysis using Black, Mendenhall, and Oddou's (Black et al., 1991) cross-cultural adjustment (CCA) model. The results show that the nurses faced several challenges. Five themes emerged: learning to speak Arabic, adapting to a confrontational communication style, facing new work practices, dealing with homesickness and loneliness, and adjusting to new gender norms at work and in public. This study contributes to our understanding of expatriate adjustment by providing new interpretations of the cultural challenges faced by female SIEs and the nature of their adjustment process. The results also support the literature on expatriation by highlighting the challenges of cultural adjustment and giving specific information on the conditions and constraints facing female RNs in Saudi Arabia, a subject that has received little critical attention so far.


Introduction
How multinational enterprises (MNEs) manage their expatriates is a vibrant topic in the international management literature. Interest in the question has been stimulated by the fact that expatriates play a critical role in the business operations of most international firms (Budhwar et al., 2019;Chen et al., 2018;Zhong et al., 2015), but scholarship in this area has so far concentrated mainly on expatriates who are organization-assigned (OAEs) (Andresen et al., 2014;Mo & Yong, 2015) rather than self-initiated (SIEs) -that is, who find work overseas independently (Cao et al., 2014;Tharenou &Caulfield, 2010 andFroese, 2011). In particular, there has been very little empirical research on female SIEs (Muir et al., 2014). The interest now being shown in SIEs by scholars (Makkonen, 2016 andVaiman, Haslberger, andVance, 2015) is in large part a response to the growing numbers of professional women who are choosing self-initiated expatriation as a way of furthering their career (Shortland, 2015;Muir et al., 2014 andTharenou, 2010). These female SIEs are now considered essential for the global workforce, filling labor and skills shortages around the world in crucial sectors, such as nursing (Walker et al., 2017).
A case in point is a large number of Malaysian RNs working in Saudi Arabia. It was observed that Malaysian nurses are better able to understand and practice Islamic religious values when dealing with patients since they are all Muslims (Almutairi et al., 2015). Malaysia consists of a multi-ethnic population where the largest group of ethnicity consist of Muslim (61.3%) and the country's official religion is Islam.
Whilst, 38.7% of other societies belong to religions such as Buddhism, Christianity, Hinduism, and other religion like Confucianism, Taoism, and Tribal or other traditional beliefs. However, shared religion aside, Saudi Arabia and Malaysia differ considerably in terms of values, norms, and ways of life (Ahmed, 2015;Budelman, 2004 andHofstede, 1980). This is important because one of the main reasons for the high failure rate among expatriates is the difficulty of adjusting to the demands of a different culture (Celenk & Van de Vijver, 2011;Haslberger, 2010 andTakeuchi et al., 2007).
Researchers have shown that for many nurses, working alongside others with very different cultural values and attitudes is a cause of stress (Alsaqri, 2014;Almalki et al., 2012 andVan Rooyen et al., 2010). However, few have explored the experiences of expatriate nurses. Furthermore, as Zhou et al. (2015) observed, studies on expatriate management have tended to focus on MNEs from developed countries and to exclude emerging countries, such as Malaysia or Saudi Arabia. The current study is the first to focus on Malaysian women with SIEs in the nursing profession in Saudi Arabia.
The purpose of this exploratory study is to understand the challenges of cross-cultural adjustment, as experienced by this particular Malaysian female SIEs due to the cultural shocks and cultural differences encountered while working in Saudi. Qualitative interviews were conducted with 22 participants and the interview transcripts were subjected to content analysis.  CCA model was employed as a theoretical lens to explore three dimensions of cultural adjustment: interaction adjustment, work adjustment, and general adjustment. This allowed for a more thorough understanding of the types of turbulence these nurses faced in the early stages of their expatriation to Saudi Arabia.

Defining Self-Initiated Expatriates
The phrase 'self-initiated expatriate' (SIE) was first coined to describe self-initiated foreign work experience (Suutari & Brewster, 2000) that transcends organizational and geographical boundaries. As global mobility has increased, the term has come to refer to any individual who chooses to travel (Myers & Pringle, 2005) overseas in search of work (Cao et al., 2014;Froese, 2011 andTharenou &Caulfield, 2010). Al-Waqfi (2012) explained that SIEs tend to make their own decision to live and work abroad, view their international experience as a means of self-development, and follow a nontraditional career path. Similarly, Cerdin and Selmer (2014) argued that SIEs are generally professionals who make their own decision to relocate internationally and that while they intend to maintain regular employment, their relocation is usually only temporary. This is the definition followed in this study. International work experience enhances the career prospects of both OAEs and SIEs (Andresen et al., 2013;Suutari & Brewster, 2000), but the latter are also free to work independently (Andresen et al., 2013). On the other hand, SIEs face particular challenges both before and upon arrival in the foreign country that result in this group experiencing high failure rates (Albana and Jelitra, 2014;Adler & Ghadar, 1990;Mendenhall & Oddou, 1985).

Cross-Cultural Adjustment Model
The level of cultural adjustment achieved by expatriates is demonstrated by the extent to which they can adapt to their new environment, learn new things, apply their knowledge to the workplace, and balance both physical and psychological demands (Black, 1988;. This adjustment is crucial, given that much of the success of the international business now depends on expatriates and their ability to function in a new environment, cooperate with local workers, apply their competencies and knowledge, learn new things, and cope with uncertainty (Koveshnikov, Wechtler, and Dejoux, 2014).
The U-Curve theory, introduced by Lysgaard (1955) and later refined by Oberg (1960), has been widely used to explain the process of adjustment for expatriates. The theory postulates four stages to this process: honeymoon, culture shock, recovery, and mastery. In the honeymoon stage, which may last days or weeks, an expatriate will experience a feeling of euphoria and excitement at the prospect of the new job, new life, and new environment. This is succeeded in the culture shock stage by feelings of irritation, stress, and discomfort as he or she encounters problems within the new work or social environment. This stage tends to last from three to six months or longer, depending on the level of stress experienced and the support obtained. In the third stage, recovery, the expat begins to feel comfortable and attuned to the workplace and its practices, and their new living environment. This is also in line with the findings of a study from Zhang et al. (2020), who stated that cultural intelligent among expatriates have a relationship with organizational commitment, and until they feel comfortable working in a new place. He will learn to accept the way things are done in the new culture and its idiosyncrasies. Finally, in the adjustment or mastery stage, the expat acculturates to the differences, absorbs the new cultural values and practices into his or her behaviors, and feels comfortable doing as others do in the host culture. According to Oberg (1960), it can take three to five years to arrive at this stage of feeling as if one is in a second home.  revisited the U-Curve theory (Lysgaard, 1955;Oberg, 1960) to examine the validity and reliability of its theoretical explanation of the four stages of expatriation, but in their review of 18 studies, they found that only twelve supported the U-Curve hypotheses. The authors responded by producing a new model of crosscultural adjustment for expatriation (variously known as 'expatriate adjustment', 'acculturation', and 'international adjustment'), in which they break the CCA down into three dimensions, namely, interaction adjustment, work adjustment and general adjustment (Black, 1988;. The first of these, interaction adjustment, refers to how the expat interacts with the host nationals on a day-today basis (Selmer & Lauring, 2014) and to the psychological comfort he or she derives from interactions with the home country nationals inside and outside work (Black, 1988). Work adjustment refers to the adjustment of the expat to the values, expectations, and standards related to working in the host country, as expressed in performance expectations, supervisor responsibilities, and specific job responsibilities (Selmer & Lauring, 2014). Finally, general adjustment refers to the expat's level of satisfaction with living conditions in the host country. This depends on factors such as food, weather, transportation, health care facilities, recreation opportunities, shopping, and housing (Selmer & Lauring, 2014). This study draws on  CCA model to provide rich insights into how one group of RNs adjusted to their new conditions in their interactions with others, at work, and beyond.

Method
We conducted semi-structured interviews to obtain a rich and in-depth understanding of these challenges. A total of twenty-two (22) respondents, all Malaysian RNs working in Saudi Arabia, agreed to participate in this study. It was only possible to conduct face-to-face interviews with two respondents, who happened to be in Malaysia on vacation. The remaining interviews were conducted online for convenience and cost. The face-to-face interviews took place in Kangar, Perlis, and lasted between 30 and 45 min. Eight online interviews took place through Facebook Messenger and eleven through WhatsApp, each interview lasting between 45 and 60 min. All respondents were Muslims and worked in Riyadh and Jeddah at the time of the interviews. Table 1 presents the demographics of the respondents in detail. Their ages ranged between 27 and 46 years old, and they had worked in Saudi Arabia for between one year and eleven years. They worked in a variety of departments/wards, including endoscopy, stroke, medical, multidisciplinary, Obstetrics, Gynecology, cancer, orthopedics, emergency unit, and hospital research center. All had initiated their foreign work experience independently (Suutari & Brewster, 2000) and met the four main criteria outlined by Cerdin and Selmer (2014).
The interviewees were selected using the snowball sampling method, with the first interviewees drawn from our networks. Family members and close friends were also asked to introduce us to Malaysian nurses they knew, who in turn introduced us to their other friends. Contacts were made informally and informally via WhatsApp or Facebook Messenger; Prospective interviewees received a brief description of the research and its potential value and a brief explanation of the mechanisms and procedures involved. Those who agreed to participate received a consent form to sign and an assurance of confidentiality, and a meeting was scheduled for a time, date, and place convenient to the interviewee.

Interviews
In developing the interview protocol, we took into account previous studies with similar research objectives and theoretical frameworks (Bozionelos, 2009;Alshammari, 2012), as well as the individual and contextual factors affecting cultural adjustment. The questions were developed to encourage the respondents to give full and honest opinions based on their own real-world experiences. Section 1 of the interview protocol dealt with demographic information, such as age, marital status, number and age of children, professional affiliation, work experience, number of cultural awareness/ competence workshops or conferences attended, foreign languages are spoken, and length of time in Saudi Arabia. Section 2 began with high-level questions, such as: 'What was your first impression upon arriving in Saudi Arabia?', 'Have you missed your family and friends back home?', and 'Have you found anything in the new environment shocking?'. Section 3 dealt with cultural competency, with questions such as: 'Do you feel that you know the appropriate social protocol in your local Saudi community?', 'What skills do you think are needed to be competent in the Saudi Arabian workplace?' and 'Do you attend cultural or racial group holidays or functions in your local Saudi community?'. Real-time interaction through online communication tools allowed us to extract key information from nurses about their challenges and to seek further clarification on any given question.

Content Analysis and Inductive Coding
Content analysis is well-established in nursing research (Elo & Kynga, 2008).It can unlock valuable cultural insights from the selected text(s) (in this case, the interview responses), it can be used to test theory (Elo & Kynga, 2008) and it enables the researcher to examine social reality in a subjective but scientific manner (Zhang & Wildemuth, 1996). By taking the whole interview as the unit of analysis, the qualitative content analysis in this study was able to go beyond merely counting words or extracting objective content to examining both manifest and latent meanings, themes, and patterns (Cho & Lee, 2014). The interview transcripts were analyzed and the results were organized into themes using Atlas.ti version 7.0. The transcripts were open-coded, with codes being grouped into categories and reclassified into appropriate sub-themes, generic themes, and main themes. Data coding and code development were performed inductively, and new concepts were tagged and reported as the codebook was developed. The themes were allowed to emerge from the narratives of the respondents, rather than being governed by our prior assumptions. Data validation involved snowball sampling to the point of saturation, as well as rigorous double-checking of codes, concepts, and themes.

Findings
Our main premise in the study was that cultural challenges influence the way female RN SIEs adjust in the early stage of expatriation. Our analysis shows that the nurses in our study experienced stress and turmoil in all three dimensions of the initial adjustment process. Very few interviewees had experienced a honeymoon stage of euphoria or excitement upon arrival. Most described feeling unprepared for the work environment and lifestyle they found despite the advice and guidance they had received before moving from family members or friends who had lived in Riyadh. Although they had chosen to move to Riyadh, most of the RNs said they felt anxious, miserable, and insecure when they first arrived, and that they had immediately experienced culture shock. First-year challenges included homesickness, differences in operating procedures, lack of fluency in Arabic, inability to interact comfortably with non-Malaysian expatriate nurses whose languages and cultures were also different from their own, and gender segregation between males and females.
However, contrary to the assumption of the U-curve theory that the culture shock stage can last up to nine months (Lysgaard, 1955;Oberg, 1960), the RNs in the sample claimed that for them, this stage had only lasted between two and three months. Most explained that their determination to make the transition a success had helped them persevere and overcome their fear and sadness. Gradually, they had adjusted to the new working environment and its practices learned to understand local attitudes and behaviors, and began to acquire some Arabic vocabulary with the help of colleagues and hospital-provided translators. For most of the interviewees, their inability to communicate properly with the patients was the main cause of stress during the initial stage of expatriation. Table 2 outlines the challenges faced by expatriate RNs while they entered Saudis as SIEs and the strategies they adopted to adapt to cultural differences. Drawing upon  model, the following sub-sections offer detailed descriptions of these challenges.

Interaction-Oriented Adjustment
As noted above, the language barrier hampered the ability of the RNs in the sample to interact effectively with colleagues and patients. Beyond this, however, they also had to adapt to the unfamiliar communication styles of the locals. The interviewees described feeling initially apprehensive and uncomfortable in their daily interactions with Saudi colleagues and patients, but some were eventually able to overcome this to the point of being able to adopt the same blunt manner and level of assertiveness as their hosts.

Language Barriers
A consistent theme that emerged among nurses when discussing the challenges of working in Saudi Arabia was the language barrier. Respondent 1 commented: The main challenge I face working in Saudi Arabia is language. Most patients cannot speak English and I can't speak Arabic. 1 Table 2 Culturally-oriented challenges faced by Malaysian female RNs working in Saudi Arabia

Challenges Descriptions
Language barriers • Patients could not speak English while most Malaysian Nurses could not communicate in Arabic • While all departments in hospitals provided Arabic classes teaching standard Arabic, locals use a different colloquial language in communications • Translators are not always available due to involvement in administrative work • Confusion arose among staff due to differences in English dialects among colleagues from varied countries Differing communication styles • In Malaysian culture, people speak softly, are well-mannered, and apply face-saving strategies to avoid causing embarrassment when relaying a message • In Saudi culture, people speak in louder tones and a straightforward manner Diverse working practices & environment • Saudi and Malaysia have differences in standard operating procedures (SOPs) and working environments, particularly in regards to interactions between men and women • Saudi Arabia uses more technologically advanced equipment than hospitals in Malaysia • Hospitals in Malaysia and Saudi Arabia also appear to have significantly different physical layouts • Saudis maintain a cultural practice of giving gifts to hospital staff, which is unusual for Malaysian RNs Battling homesickness and loneliness • Some of the RNs were married but did not bring along their immediate families, due to a spate of obstacles • RNs unbearably missed their husbands and children • The five-hour time difference between Riyadh and Malaysia is a challenge that requires good time management • Poor internet access serves as a further barrier to keeping in touch with family Adjusting to new gender norms • Need to understand the boundary between men and women among doctors, nurses and patients when it come to conversations and medical treatment • Have to seek permission before handling and treating patients of different gender although it is for medical purposes • Many restaurants provide married and single sections in restaurants and have to know such boundaries clearly in order not to offend anyone Restrictive code of dressing • In Saudi, women must wear in public an abaya-a long black dress with a headscarf when leaving a residence or the hospital compound. Some consider it unpleasant, especially when going to shopping malls.
• In Malaysia, women are free to dress according to their fashions and colors to keep it vibrant Mode of transportation • Saudi Arabia prohibits women from driving-have to depend on buses or taxis provided by the hospitals (at the time of the interview, a restrictive policy on women driving was applied. But in mid 2018, women in Saudi was granted the right to drive). • Challenges the RNs independence and freedom to decide where to go or with whom and need to use own public transportation 1 3 The dilemma of this respondent is typical; Malaysian RNs generally do not arrive in Saudi Arabia speaking or understanding Arabic, and few patients understand or speak English. Newly arrived RNs are assigned a preceptor or mentor whose job is to guide them through the orientation process. During this process, which is part socialization and part knowledge/skills acquisition (Farnell & Dawson, 2006), RNs are expected to adjust to their new surroundings. For many, shadowing their preceptor on ward rounds is their first opportunity to learn Arabic.
Six respondents noted that their department did not offer any Arabic classes. Five had, therefore, learned Arabic on their own by asking their colleagues and patients for help, and by using the Google Translate application, hospital translators, and personal notebooks. Respondent 7 is an example: The department did not provide an Arabic class. I learned by myself. I learned Arabic from senior Malaysian and Filipino staff and Arab colleagues and patients.
Although their department did provide Arabic classes (i.e. offering classes outside the department to provide language training), only six had attended these classes; because most of them were too tired since they worked twelve-hour shifts. However, the nurses who attended found that the Arabic taught in these formal classes differed from the language of the locals. Arguing that fluency requires time and practice and that the best way to attain cultural fluency is to observe local communication; as such, most nurses described themselves as self-taught. As an alternative strategy to learn the Arabic language, all interviewees had taken advantage of the hospital translator service to help them translate and learn Arabic. Respondent 4 explained: It was frustrating when I didn't understand what the patients were saying or what they were asking me. Such situations sometimes made me feel useless, fortunately, the hospital provided a translator for us. From there I slowly learned the Arabic language.
However, the need to translate everything slows down and complicates the treatment process, which can be especially problematic in emergency cases. The RNs also noted that the use of an untrained or ad hoc interpreter increases the risk of inaccurate translations and, consequently, incorrect diagnoses or prescriptions. Furthermore, as Respondent 1 noted, translators are not always available, as they are often 'busy with management work at the same time.' Even when another hospital staff speaks English, Malaysian nurses may not always understand the dialect or accent they are hearing. Colleagues may come from countries such as Australia, New Zealand, South Africa, Ireland, the USA, Canada, the UK, India, Pakistan, or the Philippines, among others, leading to a variety of accents and vocabulary. This poses challenges to interaction, both in terms of language spoken and communication style. Respondent 2 noted: In my department, there are 12 different nationalities. The main challenge is that the English slang for each country is very different, making it difficult to comprehend.
Seventeen 17 out of 22 respondents said that they could understand basic Arabic after three months of living and working in Saudi Arabia, but all commented that becoming fluent would take more time. The vast majority said that they only knew enough vocabulary to engage in daily conversation and patient treatment and that they still had to rely on translators. Only one (1)

Different Communication Styles
Another challenge facing Malaysian SIEs is the difference in communication styles between Malaysians and Saudis. In Malaysia, people speak indirectly and usually apply facesaving strategies to avoid causing others embarrassment when relaying a message that may be offensive or hurtful. On the contrary, the norm in Saudi Arabian culture is to be loud and straightforward. Lewis (2003) noted that "Saudis are extremely extroverted, theatrical, and declamatory" (p. 5). This was illustrated by Respondent 16, who asserted: They [Saudis] speak with a loud voice. If there is something wrong between the doctors and the head nurse, they don't care; if they need to say it out, they will directly say it is wrong and incorrect.
The interviewees, who came from a culture that associates loud tones with rudeness, anger, or feelings of being disturbed or depressed, found this behaviour difficult at first. Respondent 12, for example, mentioned being puzzled the first time she was spoken to in a loud tone of voice, recalling that she had become uncomfortable and distraught. She, like others, had to adjust her communication style and learn to speak more assertively to fit into the new culture.
However, most nurses mentioned that Saudi patients appreciated their Malaysian communication style and saw them as courteous. They also felt that the locals could easily identify them as Malaysian based on their language. Respondent 8 explained: The difference between us and them is the way we speak. We don't speak loudly like them, and they can easily guess that we must come from Malaysia because they know that Malaysians speak with 'padded words,' speaking slowly, indirectly, and not assertively or boldly.
Cultural differences in communication styles are also played out in the context of reprimands at work. Malaysians tend to avoid confrontation or embarrassing others, so if a reprimand (advice, rather than a warning) is required, employees can be notified through an intermediary. Supervisors will also usually try to find the least confrontational way to approach a conflict. In Saudi Arabia, in contrast, reprimands are given directly to the individual. Respondent 6 explained: If there is any reprimand at work, they will simply tell the workers. Sometimes, they directly inform the head nurse or hospital director. We need to know how to speak properly. We also need to be careful when making decisions in our daily work procedures.
The comment underscores the willingness of Malaysian RNs to adapt their communication styles to succeed in their new workplace culture. Finally, nurses noted a difference in how patients' families express their emotions. Respondent 4 shared that: Family members and relatives who come to visit patients in the hospital cried loudly to express their grief. As was the case when there were patients who died. The culture is very different from the Malay community in Malaysia.
One of the key comments made by the nurses was that Saudis do not hesitate to express their thoughts or emotions openly. Trompenaars (1984) defined a culture's level of emotional expressiveness as affective or neutral. We found that nurses come from a neutral culture, in which people usually refrain from expressing their feelings too overtly, to one in which grief and pain are communicated openly and without hesitation.

Work-Oriented Adjustment
One of the main motivations driving the study participants to relocate was the opportunity to enhance their professional skills by working in world-class facilities with advanced tools and technologies. To take advantage of this opportunity, they were forced to adapt to new work practices and a new work environment, fight homelessness and loneliness, and accept new gender norms and practices.

Work Practices and Environment
In addition to language and communication barriers, Malaysian RNs in Saudi Arabia face significantly different standard operating procedures (SOPs). Respondent 5 mentioned that: Everything is computerized here and evidence-based. Every procedure has specific details for the SOPs that I must follow. After my supervisor confirms that I am competent to apply those SOPs, they will allow me to do those procedures on my own.
Malaysia is regarded as a global leader in healthcare, but as Saudi Arabian hospitals use more technologically advanced equipment than their Malaysian counterparts, the RNs in the sample was required to undergo further training. Most had found learning the new apparatus and systems straightforward. Another difference noted by the respondents was the shortage of beds in Saudi hospitals. Respondent 9 explained: In Saudi Arabia, the emergency unit setting is different compared to Malaysia. The emergency room (ER) here looks like a multidisciplinary ward in Malaysia. This is because the hospital does not have enough beds on the ward for admitted patients. Sometimes they stay more than two weeks in the ER. So, we also take care of bedside patients in the ER here.
However, no one felt that the bed shortages and merging of the wards during crisis periods had affected their ability to do their job properly. Most explained that once they had gotten used to the work environment and knew when to expect these crisis periods, they were able to work with medical teams to give patients the best treatment.
The Saudi practice of gift-giving was a new experience for the respondents. About seven (7) RNs described how Saudis are very generous and love to give gifts, particularly food gifts, to hospital nurses in appreciation of taking care of family members. Nurses are compelled to accept these gifts or risk hurting patients' feelings and disparaging their culture. This contrasts with Malaysia where people are free to accept or reject gifts from others.

Homesickness and Loneliness
Spousal and family support can be crucial in determining whether the expatriation process is successful. The Malaysian RNs in this sample confessed to feeling homesick throughout their supernumerary or trial period. Throughout this period, nurses are under intense pressure to learn the SOPs in each department, become familiar with new equipment, and pass exams, all without spousal or family support. Significantly, the supernumerary period lasts approximately three months, placing it within the CCA theory culture shock phase (3-6 months).
Twelve (12) of the respondents in this study were married but without their immediate family, and most admitted that during the initial stage they had missed their husbands and children unbearably. Respondent 10 confessed: I miss my children and family when I am alone at home, especially before I fall asleep and when faced with a stressful situation at work.
Although they were willing to leave closeness with children and their families for better income and better living standards for these families, nurses still viewed it as a huge sacrifice. Respondent 2 mentioned: I uploaded all the videos of my children on Facebook and planned to watch them when I was missing them in Saudi Arabia. But I couldn't do that. I meant to view the videos because staying away from my beloved children was very hurtful. I was only able to do that after almost a year. Love hurts.
These feelings were typical among the respondents, many of whom were away from their families for the first time. A nurse (Respondent 16) described how she: …suffered from chronic homelessness, especially after vacationing in Malaysia. I cry 24 h a day. I cannot explain the feeling. The pain is so strong.
The five-hour time difference between Riyadh and Malaysia was another challenge, with communication requiring good time management. Respondent 11 explained that: The difference in time sometimes makes it very difficult for me to communicate with my husband. When I am not busy, my husband is busy at work. When I come home from work and call my husband to talk, he is already tired after a long day of work. We can only talk for a limited time.
Respondent 15 added that poor internet access was another barrier that prevented her from keeping in touch with her family: The internet in Saudi Arabia is very slow, especially on weekends. Sometimes there is no connection at all. This is one of the challenges we face. Sometimes we cannot communicate with family due to this problem.
The time difference and unpredictable Internet connection served to compound the sadness experienced by the RNs about being apart from their spouses, children, friends, and other family members. Some said that they liked to stay at home on the weekends so that they could rest, but others chose to distract themselves from their homesickness and loneliness by spending time with friends and going to birthday celebrations, sports festivals, and badminton games. Two (2) respondents said that they participated in local cultural activities, such as Arab weddings, just to rid themselves of loneliness and boredom.

Adjusting to New Gender Norms at Work
The challenges of early homelessness and loneliness were accentuated for nurses by the additional challenge of adjusting to Saudi gender norms, which differ significantly from those in Malaysia. Nurses explained that Saudi Arabia has a reputation for being more restrictive of women's mobility and public activities than any other Arab or Muslim society, due to its strict interpretation of Islamic principles; while Malaysian women are accustomed to working, driving on their own, and sharing public spaces with men who are not mahrams (that is, relatives), these practices are prohibited in Saudi Arabia. In the hospital context, too, the country's strict rules for inter-gender interaction are evident. Respondent 8 described this work environment as such: In Malaysia, men and women can talk as usual in public areas. However, in Saudi Arabia, they have their etiquette in conversation. For example, if the doctor wants to talk and sit together with nurses who are doing their daily report, the doctor will first ask permission before sitting and discussing things together. In Malaysia, we just sit and discuss without the need to ask permission. In addition to that, nurses also need to ask male patients' permission before any procedure can be performed. But in Malaysia, nurses do not need to do that because it is considered part of their job.
Rather than resenting these more formal communication norms, respondents saw them as a useful guide to what is considered acceptable workplace behavior in terms of gender relationships. They all agreed that the norms helped reinforce their principles and values as embedded in the Islamic religion. As Respondent 17 put it; We need to adhere to such practices with sensitivity, diligence, and respect because it is as it should be or by the book (Quran) we are obligated to follow.

General-Oriented Adjustment
The RNs in the sample had learned to live in an Islamic environment offering different practices, social norms, systems, and rituals from those of their home country. As Respondent 8 put it, In Saudi Arabia, non-Muslims must cover their hair. Men and women are not allowed to speak together in public. Restaurants offer married and single sections. Women are not allowed to drive. We can only take a bus or taxi called a limo to go to another place.
Unexpectedly, half of the respondents had even come to cherish these differences and value them as reinforcing the Islamic way of life.
Nurses noted how gender segregation permeated their lives outside of the workplace and within it. For example, not all Saudi restaurants admit women diners and those that do tend to curtain off the seating for women and families. He offers privacy and is highly appreciated by locals, but the nurses in the sample initially found this objectionable and struggled to find restaurants where they could eat. Once they had received recommendations from colleagues and friends for female-friendly restaurants, however, many had learned to appreciate the private space as giving them a sense of security. Saudi Arabia implements a strict dress code for women, requiring them to wear a headscarf and a black robe, or abaya. As Respondent 14 noted: We can only wear a black abaya when we leave the residence and hospital compound. Non-Muslims must also wear an abaya.
Fourteen of the interviewees said they had come to appreciate the requirement as it meant that they did not have to worry about coordinating their outerwear, as they did in Malaysia, where they were free to dress in a variety of styles and colors. This uniform also saved them from spending money on a more varied wardrobe. However, only three respondents disliked having to wear the abaya, especially when shopping or sightseeing with friends on holidays or weekends, because they felt it was too formal while the rest of the RNs did not have a strong preference for any form of clothing, i.e., as long as it was decent, they felt comfortable. From another perspective, five of the respondents said that they had initially felt that the Saudi prohibition of women drivers restricted their independence and freedom to go wherever they wanted and with whomever they wanted. Respondent 21 complained that: Where I want to go, I need to get a bus or taxi provided by the hospital.
Hospitals provide transportation between work and the nursing home compound, but trips outside work involve hiring taxis, which are more expensive than in Malaysia. Half of the respondents said they had to plan their monthly budget carefully to allow for this additional expense. However, many of the respondents confessed that they had come to enjoy the luxury of being driven to work at the expense of their employer. As Respondent 19 explained, they had begun to accept and enjoy being chauffeured: It is a kind of luxury here, as being a 'big boss' with a driver, because we do not have to drive after a tiring and long day of hard work. Unlike Malaysia, we drive and with all the traffic on the street, it can be tiring.
Speaking about the Saudi government's proposal to change the law to allow female drivers, the respondents said that this would empower women, changing both their lifestyle and social norms. As a summary, we are illustrating the cultural adjustment patterns of the SIEs in Table 3. The verbatim statements were chosen to reflect on the way the RNs are illuminating their adjustments in three different areas of challenges that they underwent from the initial stage of adjustment up till they are fully acculturated.

Discussion and Implications
The results suggest that the challenges faced by RN expats are rooted in the distinct cultural distance between their home country of Malaysia and Saudi Arabia, particularly in the areas of language and communication styles, work practices, social norms in terms of gender segregation, and social and living conditions, despite shared religious beliefs and practices of Islam. Drawing upon , our empirical qualitative framework (refer to Fig. 1) allows us to map key contextual elements of female SIE RNs against the facets involving interaction, work, and general.
We found that the multifaceted nature of the adjustment process is interrelated, i.e. one facet will continuously affect the other. None of the facets of adjustment should be understood in isolation, nor can they be managed separately in terms of the different skills needed. This is supported by Hippler et al. (2015) re-visit of the facets developed by  and their claim that the model is based on a structural viewpoint which shows a static-natured process, and thus lacks the dynamic character of it, as presented in the following empirical model. We also suggest that, in each of the interrelated facets, RNs need to have an appropriate skill that will facilitate them to adjust successfully. For example, when female RNs face challenges related to interaction, linguistic and communication skills are needed. Such skills will further facilitate their operational tasks in hospitals. This aspect is well argued by studies that suggest that new expats will find it challenging to operate efficiently and effectively in a culturally diverse workplace without proper levels of linguistic proficiency (Wood et al., 2020;Wang & Tran, 2012;Peltokorpi, 2008;Seak & Enderwick, 2008;Selmer, 2006).
It was established that two other conditions are needed for effective adjustments at work and in general: prior international experience and spousal and family support (Suutari et al., 2017). However, based on our findings, we further argue that despite the absence of spousal and family support, RNs could conceivably achieve successful adjustment given the support of preceptors as their mentors as well as engagement with social networks, i.e., among Malaysian expatriate communities to combat loneliness, as suggested by Harrison and Michailova (2011). However, this may only be the case if these SIEs fully consider and incorporate strategies to overcome the impact of missing spousal and family support (Mutter, 2017). Essentially, to survive in a new environment, SIEs require adaptations and adjustments to the new culture and the ability to build a repertoire of new cultural knowledge. Therefore, we suggest that a crucial skill that bridges the three facets of adjustment is the development of cross-cultural competencies. Inherently, with this skill, RNs would be able to learn, appreciate, and tolerate various cultural values and behaviors. If SIEs do not adjust, it will cause them less affective, normative and continuance commitment (Lapointe et al., 2020).
In general, the findings were strongly supported by the existing literature on international adjustment (Nolan and Morely, 2014;Isakovic & Whitman, 2013;Moon, Choi & Jung 2012;Begley et al., 2009). In specific, past studies have well established several key factors that influence the international adjustment process, i.e., provision of pre-departure and post-arrival cultural training, language proficiency ability, spousal and family support, previous international exposure, and minimal cultural distance (Abdul Malek et al., 2015;Pekerti et al., 2017;Peltokorpi, 2008;Ravasi et al., 2015). These contextual factors do not prevail in the case of Malaysian RNs as SIEs. Given some of these unique contextual conditions, mostly applicable to SIEs, our study broadens its contribution in the field of international management based on the three key theoretical implications supported by our empirical model (see Fig. 1).
First, previously, several key scholars of cross-cultural adjustment, such as Black (1988), , and Black and Gregersen (1991), have argued that CCA is a multidimensional, rather than unitary, concept. By integrating the issues of cultural adjustment and challenges Table 3 Different types of adjustments with selected quotes of similar patterns faced by SIEs, we generate wider interest for researchers to explore these issues deeper due to their dynamic characteristics and process. For instance, a study by adjustment Isakovic and Whitman (2013) using  quantitative model, found that previous international work experience and cultural novelty affect cultural adjustment, and no foreign language ability. Our study, in contrast, draws upon these facets to further explore the challenges faced by expats to explain and describe the nature of the problems, the role of culture, and the characteristics of registered nurses who made huge sacrifices when they entered the global workforce, given their multiple roles as mothers, wives, and daughters.
The findings of our study also shed a different perspective on past studies by key scholars such as Mendenhall and Oddou (1985), Tung (1987), Black and Gregersen (1991), Harzing and Christensen (2004), who have argued that expats who are given pre-departure as well as post-arrival language proficiency and cross-cultural training experience enriched expatriation processes and reduced failure rates. However, such findings are confirmed true only for organizational expatriates and are yet to be proven for SIEs. Currently, much has been debated about the absence of predeparture cross-cultural as well as language proficiency training for SIEs. Questionably, to what extent are the role and functions of cross-cultural training advantageous to SIEs, as pertinently argued in the OAE literature? Since the topic is scarcely in existence within the literature, our study provides a rich understanding, allowing us to fully appreciate the key questions of how SIEs adjust when they Second, on the interaction-oriented adjustment facet, it is noted that the greatest challenge for SIEs rests on the language barrier, that is, speaking Arabic in the workplace. SIEs must be proficient with the foreign language in the new host country they entered to be efficient and effective in understanding the culture of the country where there were relocated (Isakovic & Whitman, 2013). The Malaysian nurses confessed that they managed to learn the language between three and six months during their probation period. As they said, they had to learn it quickly because they needed to provide healthcare care to Arab patients daily and patients do not understand other languages, except Arabic. In such a situation, they were forced to reach a certain level of proficiency to obtain efficiency at work. Furthermore, studies have also mentioned that acquiring the local/host language will facilitate SIEs to handle their work more effectively because they can understand the needs and preferences of others for healthcare treatment (Lidström & Laiho, 2014;Beitin, 2012;Cioffi, 2003). Farnell and Dawson (2006) further suggested that the roles of preceptors are crucial in the effort to facilitate RNs in reaching a satisfactory level of socialization during the early stage of expatriation.
Third, past studies of female SIEs have looked at several criteria that make expatriates successful in their international adjustments. In particular, spousal or family support is considered critical in the work-oriented adjustment process (McNulty, 2015;Abdul Malek et al., 2015& Ko, 2014. Unfortunately, these types of support are unavailable to RN women in our study. A study by Kraimer et al. (2001), however, provides a contradictory finding, which affirms that spousal support has no direct effects on the performance of organizational expatriates. Specifically, a key study conducted by Bozionelos (2009) on SIEs nurses working in Saudi hospitals found, alternatively, that protégé experience and peer support are related to job satisfaction and intention to change, while crosscultural training did not show any correlation with expatriate performance. To support this assertion, a recent study by Claus et al. (2015) suggests that support networks and the role of social ties (Osman-Gani & Rockstuhl, 2009) potentially combat the problem of unsuccessful international adjustment when spousal support is deficient. Therefore, to a certain extent, despite the non-available support from spouse and family, our findings contribute uniquely to the literature on female SIEs in terms of required individual characteristics, such as independence, perseverance, self-sufficiency, commitment, and mental, emotional, and environmental fitness to undergo the different facets of adjustment single-handedly. Hiring organizations expect women to be as independent and competent in their professions as their male colleagues (Koveshnikov et al., 2013;Haslberger, 2010).
Essentially, our contribution to the literature of SIEs also informed us of the novelty of one type of noble female profession in an important industry in any country, i.e., registered nurses in the healthcare sector. Therefore, these RNs require three specific skills to facilitate their adjustment, as illustrated in our empirical model (see Fig. 1), namely linguistic and communication skills, previous international experience, and cultural competence. In addition to this, this study also informed us that their fundamental survival conditions in Saudi Arabia were supported by other facilitating factors, including the availability of mentors known as preceptors, peers, and Malaysian social networks. This is an insightful finding because it supports the fact that Malaysian SIE RNs can undergo the three facets in a time that is faster than the suggested time frame explained by the U-Curve model. After all, they benefit greatly from the above-mentioned support, which they described as being empathetic and caring when entering the new workplace and social settings. In addition, these RNs were equipped with ongoing post-arrival training during their probationary phase, i.e. Arabic classes and numerous competency tests to advance their knowledge and skills. Finally, as Muslims themselves, they were able to comprehend and appreciate the religious practices they faced in their new environment. Based on practical implications, the model highlights the importance of SIEs developing their linguistic and communication skills and cross-cultural competencies upon arrival in the host country. Recruitment agencies could help by providing preparatory training (especially language training) before relocation, but recruiting hospitals must make it a strategic priority to offer newly arrived expats the training they need to work effectively in their new environment. The more comprehensive this training is, the greater impact it will have on the recipient's cultural intelligence, where scholars have argued that it should address the cognition, emotions, and behaviors of expats (Moon et al., 2012;Hippler et al., 2015).
Several studies have asserted that perceived organizational support affects expats' adjustment processes (Cao et al., 2014;Kawai and Strange, 2014); if they know they will be offered assistance before their departure, they are less likely to be anxious about the expatriation experience (Abdul Malek et al., 2015). Several studies have shown that spousal support is a key facilitator of successful adjustment (Peltokorpi, 2008;Abdul Malek et al., 2015 andBeitin, 2012),s and the RNs in this study did indeed admit to struggling emotionally with being far from their spouses and families. From a practical point of view, Saudi hospitals might find it worthwhile to consider the impact of family separation on the adjustment process and to introduce incentives, financial packages, and job opportunities for spouses to encourage the families of SIEs to relocate with them.
Lastly, the policy of recruiting young nurses without international experience needs to be revisited. Studies have shown that individual variables such as previous international experience affect adjustment success. Isakovic and Whitman (2013) and Moon et al. (2012), for example, argued that it is more important than work experience in the development of cross-cultural competence in the workplace. However, none of the RNs interviewed in this study had prior international experience; all had seized the opportunity to work in Saudi Arabia as the first step in advancing their career. What is worrying is that hospital recruiting agents expected these first-time expatriates to demonstrate the same perseverance and toughness as more experienced colleagues. Several of the RNs described facing numerous challenges when settling in the host country. From a practical point of view, HR departments must be vigilant in recruiting and managing global talent so that the failure rate can be minimized, if not eliminated.

Conclusions
Culturally oriented challenges are inevitable in any expatriation process, especially when the home and host countries are culturally diverse. In this context, culture matters as much as distance. Therefore, it is important to understand how SIEs negotiate the adjustment process when they are constrained by surrounding contextual elements. Our findings fill a void in the IHRM literature by revealing the challenges faced by Malaysian RNs working in Saudi hospitals and how these challenges illustrate the different aspects of cultural adjustment.
The findings align with those of previous studies on cultural adjustment among SIEs while offering new insights into the unique attributes and characteristics of female SIEs in a particular group. In a nutshell, we found that these female SIE RNs were: 1) committed to learning Arabic 2) able to accommodate and adjust to new and different communication styles and mannerisms 3) keen to enhance their knowledge and expertise by mastering new SOPs, using advanced technology, and learning about global healthcare practices; 4) willing to tolerate homesickness and loneliness, 5) willing to make compromises to adjust to new living conditions (e.g. getting used to a different climate, dress code, gender relations, and restricted female mobility).
However, these sacrifices were highly dependent on the internal and external rewards obtained (or anticipated) during their tenure. The interviewees explained that attractive remuneration packages and professional global exposure compensated in part for the sacrifices they had made to relocate to Saudi Arabia, but for many, the expatriation experience also represented a life experience the value of which could not be measured in monetary terms. For their home country, meanwhile, a vital by-product of their expat experience was that these nurses would bring back new and valuable tacit and explicit knowledge.

Limitations and Future Research Directions
This research was limited to 22 Malaysian SIEs, all working in hospitals in Riyadh, Saudi Arabia. Since expat experience can be significantly impacted by their country of origin (Froese, 2011), the findings may not reflect the challenges faced by RNs from other countries or those working in localities other than the afore-said cities. Thus, sampling ought to take into consideration the concentration of Malaysian expatriates, in particular from the nursing industry, working in other localities in KSA, which future researchers should take note to add value to current literature. In addition, sampling ought to consider expatriates from other foreign countries, whereby looking both in totality, would aptly describe a true perspective of the overall acculturation process facing expatriates working in KSA. We suggest that the future research direction could be explored and replicated based on a different culturally-attuned context to obtain a rich understanding of SIEs turbulent adjustment periods and the different aspects of adjustments.
Another limitation of this study is that it does not address the forces or coping mechanisms driving the willingness of these workers to leave their families and loved ones to work in a foreign country. Culturally-oriented challenges are inevitable in any expatriation process, especially when the home and host countries are culturally diverse. In this context, culture matters as much as distance. It is therefore important to understand how SIEs negotiate the adjustment process when they are constrained by the surrounding contextual elements. Going forward, future research directions should also fill a void in the literature by looking at how the acculturation model could be expanded to explore other strategies or coping mechanisms among SIEs in a different industry, i.e. hotels, finance, logistics and transportation, and others. Despite these limitations, the findings of the study may be of significant use to governments, aspiring SIEs and strategic planners and HR managers in the healthcare industry. Data Availability My manuscript has no associated data or the data will not be deposited. The datasets generated during and/or analyzed during the current study are not publicly available due to the professional code of conduct but are available from the corresponding author on reasonable request.

Declarations
Ethical Statement Compliance with ethical principles in human research is fundamental to ensure objectivity and transparency in research and to ensure that accepted principles of ethical and professional conduct have been followed. Unfortunately, at the university where the research was granted, there is no specific ethics review system for ethical approval, and similar to other non-developed countries, there is nominally a system in place, and in reality, the mechanism is purely administrative not ethical (COPE, 2003). However, despite the lack of a formal system in place and to ensure that the current study adheres to ethical principles, all authors signed the consent form. 2

Conflict of Interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.