Examensarbete i omvårdnad Malmö högskola
61-90hp Hälsa och samhälle
INTERPERSONAL
COMMUNICATION AS
EXPERIENCED BY NURSES
WORKING IN CULTURALLY
DIVERSE INDIAN HOSPITALS
RISA LARSEN
AGNES NILSSON
SJUKSKÖTERSKORS
UPPLEVELSER AV
MELLANMÄNSKLIG
KOMMUNIKATION PÅ
MÅNGKULTURELLA INDISKA
SJUKHUS
RISA LARSEN
AGNES NILSSON
Larsen, R och Nilsson, A. Sjuksköterskors upplevelser av mellanmänsklig kommunikation på mångkulturella indiska sjukhus. Examensarbete i omvårdnad
15 högskolepoäng. Malmö högskola: Fakulteten för Hälsa och samhälle,
Institutionen för vårdvetenskap, 2018.
Syfte: Syftet med studien var att skapa djupare förståelse kring sjuksköterskors upplevelse av mellanmänsklig kommunikation med patienter med annan kulturell bakgrund. Bakgrund: Kommunikation spelar en viktig roll i kulturen och är en stor del av relationen mellan individer. Kommmunikation är en grundbult i sjuksköterskans arbete och är av högsta vikt för att kunna erbjuda en
patientcentrerad och säker vård. Transkulturell medvetenhet är essentiellt för god vård, speciellt som världen blir alltmer mångkulturell. Såväl sjukvårdsturism som utökade globala samarbeten inom Hälso- och sjukvården ökar kraven på kulturell kompetens bland sjuksköterskor. Indien är ett föregångarland inom
sjukvårdsturism och människor från olika kulturell bakgrund reser dit för sjukvård. Metod: Semistrukturerade intervjuer genomfördes med 12
sjuksköterskor mellan 23 och 53 år från två indiska sjukhus. Sjuksköterskorna möter ofta patienter med olika kulturell bakgrund. En tematisk innehållsanalys utfördes på det insamlade materialet. Resultat: Två tematiska inriktningar
framkom från materialet; ett tema med fokus på praktiska verktyg och tekniker för att arbeta med patienter med annan kulturell bakgrund och det andra temat handlar om att bibehålla vårdkvaliteten. Utökade språkkunskaper och
kommunikationsverktyg skulle underlätta sjuksköterskans arbete. Kulturell medvetenhet leder till ett ökat självförtroende hos sjuksköterskan och hjälper denna förutse eventuella behov hos patienten. Slutsats: Transkulturell
medvetenhet och kommunikationsverktyg bidrar till en säkrare och mer effektiv vård. Sjuksköterskeutbildningen behöver lägga mer fokus på kulturell mångfald inom hälso- och sjukvård. Mer forskning krävs inom detta område då vården globaliseras allt mer.
Nyckelord: Kommunikation, Kulturell kompetens, Omvårdnad, Tolkar,
INTERPERSONAL
COMMUNICATION AS
EXPERIENCED BY NURSES
WORKING IN CULTURALLY
DIVERSE INDIAN HOSPITALS
RISA LARSEN
AGNES NILSSON
Larsen, R and Nilsson, A. Interpersonal communication as experienced by nurses working in culturally diverse Indian hospitals. Degree project in Nursing 15
Credits. Malmö University: Faculty of Health and Society, Department of
Department of Care Science, 2018.
Aim: The aim of the study was to gain a deeper understanding of interpersonal communication as experienced by nurses working in culturally diverse hospitals in India. Background: Communication is an important part of culture and a base in any interpersonal relationship. Communication is a foundation in the nursing occupation in order to give patient centered care which is safe and effective. Transcultural awareness in nursing is an important factor in order to give good care, especially as the world is becoming more multicultural. Medical tourism along with the expanding network of global interactions in healthcare ads to the necessity of developing culturally competent nursing care. India in one of the forerunners in medical tourism and cares for patients from many different cultural backgrounds. Method: Semi-structured interviews were conducted on a sample of 12 nurses between the age of 23 and 53, working with diverse patients at two different hospitals in India. A thematic content analysis was performed. Results: The developed themes focus on specific tools and techniques for working with culturally diverse patients and how to sustain the quality of care in diverse
hospital settings. Language resources and tool which aid in communication would alleviate the nurses work. Cultural knowledge helps the nurses gain confidence and foresee possible needs of the patient. Conclusion: Highlighting transcultural interpersonal communication techniques within nursing leads to a safer and more productive practice of nursing care. Nursing education needs to prioritize cultural diversity in health care. More research needs to be conducted on the subject of interpersonal communication in culturally diverse hospital settings since healthcare is a continuously growing globalized organization.
Keywords: Communication, Cultural Competence, Interpreters, Language
CONTENTS
BACKGROUND
Communication and Culture Cultural competence
Cultural competence in Swedish healthcare Theoretical framework Medical tourism India 4 4 5 5 6 7 7 PURPOSE 8 METHOD Sample Data collection Pilot Data analysis 8 8 9 9 10 ETHICAL CONSIDERATIONS 11 RESULTS
Tools and techniques for working with culturally diverse patients Language as an important nursing competence
The interpreter as a nurse resource
Vehicles for comprehension in healthcare
Being prepared in the globalized health care system How to Sustain Quality of Care in a Diverse Hospital Setting
Cultural competence as a Tool for Nursing
Fulfilling the Personal and Cultural Needs of the Patient Compassion and Comfort in the Nurse Patient Relationship
11 11 11 14 14 15 16 16 17 19 DISCUSSION Method Discussion Data collection Sample Integrity Data analysis 20 23 23 24 24 25 CONCLUSION
Further research and value for the study 25 26
REFERENCES 27
APPENDIX 1 31
BACKGROUND
According to the ICN Code of Ethics for Nurses the nurse promotes, advocates for, and strives to protect the health of the patient (International Council of Nurses (ICN) 2012). ICN (2012) also states that the nurses' responsibility falls within improving health and social situations for marginalized groups, as well as working for a society where human rights are respected. In order to achieve these goals, the nurse must first lay a baseline of trust and understanding, this happens through good communication (Huston & Marquis 2015).
Communication and Culture
Culture is passed down from generation to generation and is defined as the commonality of shared behaviors, customs, beliefs and values that enable members of society to deal with one another and the world around them (Sam 2006). Migration is a commonality in human history and is defined as the movement of people among countries, modern migration refers to long-term or permanent residence (Kankipati 2012). People migrating from other countries risk facing many challenges within cultural differences in political, economic or religious contexts. Difficulties are also faced within language proficiency, as well as a psychosocial aspect where there is a difference in the attitudes and values in the country migrated to (ibid.).
Communication is an important part in the nurses' work creating a common groundwork for goals, education and follow up (Travelbee 2002). Effective communication is known to be essential to safe and high-quality care (Schyve 2007). The most serious problems within medical errors have been closely connected to communication barriers (ibid.). Communication problems between nurses and patients can cause a lack of compliance which could arguably reduce the safety and quality of the patient care (Savio & George 2013). In order for high quality patient care and patient safety to be achieved, the challenges around health literacy, language and cultural differences need to be taken into consideration by healthcare professionals and institutions (Schyve 2007).
According to the World Health Organization (WHO) the amount of international aid is increasing every year, expanding this network and global interaction with different cultures, making these cross cultural collaboration scenarios occur more frequently (Piva 2009). The increasing trends in migration of healthcare workers from developing countries as well as medical tourism is affecting the transcultural environment of healthcare all over the world (Kaspar & Reddy 2017). It is
therefore crucial to identify pre-existing barriers within the communication relationship, such as language barriers, cultural factors and differences in expectations in order to reduce the risk for mistakes (ibid).
Patient-centered care embodies the acknowledgement that every patient is individual in their needs and values, thus involving them in the decisions regarding their care is of utmost importance (DeWilde & Burton 2017). Patient-centered care is achieved through the nurse's interpersonal communication (Huston & Marquis 2015). The definition of interpersonal communication can broadly be described as "communication between two persons" (Encyclopedia 2002). But because interpersonal communication is often complicated and private it requires a narrower definition (ibid.). It is said that what constitutes
for effective interpersonal relationships (Donnelly & Pavord 2015). These personal qualities are empathic understanding, unconditional positive regard, warmth and genuineness (ibid.). These personal qualities form the base in all effective interpersonal relationships and open up a platform where both
communicators are equally participating (Encyclopedia 2002; Donnelly & Pavord 2015). This base of communicating leads to a deeper understanding of the true person or people in the conversation instead of an assumption of whom they are (Encyclopedia, 2002). Non-interpersonal communication can instead be defined as a relationship where ideas about sociological or cultural knowledge is based on predictions. The relationship is therefore based on assumptions about a social or cultural group and not on the specific individual person. While non-interpersonal communication can lead to generalizations which can in tune be false.
Interpersonal communication can instead identify a persons "self", and their discernable personal characteristics can develop and emerge (ibid.).
Cultural competence
Cultural competence is defined as a continuing process with a goal of effectively caring for culturally diverse people (Maier-Lorentz 2008). Nursing care that is culturally competent helps promote positive outcomes and patient satisfaction (ibid.). Cultural competence is described as the nurse's capacity to identify their own cultural factors as well as being aware of and trying to understand that of the patient (DeWilde & Burton 2017). Culturally competent nurses also have a specific sensitivity around issues of sexual orientation, cultural differences, race, and gender (Maier-Lorentz 2008). Having the specific knowledge of patients cultural needs ensures holistic and competent nursing care (ibid.). Nurses who are culturally competent are experts in the knowledge around different cultural practices, cultural assessments, and communication skills (Maier-Lorentz 2008). Nurses must constantly be conscious of cultural factors that may affect
communication, since cultural competence in this aspect is important in order to effectively exchange information with patients and family members (Schyve 2007). Cultural competence makes it easier for the nurse to understand the
patients, which creates a better environment for communication, even if the nurse has a different cultural belonging than the patients (Karolinska Institutet 2015). Cultural competence in Swedish healthcare
The foreign-born population in Sweden now exceeds 1,7 million, about 18% of the citizens (SCB 2017). Because of the growing cultural diversity of the nation, Swedish healthcare is starting to focus its resources on educating staff on the importance of transcultural questions and awareness, especially the ability to understand one another even with different languages and traditions (Stockholms läns landsting 2017). The nurse is instructed to always strive for cultural
sensibility and consider the individual capacity and perception of the health of the patient, but is in need of further education on the subject (Jirwe et al. 2010; Karolinska Institutet 2017; Malmö University 2017; Vårdhandboken 2016). Cultural competence is a subject emerging in some programs for nurses at the Swedish universities. Karolinska Institutet offers a postgraduate course focused on transcultural nursing care (Karolinska Institutet 2017). This subject, being
relatively new to the curriculum, started focusing on ethnic questions but is now geared towards cultural belonging, or what makes a human the way they are. Another large focus of the course is the nurse's cultural competence (ibid.). Malmö University has integrated cultural competence as a component of a newly started post graduate program for nurses working with elderly care (Malmö
University 2016). A study conducted in 2010 on final year Swedish undergraduate nursing students indicates that the education lacks sufficient teaching in cultural awareness. The nurses could benefit from more preparation, gaining confidence which would support their work with culturally diverse patients (Jirwe et al. 2010). Some of the undergraduate Swedish nursing programs, such as the previously mentioned Malmö University do include cultural competence in the educational plan as a part of the international or multicultural focus, but with no specific tuition on the topic (Malmö University 2017).
Theoretical framework
Theorist and nurse Madeleine Leininger (1925-2012) highlighted the importance of health workers learning about other cultures to strengthen the trust bond
(Gustin & Lindwall 2012). Leininger states that the world will quickly continue to grow culturally, and persons within health organizations have to hurry to learn not only about their own cultures and ways of communicating, but also that of others. This is so that nurses can create a livable work space that is effective and
responsible (ibid.). In 1965 the first course of transcultural nursing care was introduced (Leininger & McFarland 2002). It focused on Leininger's three phases important in the development of culturally competent nurses. 1: Awareness and sensitivity for transcultural nursing care and an understanding of similarities and differences between different cultures. 2: Use of the deep knowledge of theories based on scientific research within cultural nursing competence. 3: Using
qualitative and scientifically documented knowledge about transcultural care and evaluating the result in the daily nursing care (Leininger & McFarland 2002). If patients and healthcare professionals do not fully understand each other it causes a vulnerability in the relationship, which leads to insufficient emotional support (Savio & George 2013).The risk of miscommunication, and the possible following damage, increases considerably when patient and caregiver do not speak the same language, or if other cultural or social barriers exist. In addition, the complexity of medical vocabulary does not make the comprehension easier (Kaspar & Reddy 2017) The basic understanding between the nurse and patient affects both their relationship and the care given. Thus interpretation of language is a crucial part of communication (McCarthy 2013). Language barriers arise whenever the nurse and patient do not speak the same language or when the patient has limited knowledge of the language spoken by the medical staff. These barriers may have negative impact on treatment and health outcome for these patients, and a method of interpretation has to be considered (Karliner et al. 2007). Even the safety of the patient can be at risk and therefore the level of language knowledge and understanding of the patient must early be identified (van Rosse 2016). To deliver culturally adequate care to the diverse patient the language barriers must first be over-bridged (Azam Ali & Johnson 2016). Studies report that using professional interpreters instead of an untrained person, such as a family member or bilingual staff increases the consistency and improves the quality of care (Karliner et al. 2007). These communication problems become more common as the world grows increasingly culturally diverse (DeWilde & Burton 2017). The diverse cultural interaction also requires a greater sense of self and self confidence in the nurse, which can be difficult (Philip et al. 2015). Madeleine Leininger's theory and teachings focuses on these comparative human healthcare differences combined with similarities in cultural patterns, beliefs and values to provide healthcare which is culturally congruent, meaningful and beneficial to its patients (Leininger & McFarland 2002). Transcultural awareness
is thus a necessity in healthcare because of the multicultural population in our communities (Maier-Lorentz 2008).
Medical tourism
Medical tourism has started to become a highly sought after attraction in countries such as India, Mexico, South Korea, Thailand and the United States (Patients Beyond Borders 2017). Some of the factors which make these destinations
popular is the availability of internationally trained and experienced medical staff, international patient flow, and potential for cost savings on medical procedures (Patients Beyond Borders 2017). Patients coming to India for medical treatment are a heterogeneous group and differ in ethnic, economic, social and educational background (Kaspar & Reddy 2017). The study by Kaspar and Reddy (2017) stated that in order to draw patients to the transnational hospitals in India two factors were important; an effort of demonstrating affordable world class care, and care which understand and meets the practical and emotional needs of the
patients. Building trust with healthcare professionals is also a factor when patients are choosing international hospital care, and it is found that potential patients look for competence, empathy and reliability in the caregivers (ibid.). Many
international patients chose India because it is the cheapest in regards to
transnational medical care (Kaspar & Reddy 2017). Medical travel also involves some risks for vulnerable people whom are ill and their positive outcomes for recovery (Hilton et al. 2015). Examples include the setting of an unfamiliar place, different cultures, unfamiliarity of language and care givers, and a lack of social support (ibid.). It is however, difficult to fully understand the extent of medical tourism in its size and influence because of the lack of literature on the subject (Hilton et al. 2015). A better understanding of cultural factors would provide an essential background for the future development of medical travel policy and the needs of the medical travelers (ibid).
India
India is a country of great diversity and holds some of the oldest history of
civilization (The World Factbook 2017). In 2011 the People's Linguistic Survey in India counted 780 Indian languages, 23 of these languages recognized by the Indian government (Biswas 2017; New World Encyclopedia 2017). Hindi is recognized as the official language by the central government and is spoken by 40% of the population, but in many parts of south India Hindi is seen as a foreign language to the people (Biswas 2017; New World Encyclopedia 2017; Pathi 2017). A national language implemented on the country also creates difficulties because language is considered part of people's cultural identity (Pathi 2017). English is officially recognized by the government as sub language in India (New World Encyclopedia 2017). Individual state legislatures can also make any
regional language their own official language of that state (ibid.) People however, feel it's difficult to move from state to state because of these many language differences, and many don't know Hindi or English (Pathi 2017). India's focus on medicine is also a foundation for its culture, health and tradition that has dated back thousands of years (Ravishankar & Shukla 2017). India has a varying approach to medicine, combining methods such as traditional Ayurveda and western scientific medicine (Unnikrishnan P 2017; Ravishankar & Shukla 2017). Previous studies conducted in India show that nurses are experiencing
communication issues when caring for patients from culturally and linguistically diverse backgrounds (Savio & George 2013). It is stated that more education and
training in communication is needed, as well as additional nursing research (Savio & George 2013). Communication skills training in the existing Indian nursing programs is found to be insufficient and additional schooling is called for, especially in regards to transcultural education (Imran 2013; Savio & George 2013). Many patients traveling to India for medical reasons do not speak the local language, Hindi or English. Hospitals with a large multilingual patient base tend to use interpreters to over-bridge the linguistic gap and cultural chasm when possible, though the competence and availability of the interpreters in Indian hospitals and healthcare facilities vary, and some misinterpretations are considered impossible to avoid (Kaspar & Reddy 2017). Furthermore, the interpreters job is to both correctly translate the spoken language and mediate emotions and other complexities connected to the culture. (ibid.). This is not only the case for international patients, but also for patients arriving from other regions or relocated medical staff. Thus the importance of cultural awareness and proper preparation of the nurse has to be acknowledge (McCarthy 2013; Repo et al. 2016).
PURPOSE
The aim of the study is to gain a deeper understanding of interpersonal
communication as experienced by nurses working in culturally diverse hospitals in India. The following topics were explored:
• What characterizes communication while working with culturally diverse patients?
• How does cultural competence affect the quality of care in the nurse-patient relationship?
• What barriers and enablers affect transcultural interpersonal communication?
METHOD
Qualitative research was conducted and an exploratory study design, as described by Polit and Beck (2006), was selected. Data was collected through
semi-structured interviews with open ended questions about transcultural
communication, focusing on the experiences of the nurses. This design was considered appropriate for the purpose of the study and in line with the somewhat diffuse nature of the topic. A qualitative method is suitable when studying peoples first hand experience of a phenomenon (Polit & Beck 2006). Exploratory research is used when the aim is to gain understanding and insight of a topic and its
underlying processes (ibid.). The purpose of semi-structured interviews is to guide the interview subject to talk openly within the structure of different themes and open-ended questions allow for less restricted answers (Polit & Beck 2006). An interview guide, shown in Appendix 1, was used to help focus the interview questions and make sure no theme was left out or forgotten.
Sample
According to Polit and Beck (2006) saturation can be achieved even with a small number of participants if the information is of sufficient in depth and collected in a manner of persistent observation. Generalizability was not the purpose of the
interviews, but rather to gain an in-depth, and holistic understanding of the concept of transcultural communication, as intended by inductive, qualitative designs (Polit & Beck 2006). Two hospitals were hand picked due to their focus on medical tourism and wide range of international patients. Hospitals in two cities were selected with the intent of widening the perspective. The first hospital was located in the state of Kerala where the official language is Malayalam (Languages of India 2017). The second hospital was located in the state of Tamil Nadu where the official language is Tamil (New World Encyclopedia 2017). Nurses at each hospital were selected through an in-house nursing director before arrival. As suggested by Polit and Beck (2006), a nursing director at each hospital was used as a gatekeeper to contact the nurses, asking for their participation in the research and arrange the meetings. The gatekeeper´s function was to help select interview subjects matching the inclusion criteria, as a way to easier gain access. The inclusion criteria were female and male nurses between 20 and 65 years, working with international patients for a minimum of five months at the one of the selected hospitals. The sample included a total of 12 nurses between the age of 23 to 53 years. They all spoke English and had experience from working with
international, national and local patients at the current hospitals. The origin of the patients included Oman, Saudi Arabia, Sudan, Bangladesh, Nigeria, Europe and US. They also received patients from all parts of India. All nurses interviewed originated from and received their nursing education in India. None of the 12 nurses declined answering any questions or wished to withdraw from the study. Data collection
Prior to the interviews all participating nurses were given verbal and written information about the aim of the study. It was clearly stated that taking part in the study was entirely voluntary and participation could be withdrawn by the
informant at any time, without further explanation, as in accordance with the ICN Code of Ethics for Nurses (ICN 2012). A document of informed consent was signed by all participants, shown in Appendix 2. The nurse participants were assured that no personal information would be included in the report or passed on to a third party. Approval in regards to the recordings was also granted before the start of the interviews. The interviews took place in private rooms at the hospitals, present were the two authors and one informant. To minimize bias this is a
procedure recommended by Polit and Beck (2006). The conversations lasted between 21 and 39 minutes and the responses were recorded and notes were taken. The authors took turns interviewing the nurses and the one not interviewing took notes and filled in when further questions arose.
Pilot
To ensure a comfortable setting, sufficient length, and effective format for interviewing, a pilot interview was conducted, as suggested by Polit and Beck (2006). The pilot interview also tested if the questions were understandable, that they encouraged conversation and that the topic was understood and of interest to the participants. The pilot interview subject was the first scheduled nurse
informant. A decision was made, after careful evaluation to add one question to the interview guide. No further changes to the questions or format was required. The pilot interview was considered successful and therefore included in the sample, analyzed and used in the result.
Data analysis
A thematic content analysis was performed to systematically and appropriately analyze the gathered data, as described by Burnard et al. (2008). This is a suitable method when analyzing semi-structured open ended interviews, and is also one of the most common analysis practices for qualitative research (Burnard et al. 2008). The authors task is to interpret and search for understanding in the gathered data by identifying categories and themes (ibid.). This was done by first transcribing the interviews verbatim, and using the recordings to check each others transcripts. While carefully reviewing the transcribed material, notes were taken of words or phrases summarizing what was being said in the interview. These words and phrases were numbered to easily link back to the correct segment of the transcript and then pasted into a clean document. This is described as initial coding (ibid.). The codes were then sorted into matching categories, similar categories grouped together and reduced until the analysis contained no more than 10 categories. Categories were applied to every code in all 12 transcripts and reviewed to verify relevant classification of the content, making sure every piece of code was applicable to only one of the 10 categories. Throughout the process two comprehensive themes emerged. As an example of the analysis procedure an extract of the analysis, with the final set of themes, categories and codes is shown in Table 1. Each category was assigned a color. The transcripts were reviewed and highlighted in accordance with the category applied to each code. Lastly the transcripts were cut up and all parts of the same color pasted into 10 individual documents. Out of these color-organized documents it was then possible to compose the report of the findings for each separate category and hence start the writing process.
Table 1.
Interview transcript Code Category Theme
So I know Hindi better and I know English better so I can speak to them, so if the north Indians are coming I can speak Hindi to them. So if we speak in their own language it will be making it very much comfortable for them also.
If we speak in the patients own
language it will make them comfortable.
Language as an important nursing competence
Tools and techniques for working with culturally diverse patients
But when we both not knowing the particular language, and we want to share something, it is very difficult but definitely I would prefer translator.
If we dont speak the same language I prefer to use an interperter. The interpreter as a nurse resource
Tools and techniques for working with culturally diverse patients
Cultural competence or cultural knowledge as a basic thing is very much essential to dealing with patients of different cultures and different traditions, because most of them consider their own culture as a valuable thing. Cultural competence is essential because patients consider culture a valuable thing. Cultural competence as a tool in nursing How to Sustain Quality of Care in a Diverse Hospital Setting
We used to ask different questions like any cultural tools or different cultural differences regarding food. And their bathing pattern, their sleeping pattern we use to enquire.
Inquires about cultural preferences regarding food, bathing and sleeping patterns. Fulfilling the personal and cultural needs of the patient How to Sustain Quality of Care in a Diverse Hospital Setting
ETHICAL CONSIDERATIONS
The ethical application was accepted by the Ethical Council at the Faculty for Health and Society, at Malmö University on June 16, 2017. Application number HS 2017 nr 59. The utmost integrity was followed in regards to data collection and storage to ensure that private information was not leaked, as suggested by The Research Ethics Guidebook (2017). All gathered data was stored on two separate encrypted USB drives. Computers used were not network connected and no data was be shared or stored online. Highest integrity was regarded to not reveal any of the participant's identities or personal information, as recommended by The Research Ethics Guidebook (2017).
RESULTS
The results are derived from the compilation of two themes. The themes are presented with smaller categories, each shown with verbatim sections from each interview. This strengthens the credibility of the study as well as developing a greater understanding of the material. Throughout the interviews similarities between the nurse's experiences with interpersonal communication in nursing evolved into these clear categories. They were analyzed into the following result. Tools and techniques for working with culturally diverse patients The theme Tools and techniques for working with culturally diverse patients refers to the nurse's practical experiences of meeting patients with a diverse cultural and linguistic background. The theme is divided up into the following categories, Language as an important nursing competence, The interpreter as a
nurse resource, Vehicles for comprehension in healthcare and Being prepared in the globalized health care system.
Language as an important nursing competence
This category emerged from the nurses’ straightforward solution to the
transcultural challenges of communication. They emphasize the importance of language skills for nurses working with a diverse patient group, and declare their enthusiasm for further knowledge and language training. All nurses in the study speak at least two languages; their mother tongue Malayalam or Tamil, and English. Their nursing education was in whole or parts in English. Several of the nurses also know additional languages such as Hindi, Arabic and Malay. All of the nurses mention language problems and misinterpretations as the main barrier or one of the biggest challenges when communicating with their culturally diverse patients.
“The greatest challenge is no human is well versed with all languages in the world. So often misinterpretation is the greatest challenge that we are facing.”
(Nurse #12)
The nurses all more or less frequently care for patients from other countries or states, with different linguistic backgrounds. Mainly the patients are speaking English or Arabic. Patients speaking English pose no major problems
according to the nurses, unless being cared for by staff not as familiar with the English language. If the English knowledge is insufficient the nurse will get
uncomfortable and not be able to have an adequate dialogue with the patient, leading patients to feel under informed and worried. Having nurses and other staff who do not speak any other language but their mother tongue may result in communication problems in a ward with diverse patients, according to one nurse interviewed.
“Some of the announcers and staff here is not much eligible for talking in English, and leads to communication problem. Only that of the region or mother tongue only. So most of patients sometimes they more worry about nobody's talking and asking questions. Then leave the patient. Sometimes nurses not at all good at English and other languages, so that’s other different problems.” (Nurse #5)
The majority of the nurses refer to language proficiency as a natural solution to the communication challenges when working with culturally diverse patients. Learning the languages of the most common patient groups helps the nurse understand the patient, avoid miscommunication and make their work more efficient. According to one nurse, it is important for the nurse-patient relationship to be able to communicate in a language they are both familiar with. Therefore, nurses have to know the languages of the patients. The nurses believe that speaking the patient's own language makes the patient more comfortable. One nurse expresses feeling more comfortable dealing with local patients, because they know their language and how to speak to them. This helps the connection between nurse and patient and improves the care through better communication. Another nurse mentions local patients as being more cooperative because they share languages with the nurse.
The majority of the nurses interviewed speak Arabic. Some speak it fluently; others know simple words and phrases enabling them to manage patients in absence of an interpreter. A few nurses mention learning the language by themselves outside of working hours, or by the help of patients and
interpreters at the hospital. A few nurses speak Arabic and Malay because of former positions abroad. Several of the nurses say it helps them to know Arabic, even if the knowledge is rudimentary.
“Even I learn some Arabic words also, just for making the situation not much trouble. So I’ll say ‘please sit down and tajim will come’. Like that. ‘Tajim’ in Arabic means translator. So I will say ‘tajim’, so when they hear the word ‘tajim’ they will get to know that the will be coming.” (Nurse #3)
In the absence of an interpreter, a nurse who speaks the patient’s language will assist. The nurses are used to ask experienced colleagues for help when
confronting language problems. One nurse also says they sometimes divide up the patients in accordance with the specific language skills of the nurses working that day. In a medical setting there are words that do not have a proper translation in a particular language. This can lead to
miscommunication, misinterpretation and information loss.
“So what patient was telling ‘an 'amut’, ‘I want to die’, that's the complaint of the patient. So my colleague she went and said ‘insha'Allah, in de mut’. That means ‘By the grace of God you may die’ like that. […] Literally they don’t want to die, they just, you know it comes, while talking it comes. So sister
doesn’t know what is the meaning of ‘mut’, she just used that word that's it. So that made her more sick.” (Nurse #8)
The nurse has to really know the meaning of a word before using it, and yet the nurses interviewed all claim that knowing even just a few words helps them in managing the patient. One nurse brought up an incident that occurred when a patient with diarrhea accidentally was prescribed laxatives, because of language misinterpretation.
The interpreter as a nurse resource
The two hospitals both have in-house interpreters employed. The availability varies depending on workload and time of day. All nurses interviewed use professional interpreters in their work with culturally diverse patients. They express a need for more interpreters available at all hours. However, they also point out the importance of being ready to handle patients with language barriers, even in absence of the interpreter - a frequently faced situation. They find workarounds by using family members translating, asking colleagues for help, learning the languages of the patients and using their smartphones.
“So we need to manage it. We got translators at times and at times we don't have, we just have to do it in action sometimes because we don't understand.”
(Nurse #11)
All the nurses say they call for help from an interpreter when confronted with a patient not speaking any language they know. The interpreters are especially useful in the initial assessment process, when the nurse collects all important information from the patient, and makes sure the patient knows the routines and practical details of their hospital stay. A few of the nurses mention they first try to communicate with the patient in a language they speak, before contacting the interpreter, while others say they always use the interpreter to assure accuracy in the communication. Many nurses claim that using an interpreter ensures no miscommunication with their patients. They argue that there is no problem in the communication if the interpreter is good enough, which the majority of interpreters at the hospitals in question are trusted to be.
“Basically if the translator is there then I don’t face any problems to
communicate with the patient - because obviously the translator and I will be knowing the same language - and the translator and patient will be knowing the same language.” (Nurse #3)
The nurses interviewed find it easy to communicate with an interpreter, and believe it facilitates their daily work. A few nurses claim any
misunderstandings will quickly be solved as soon as the interpreter arrives, though delays might affect the treatment. A majority of the nurses
acknowledge the absence of interpreters to be the main challenge when working with culturally diverse patients. That includes interpreters being occupied with other patients, located in other departments of the hospital, unable to reach or not available at certain hours. This will have negative impacts on patient care, such as delayed treatment or worried patients.
“There is two interpreters but I tried both, and both did not pick my phone, phone was ringing. […] Finally they picked up my phone after a few minutes
and then they came, they said that she had some pain, and after that we have given pain killers.” (Nurse #7)
The time spent on trying to get hold of an interpreter was referred to as “a lot
of time wasted” by one nurse (Nurse #10).
Another problem surfaced is the lack of competence among some interpreters. An incorrect or insufficient translation will directly affect the communication between the patient and the nurse. Some interpreters do not come from the same place as the patient, or are not familiar enough with the local languages to be able to accurately translate some complicated words. In addition, one nurse mentions the problem of interpreters not being engaging enough and not treating the patient in a friendly manner.
“Some translators they're not really keen to help us. Some are very good and
some they're not. They're just like a doll, whatever you say the doll will talk only. […] The translator should not be in that way. They should be more friendly as a friend. What be said, even I don't know the language, we should talk in nice way to the patient.” (Nurse #11)
However, another nurse claims to be working with interpreters who all show a great deal of engagement by being involved in the patient care, and
contributing to the medical team. According to a few nurses, trust issues might occur when working with an interpreter as a mediator. It affects the
relationship and unity between nurse and patient as well as the confidentiality, and when possible they prefer to speak directly to their patient.
“Whenever you know about the language then you ask that patient and then patient answers the nurse. Otherwise three person is meet.[…] Whenever you translate, that translator, that confidentiality is difficult. My experience third person is coming, the confidentiality is breaked.” (Nurse #6)
The nurses feel they are personally responsible for making sure the patient gets the correct information even when using an interpreter, and they have different ways of doing so. One way is to look at the patient’s facial
expression throughout the translation and afterwards ask that the patient repeat what was said. The nurses express a fear of losing information, but overall interpreters are seen as an indispensable resource in their daily work, without whom the patient care would suffer.
Vehicles for comprehension in healthcare
The nurses all have various tools and techniques to manage their diverse patients. If left without an interpreter, the nurses all describe taking to non-verbal communication techniques such as facial expressions, body language and signals to manage patients as needed. Actions and gestures can be used to ask simple questions or to let the patient know they have to wait. A simple smile can be helpful when facing difficulties in communication.
“We will use a smiley face and they will understand we cannot speak like that. Then we will use some kind of actions, you know, some kind of actions like that we will use. ‘At what time you ate last?’ [Shows with hands] We ask like that and they will understand.” (Nurse #5)
There are tools the nurses use to help make their patients understand
instructions and information, for example audio-visual aids, flash cards and written information. Pain charts and other analog scales are frequently used, and pen and paper can help aid patient communication. Some nurses also argue for the advantages of smartphone apps, Google Translate and computers. In absence of an interpreter, family members can be asked to translate or participate in the conversation to support patient compliance. The patient understanding is confirmed by direct response and feedback forms following the hospital stay.
Several of the nurses say they wish for additional creative strategies to enhance communication with their culturally diverse patients. Manual aids asked for are written information and educational pamphlets prepared in different languages. Flash cards that can be saved and reused, and printed dietary options in accordance with different cultures are other suggestions. They also propose ready made consent forms in different languages to ensure the understanding of patient and relatives in critical situations. Some nurses request more digital and audio-visual aids. These can be used to instruct patients and relieve the nurse of certain time consuming tasks.
“I believe, here we are using charts, visual analog scales, pain scales. But I use to prefer always advancements. I believe some audio video aids can be used to make patients room oriented. Orientation regarding hospital and orientation regarding rooms. So that's that job will be eased for nurses, so we don’t need to explain regarding that again, because a video supplement more than we explain it physically.” (Nurse #12)
In addition, the nurses want scheduled language training and communication classes in their workplace as well as more interpreters at hand.
Being prepared in the globalized health care system
All nurses interviewed, with one exception, received some kind of communication training as part of their nursing program. One nurse was trained by being posted in communities during nursing school. Several nurses received language instruction, and some could recall practicing how to
approach patients and using various communication techniques. Several of the nurses say they received communications training in their workplace.
Language classes are at times provided at both hospitals studied, and one nurse mentions she went through cultural training on the job. They all have a
positive attitude towards gaining further knowledge on the subject. Some wish for more collaborative workshops with other departments, or more frequent gatherings in their ward for the purpose of sharing experiences.
“I will be very much grateful if we are providing here communication classes and all. I'll be very much interested to get inside and attend that. Because while sitting in a communication program there are different staff, different colleagues will be there, so each colleague will be there sharing their own ideas about communication.” (Nurse #3)
One nurse stresses the weight of teaching students and newly graduated nurses the importance of communication. Learning from colleagues is considered an important source of information about different cultures, as well as the everyday work with diverse patients. The nurses who have been working
overseas feel they have gained a lot of transcultural knowledge and practice in communicating with foreign patients and colleagues. It has given them
experiences that help them in their work back in India, and they want to encourage others to go abroad and come back to receive the same understanding. The majority of the nurses think it would be good to
incorporate transcultural training in the nursing curriculum, extend the subject of communication, and add more language instruction.
“In the nursing education we can include this base of communication with different cultures or different countries, or people in different countries. And also cultures of different countries should be included in the nursing education so it will be very helpful while coming into practice in this situation.”
(Nurse #2)
To better prepare their future colleagues, the nurses believe more emphasis needs to be put on the issues of transcultural communication.
How to Sustain Quality of Care in a Diverse Hospital Setting
The theme How to Sustain Quality of Care in a Diverse Hospital Setting refers to understanding the awareness and skill required to have interpersonal relationships. It is also about the cultural knowledge required by nurses in order to give good and individualized patient centered care. The theme was divided up into three categories, Cultural competence as a tool in nursing Fulfilling the personal and
cultural needs of the patient, and Compassion and comfort in the nurse patient relationship.
Cultural competence as a Tool in Nursing
The category cultural competence as a tool in nursing refers to the need and skill of knowing about other cultures in order to give the best nursing care. All the interviewed nurses consider knowledge about other cultures important in order to do their work well. They feel it is important because of the globalization of healthcare. According to the nurses, cultural competence is not only important, but a basic qualification for their work. They define cultural competence as the ability to give good and safe care, no matter where the patient comes from or what cultural background they have. The nurses consider cultural competence as being aware of the different cultural or personal needs of the patient. One nurse
especially emphasizes that cultural competence is important because culture is valuable to patients.
"Cultural competence or cultural knowledge as a basic thing is very much essential to dealing with patients of different cultures and different traditions, because most of them consider their own culture as a valuable thing. So if it's getting violated they will be getting definitely distressed or dissatisfied. So it's a basic need, or it´s a basic qualification of a nurse to have a generalized
knowledge regarding different patients from different nationalities, different cultures." (Nurse #12)
The nurses express that having cultural knowledge gives them the ability to work out of kindness. They experience cultural knowledge as a base in the nurse-patient relationship leads to increased patient comfort. When the nurses base their work on kindness, the patients are comfortable and speak more freely. The nurses feel that these tools lead to nurse and patient confidence and helps nurses foresee patient needs.
“So I think language is not a problem, only how we are approaching the patient.
And we should convey the message that ‘we are here to care you’.” (Nurse #8)
All the nurses say that the base of pleasing patient expectations is having
knowledge and respect for personal and cultural differences. One nurse explains that culture is part of each person, and therefore must be respected. They
experience that it is easier to work with patients who are local and have the same cultural background as the nurses. They find it challenging to care for people with different cultural needs or expectations than their own. One nurse says that
knowing other cultures is important because of the close relationships nurses have with patients.
“When we are working in Kerala we know already this cultures like this and all... We must also know about (other) cultures, because we are mingling with that culture patients and all. So we need more knowledge about their own cultures and all. It’s important for nurses.” (Nurse #4)
Some nurses experience that cultural competence is gained by travelling, visiting, or working in other countries. This gives them a sensitivity to other cultures, which they can apply in their work. They say that increased encounters with other cultures is helpful in gaining cultural competence skills. They also say that
knowledge of their own culture is important as well, and helps them understand other cultures. Many interviewed nurses emphasize that a clear understanding of their own culture helps them to not impose their own culture on the patients.
Fulfilling the Personal and Cultural Needs of the Patient
The category fulfilling the personal and cultural needs of the patient explores how the nurses prepare to meet the varying desires of the patient. All the nurses say it is important to have respectful and clear communication while speaking with and educating patients.
“Communication is our feelings and our fears explained to other person. To reduce our fear and doubt... Patient communication is very important. Otherwise more more issues. We communicate with the patient more more issues is
reduced.” (Nurse #6)
In order to find out the personal or cultural need of the patients, the nurses say the first step is to listen carefully. They then ask what the patient needs, what their expectations are or if there is anything else that the patients would like to share.
“We should respect their cultures. Because we can’t comfort the patients or the bystanders to do in our own way, we should always ask what they need and what they are expecting from us - so, only by that the patients and bystanders will get the trust, then only it can be taken in a good manner.” (Nurse # 3)
Nurses experience that starting with small questions establishes a base of communication. Then they can understand the language abilities of the patients. Once the nurses have determined these language abilities they can ask questions about the patient's origin. The nurses experience that this helps the patients to open up. Another nurse emphasizes that asking open ended questions encourages the patients to talk more freely. When a patient opens up, gathering relevant
information is easier. The nurses say that this first gathering of patient information is crucial to fulfill the patients needs during their hospital stay. Through these conversations a relationship of mutual respect is established.
In one hospital, the nurses treat their international patients as guests. The care is not different, but the nurses are extra sensitive to the difficulties the patients face being in a different country. Some nurses say that the family is considered a part of patient care and include family members in the conversations around treatment. Some nurses attempt to treat patients like members of their own family. This creates closeness, understanding and respect for the patients and their family.
“If you keep on with them and you talk with them, you talk to the relatives, you have a close relationship - then sure they will listen to us. At least in 10-20% we can achieve something from the patient, for their improvement, if we are close with our patients.” (Nurse #11)
Patients often ask the nurses for help regarding their needs around cultural
traditions. Many patients inquire about places to pray. If the patients don’t ask, the nurses will offer help finding places for religious purposes such as churches, mosques or temples in or around the hospital. Often a religious representative comes to the hospital to perform wished for ceremonies for the patients. When patients ask to perform prayers before a procedure or after the passing of a family member, the hospital tries to arrange for time and privacy. Nurses also ask about for example, traditions around death, blood transfusion, metal implants, rituals during childbirth, disposal of amputated body parts, which in some cultures require special care, or other varying cultural preferences. Nurses then try to adapt to these various patient needs. In some situations, patients want to for example, film the operation, bring religious artifacts into the operation, or hold prayers before procedures.
According to the nurses, patient comfort in regards to culture is especially important when caring for patients. Private rooms, women nurses, and clear information is respected for women patients where it is culturally sensitive to expose their body parts. The nurses all want to make the patients physically and emotionally comfortable. Many of the nurses say that when procedures requiring exposure are prescribed, procedures are clearly explained and if possible only the doctor and women nurse are present. Sterile "head coverings" for surgery is offered and anticipated for Muslim women, and clothing options are offered in order to achieve highest comfort.
“Maximum we will address. We will adapt to situations, you know? If a patient is
needing to cover the head we will give some kind of cloth to cover. Some patients need to take something inside the OR, this one we can do. And some patients need to see the operation. Need to see. So we will tell that, we will record it. And we will give the videos, later they can see- now we cannot see. So, they are also happy with that.” (Nurse #5)
If the nurses can’t personally help the patients with their cultural sensitive requests they try to escalate it in the hospitals higher authority. One nurse says that she should not stand in the way for her patient's traditions, so tries her best to support these inquiries.
"I can ask him, ask my superior who will be there. By that time if (family) get reason for ten minutes they can be with the patient, they can continue their tradition. It should not be dislocated because of me. So they can continue their tradition with them, and then they can get out after their cultural programs have been done." (Nurse #3)
The nurses also say they wish to treat patients peacefully and with respect regarding food. Many patients inquire about specific food items and most often the nurses can provide these options. Other times the nurses offer from a varying array of food already available at the hospital. A nutritionist also supports the nurses, and the patients are asked different questions regarding cultural food preferences. The nurses also experience that by paying attention to and respecting patients sleeping patterns they can help make the patients more comfortable. The nurses notice that people in different cultures have different sleep patterns. Some patients wake up early and some sleep late, and nurses feel they should respect these different sleep patterns when for example giving food, medications, or baths. Sometimes however, during rounds and surgery, these wishes cannot be granted.
Compassion and Comfort in the Nurse Patient Relationship
The category compassion and comfort in the nurse patient relationship emphasizes how the nurse develops an interpersonal relationship with each patient. From a compilation of the nurse's answers, compassion is defined as having empathy, the ability to understand and be understood, to be considerate and tolerant, and to give care. Comfort means developing trust between the nurse and the patient, and forming a foundation where the patient feels free to ask any question. In the conversations with all the nurses, compassion and comfort holds value in building trust, listening, understanding and educating.
Especially during shameful or embarrassing moments the nurses feel that the interpersonal relationship is important in order to encourage comfort and
confidence in the patient. From there the patients can feel comfortable enough to bring up difficult issues or personal concerns. The patients can in an interpersonal relationship with the nurse express fears and concerns which might otherwise not be verbalized, which can then reduce the quality of care.
"That they have interpersonal relationship is more important in nursing to the patient, then they can, they will trust us, they will tell everything, what their fear, their concerns, everything they will tell. Like that we get into the patients.
Empathy and see ‘this is happening,’ most of the patients will get to understand."
(Nurse #10)
The importance of caring for patients is a thread woven through all of the conversations with the nurses. They feel it is important to treat each patient as their own people, no matter where they come from.
"Because patients who come here are not our own people but we treat them as our own people. So when we treat we have to give our knowledge, our love to them as if they feel they are close to us." (Nurse #9)
Each nurse weighed on the importance of patient understanding and have varied thoughts on how to make sure the patient truly understands. Nurses observe the
patients to see if they are expressing emotions or sensations beyond the use of words, or if there is any fluctuations in their condition. Careful watching is important to see if the patient understands, which can often be seen in subtle changes in their eyes. One nurse says it is important for the nurse to be aware of their own facial expressions while explaining to the patient. The nurses also feel that repeating the question often, having many conversations with the patient, and taking time with the patient helps with patient comprehension. Some even
expressed that by talking a lot the patients can understand even when language barriers are present.
“According to me, that if we are dealing with a patient we should be very much talkative to that patient. So if we keep mum, if we keep the face like a doll face, the patient will not be happy to share with us anything. So I think when we are facing a patient we should be very much pleasant, and to speak to them. Then only can they share something, then I can ask him or her, the patient I can ask, ‘whether you need anything else’, ‘whether you prefer something from us to do for you at that time of the treatment’ and all. So they are willing to open, and by that time I can do.” (Nurse # 3)
The nurses express that communicating with compassion allows for patients to feel comfortable and open up to a nicer nurse-patient relationship, or in other words an interpersonal relationship. Some nurses experienced that a smile can give much in terms of patient care and healing, especially when communication difficulties are present.
"All the patients requires care, mainly care. They will be very sick, and if a smile is enough, one smile is enough for their cure. So I believe that all the care is, care, patient care is the most important." (Nurse #1)
The nurses say that giving comfort is the most important ability of the nurse. Even when nurses only have five minutes to speak with a patient, for example before surgery, the goal is to make the patient comfortable. The nurses see that a base of comfort lays the groundwork for patient trust. And trust is seen as important in reducing fear and anxiety with patients. Nurses also see that gaining patient trust is important in order to build a strong foundation in patient centered care.
DISCUSSION
Good communication between nurse and patient is considered fundamental to health care, both according to the nurses interviewed for this study and existing literature (McCarthy 2013). Language was highlighted as one of the primary sources of communication problems. Not sharing the same linguistic background creates communication barriers between nurse and patient (ibid.). This was something all the nurses interviewed for this study could relate to. Meeting diverse patients on a daily basis - many of whom have only a cursory knowledge of the English language - had given them experience in this matter. According to Kaspar and Reddy (2017) many medical tourists coming to India do not speak English at all, creating language barriers that challenged the quality and safety of the care. The nurses in this study gave examples of both delayed treatment and medication errors. This can also be found in the literature. In a study about patient safety risks due to language barriers, van Rosse et al. (2016) found that not only
were there a number of possible safety risks for patients with low language proficiency, but that sufficient record keeping of these risks was also rare. They suggest that standardized record keeping is key to improved communication and enhanced safety of care. Only after having been identified, such language barriers can be bridged (van Rosse et al. 2016).
The first solution to overcome language barriers among the nurses in this study was to call the interpreter, who represents a vital resource but also a source of frustration. Kaspar and Reddy (2017) emphasize the complexity of working with interpreters, translating both between languages and cultures, as well as the problem of availability. Many nurses explained how they at times were left
stranded, forced to manage the patient to the best of their abilities. van Rosse et al. (2016) also point to many situations when using an interpreter is neither
convenient nor realistic. For shorter questions or simple nursing tasks there may be little need for an interpreter, and in emergency situations there may simply not be any time to spare. In the absence of an interpreter a family member could be used, though Karliner et al. (2007) stress the risk of reduced quality of care when asking untrained persons to translate. This was not a common occurrence
according to the nurses in this study. Rather, they emphasized the need for themselves and their colleagues to learn the language of the patient. This result was interesting because it indicates how globalization requires new expertise from the professional nurse. They need not only cultural competence and the ability to deliver culturally congruent care but also a substantial language knowledge.
It is remarkable how the nurses seemed to view language skills as an obvious aspect of their profession. They suggested adding language instruction to the nursing curriculum, something several studies support (Repo et al. 2016). The nurses felt that communicating in the the same language provided comfort to the patient and nourished the nurse-patient relationship. The recent study by Azam Ali and Johnson (2016) on bilingual nurses’ experience of language-congruent care supports this assumption. It argues that both patients and nurses become more comfortable, and that patient compliance improves. Therefore, the bilingual nurse is and will continue to be in high demand (Azam Ali & Johnson 2016). No studies of the possible danger of using limited language skills in a medical setting were found, however. The nurses in this study shared their experiences of
miscommunication happening when using words whose meaning they do not fully understand. They also emphasized that learning every language is an impossible task. This is true, of course, but the enthusiasm among the nurses to increase their language skills must be viewed as a great asset.
The results demonstrate that several of the nurses have reflected a great deal on other solutions to the language barrier issue. Some of them had suggestions for improvements and wished for technical advancement to assist communication. van Rosse et al. (2016) recommend the use of technological audio-visual aids, for example tablets. Providing the patients with informed consent forms in their own language could greatly improve the understanding of and safety for diverse patients (van Rosse et al. 2016). This was also one request out of many that emerged from the interviews in this study. The results show that the nurses working daily or weekly with diverse patients have well-reasoned methods and ideas of how to deal with communication issues. In order to actually implement these ideas, they express a need for more resources and more training, however.
Effective interpersonal relationships are complex and require the understanding of many personal qualities (Pavord & Donnelly 2015). These personal qualities are empathic understanding, unconditional positive regard, warmth and genuineness (ibid.). The interviewed nurses in the study consider compassion, comfort, understanding, kindness and caring to be important in their nursing occupation. Some of the interviewed nurses say kindness is more important than words, which is congruent with the definition of interpersonal communication. These ways of caring for patients are some of the personal qualities which form effective interpersonal relationships, according to Pavord and Donnelly (2015).
Caring is a common and important value in both Leininger's theory on culturally competent care as well as in the definition of interpersonal relationships. “Nurses are expected to get close to people and to establish and maintain intimate caring relationships" (Leininger 2006). All the interviewed nurses noticed the importance of care and trust for their patients. They define caring as the basic foundation for nursing. Even if they did not specifically define cultural competence as the basic skills of care and trust, their explanations support this. Their experiences of what is important in their work, and how to achieve a connection with their patients, is in line with the definition of culturally competent nursing. In the study by Maier- Lorenz (2008) the term cultural competence is defined as the nurses achieved efficacy in cultural assessment, acknowledging health practices related to different cultures, and a knowledge in good communication skills. The findings from the present study show that nurses at both the hospitals are congruent with Maier-Lorenz (2008) article. The nurses all state the great importance of cultural competence in their work and they highly value assessment, cultural understanding and communication.
Like Madeleine Leininger’s theory of transcultural nursing, the nurses in the study understand the importance of knowing their own cultures, values and beliefs in order to give good care (Gustin & Lindwall 2012). The nurses express the importance of understanding their own personal culture in order to be able to respect, notice and satisfy patients with varying cultural needs. Many of the nurses hold their own culture in high regard and say that this gives them a better
understanding of patients with other cultural backgrounds. They articulate that this is especially important as culture is an influential part of each person's’ personality.
The nurses were not asked if they were familiar with Leininger’s theories, but they still had strong opinions for the need and necessity of transcultural education in nursing. The culture care theory says that culturally congruent care can be only be provided when the expressions, practices, and patterns of the patient’s culture is known (Mixer 2011). Cultural care takes into consideration the holistic
perspective in nursing care and involves the values, beliefs and lifeways of people (Leininger 2002). All the nurses in the study strive to give care which is holistic in nature and culturally specific for the individual patient, which is in line with Leininger’s cultural care theory (2002). Through their life experiences as well as their experiences in patient care, the nurses naturally started laying a base of culturally congruent care. They supplement this by being sensitive to the varying needs regarding prayer, clothing and other personal habits of the patients. Food preferences are also considered in the patient care. This is in line with Kaspar and Reddy’s (2017) study that food is a consideration in many of the international hospitals.
