Nurses' Experiences of Caring for Patients with Different Cultures in Mashhad, Iran

Abstract

Background:

Mashhad is a center of diverse cultures, where many local and foreign cultures live together in its context. One of the main needs of a society with cultural diversity is transcultural care of patients. Hence, the present study took the first step for care of culturally diversified and minority patients in Mashhad. This research has been conducted to explore the nurses' experience of caring from patients with different cultures.

Materials and Methods:

This study is a qualitative research using phenomenological hermeneutics approach. The participations include nurses who have been working 5 or less than 5 years in the hospitals affiliated to Medical University of Mashhad. They were selected using purposeful sampling method. For data collection, semi-structured, in-depth interview was used. For data analysis, interpretation method was used. The interviews continued until saturation of data was obtained.

Results:

Data analysis resulted in extraction of 4 themes including ethnocentrism, contradicting perceptions of care, it is not our fault, and lack of cultural knowledge.

Conclusions:

The experience of nurses in taking care of patients with other cultures showed that minorities and small cultures have been neglected in Mashhad and hospitalization of such people in hospitals and other clinics is not specific. We recommend that an educational curriculum about transcultural care should be added to nursing courses. Also, necessary equipment and facilities should be considered and prepared for culturally different patients in hospitals.

Introduction

Cultural diversity among patients is one of the issues, which are faced by nurses. The increasing growth of international exchanges, increased amount of transfers among human forces, and migration require the nurses to be equipped with cultural knowledge. Taking care of patients with diversified cultures (transcultural care) has been described as a complex and challenging issue by nurses, which are related to multiple individual and situational factors.[1] The cultural knowledge of nurse and their understanding from the culture of the patient is one of the vital factors in providing effective nursing care.[2,3,4]

Various studies have been done on the experience of nurses from care of patients with diverse cultures and minorities.[1,2,5,6,7,8,9,10,11,12] Each of these studies achieved a valuable finding regarding the studied domain but the context is different, and they have exclusive result. We cannot find any study on the transcultural care among nurses in Iran. Hence, through this qualitative study, the researcher intended to pay attention to this subject in nursing field and obtain results based on the context.

Iran is the cradle of various cultures; both local and foreign cultures live in Iran. Among different cities of Iran, Mashhad has a unique religious status and hosts around 2 million pilgrims every year. In addition, different local cultures of Balooch, Tork, and Arab with different dialect live in Khorasan province. Mashhad is a capital and large city of Khorasan, in which many patients from towns and village refer to Mashhad's hospitals for treatment and cure of their disease. Hence, there is diverse local culture of people in hospitals that most of them can speak Farsi and some of them cannot but various cultures are prominent. Also, there are many foreign cultures in this city from Afghanistan, Pakistan, and Iraq and other Arab countries because of being pilgrimage.[13]

In such a city, transcultural care of patients is a necessary prerequisite for nurses. However, the problem is that it has not been paid enough attention in Iran's nursing context. Hence, as the first step of transcultural care, this study explores the experiences of nurses in care of patients with different culture in Mashhad, Iran.

Materials and Methods

Design

This study is a qualitative study with phenomenology approach. The hermeneutics phenomenological approach is a good way to interpret and discover the experience of nursing from the context in which they live. Since every human is unique, the experience of care varies from one person to another.[14]

Participants

In this study, participants were selected using purposeful sampling method and the interviews were continued until data were saturated and no new ideas emerged. In this study, the participants included nurses who were working 5 years or more in the hospitals affiliated to Mashhad Medical University. The condition of 5 years of experience was taken from Benner, who regards it necessary for the professionalization progress.[15]

Data collection process

Deep, semi-structured, and face-to-face interviews were used for data collection. Data were collected from April to January 2015. In the phenomenological studies, the researcher helps the participants to describe their lived experiences without leading the discussion. Through deep conversation, they try to enter into the world of participants to have full access to their experiences.[14]

In the present study, in the first meeting with nurses, the nature of research, its goal, and methodology were explained to them and if they met the necessary criteria and were willing to participate, a written form of agreement was signed by them. Then, the time and place of interview were set for every participant based on their opinion. It means that some participants prefer to have interview in their rest time in ward and some of them prefer to have interview beyond their job. For first group, interview was done in nursing room and for the second group, interview was held in nursing and midwifery faculty.

Every interview started with open questions such as “would you please tell me about your experience of taking care of patients who had different culture or language? What does care for a patient with different culture or language mean to you?” The participants were free to express their feeling and experience. Then, according to the answers provided by the participants, more detailed questions were asked to reach the result and goal of interview such as “can you explain more? What is the meaning of the sentence you told? How do you feel about this issue? What did disturb you the most?” Such questions caused participants to present a detailed and extended description of their experience.

A researcher who was candidate of PhD in Nursing did all of the interviews. Each participant was invited twice or 3 times for the interview. The location of interview was determined according to the preference of the participants. The interviews lasted between 30 and 60 min and were recorded with the permission of interviewee. Besides recording the voice of interviewees, their body language (face gestures and body moves), pauses, and nonverbal communication were written by the researcher. The recordings were immediately transcribed on the paper.

Data analysis method

Data were analyzed based on interpretation method of Dickelman, Allen, and Tanner (1989) which is used frequently in nursing research. According to this method, data collection and analysis were done simultaneously and hermeneutic cycle was taken into account.[16] According to Dickelman approach, at first, the text was read and the gist of it was obtained. Transcriptions were read several times to find the similarities in the data and general sense of it was realized. Then, data were unified and categorized. Unification of data included coding raw data into distinctive units of meaning and categorization included putting these units of meaning or codes into groups based on similarities. After that, it was attempted to identify and formulate themes and at the final stage, a comprehensive understanding was done and the experiences were extracted. In all of these stages, the researcher moved between the first stage and stage of creating the essence of experience; where more data were needed, the researcher looked for more data and experiences purposefully.

Trustworthiness of data

To determine the accuracy and validity of data, Lincon and Gaba evaluation scale was used.[17] Data were validated through member check and participants' review of transcriptions. Reliability was achieved through constant analysis and devoting enough time to data collection, as well as more and longer involvement during the research. Also, consulting with colleagues was done to obtain deeper data and general understanding. Data were confirmed by the review of a foreign supervisor; also, the research group confirmed coding and categorizing processes. To achieve the criteria of transferability, it was tried to explain the process of research precisely so that other researchers can use this method.

Ethical considerations

To keep ethical considerations, the Ethics Committee of Mashhad University of Medical Sciences has approved the study. Before the interview, participants were informed of the objective of research and all of them took part in the research voluntarily. Permissions were taken for recording the interviews from them. They were assured that data will be used only for research objectives and will remain confidential. Also, it was emphasized that participants can quit research at any stage, and their personal information is confidential during and after research.

Results

Twelve nurses entered into the study. The study consisted of seven female and five male nurses. They had Bachelor's or higher degree of academic education; and their age was 28–55 years old. They had 5–20 years of work experience. Each participant was interviewed about 30–60 min in each session. Two or three sessions of interviews were run for each nurse.

Ethnocentrism

This theme consists of three subthemes, namely, antipathy, the patient is under our control, and mutual understanding.

Antipathy

Some of the nurses proposed that they feel antipathy toward some of cultures because of reasons such as conflicting religious beliefs (Sunni patients), lack of cleanliness of patient, and distrust to such patients. These reactions were often target at domestic cultures, but the same experiences were also reported with Afghan and Iraqi migrants.

A 27-year-old female nurse with 5 years of work experience at women ward says, “some cultures are not clean at all. When I am doing their work, I do it fast and finish it because sometimes it disturbs me. Their behavior is not good too. I do not prefer to care of them.”

Patient is under our control

The nurses also stated that patient is under our control, and cultural difference cannot be understood. In the medical system, patients are obliged to follow the rules and regulations of hospital as participants say, “They act like us.” Patients with different cultures try not to dispose of themselves. They are usually isolated, dissociable, unassuming, and quiet. These characteristics are the reason why nurses even do not notice their cultural differences.

A 45-year-old male nurse with 12 years of work experience says, “sometimes, I did not notice that the culture of the patient is different with me because they tried so hard to match themselves with our culture, so I did not see the difference.”

Mutual understanding

Some of the nurses indicated that when the culture of the patient is different, they try to provide better support, more attention and care, and do their best so that the patient does not suffer because of his difference. Culturally hybrid nurses often stated that they understand the patients' strangeness because they have experienced being strange and its difficulties. Hence, they try to pay more attention to these patients.

A 38-year-old female nurse says, “I am Turk but I can speak Persian very well. I know how they behave with a stranger here. They label every other culture. Even when my colleagues know that I am Turk they change, their behavior toward me differs. They do not show it obviously, but I can feel it. I have the same pain. When I see such patients I pay more attention to them, I explain more and try to relax them.”

Contradicting perception of care

The nurses had different perceptions of care for culturally different patients, which are completely in two contradicting categories.

Easier care due to less complaints and demands

Nurses told that in their experiences, patients with other cultures such as Turk, Kurd, Baluch, and Turkmen have less demands. They are often unnoticed in the ward, and they are not aware of their rights. They have warm, simple, and unassuming behavior, so caring them is easier.

A 34-year-old male nurse with 10 years of work experience says, “People from other cultures are often voiceless compared to others; they are easier to work with. They are not aware of their own rights and cannot propose their problem, so they often tolerate. But patients from Mashhad are often troublemakers. I prefer taking care of these patients.”

Difficult and challenging care

Some nurses stated that caring from culturally diverse patients is a difficult, challenging task. They proposed that because of unfamiliarity with the different culture and language of patients, care becomes challenging. The needs of such patients are often more, and caring from them is usually more difficult, especially when there is a linguistic gap between nurse and the patient, the biggest challenge in communication happens.

A 38-year-old female nurse says, “I do not like to work with these patients because I do not know much about their language and culture. They cannot be treated as of other patients and confuse me. I do not know what they would like or what would disturb them. I do not know if I can take their hand whether they feel calm or bad. Hence, it is difficult to care for a patient with another culture especially if the language differs too.”

Nurses proposed that since they are not familiar with the culture of patients, they feel confused when taking care of them. They sometimes feel despair and fear; fearing that they have not been as useful and good as they have to be for the patient. They often stated that when we do not understand the language of a patient, first, we try to get help from his family. However, sometimes, the patient has no companion or interpreter. In such cases, they would seek help of their bilingual colleagues who know that language and if no one could help, they would withdraw and leave the patient. However, even these simple works are time-consuming for them, and the system does not support nurses when doing these works.

It is not our fault

Nurses proposed that even if they try to provide good care for a culturally diverse patient, the system will not allow them. They said that hospitals have not any facilities for such patients, and this matter has no importance in the hospital. On the other hand, the jobs of nursing personnel are very heavy and in such cases that need more attention and time, nurses are not able to provide care according to the culture of patient; hence, works are done as routine.

A 38-year-old female nurse says, “In such cases, the nurse is alone. When there is a foreign patient, we have to find a way to deal with him ourselves or ignore the rights of patient. I had an Arab patient; I was frustrated how to communicate with him; I wanted to give him comfort at least and introduce myself. I called all my colleagues and asked for help. Finally, I got someone and I could communicate with my patient and exchange some information. However, you know this took a lot of time and my other works were disrupted. In such cases, the nurse is alone, and the hospital provides no support.”

Lack of cultural knowledge

Nurses proposed in their experiences that when they want to care for a culturally different patient, they become desperate, worried, and fearful and sometimes choose to avoid the patient. They relate the reason of such behaviors to lack of familiarity with different languages and cultures.

A 28-year-old female nurse says, “I was nurse in Baluchistan for some time. Believe me it was very difficult for me. They did not like it when I touched them, especially men. When I talked friendly, they misinterpret it and when I checked their blood pressure they felt uncomfortable. I gradually learned to consider such things in their culture. They were sensitive to the dressing of their patients; when the surgery of a patient was finished, she had to be completely dressed. They were annoyed if some part of her body was seen.”

Discussion

According to the results of the present study, which aimed at realizing the experience of Iranian nurses in caring from culturally different patients, four themes were extracted including ethnocentrism, contradictory perceptions of care, it is not our fault, and lack of cultural knowledge.

In the first theme, ethnocentrism, one of the subthemes was feeling antipathy toward other cultures. It refers to the unwillingness of nurses to care patients with other cultures and to ignore them. This ignorance was observed with some of the local cultures and foreign cultures including Afghanistan and Iraq. The tendency to look at others from the lens of dominant culture and rejecting or devaluing cultural difference is also reported in studies of Cioffi and Murphy and Clark.[6,11]

One of the findings of the present research was that nurses do not notice cultural difference at all. Patients try to accept the dominant culture and show the nurses that they are committed to it. Other studies also point that because of the dominant culture, nurses expect the patients to behave similar to them and know their language completely.[6,10]

Another finding of this study was that some nurses try to stay more beside someone with different culture and support them because they had the same problem. The common experience of personnel from ethnocentrism or as they say the common pain with the patient was stated as the reason of such behavior. Hence, nurses with two cultures or from another culture understood patients better. In our study, some of the personnel had antipathy toward some other cultures.

The second theme is contradictory perception of care. One of its subthemes was easier care due to lack of complaints and less demands. Nurses frequently mentioned that caring from these patients is easier because they do not object and are not aware of their rights. They cannot demand their rights due to their lower level of education, less social relationships, or feeling strange and are very exposed to be ignored. This finding shows that the rights of people from different cultures are usually undermined. Vydelingum also reported “similar behavior toward them as others” as one of his findings. Nurses try to treat a culturally different patient similar to others thinking that equal behavior is considered justice.[2] This finding originates from a general consensus that nurses have to behave equally with all patients; they should not discriminate between cultures and have fair behavior.[18] Vydelingum proposes that this statement is paradoxical. If we have an equal behavior with all, in fact, we have rejected cultural difference. This view of justice is wrong because there are people with different cultures who have more needs and need more attention.[2] In fact, it is suggested that more attention is given to culturally and linguistically different people while the present condition found in our study indicates the opposite.

Another subtheme of the study is that some nurses defined care for culturally different patients as challenging and time-consuming. Definitely, due to cultural difference, more time is needed spent with the patient and the biggest problem occurs when a linguistic obstacle exists between patient and nurse. Communicating with other cultures, especially in the case of linguistic difference, is reported difficult in other studies as well.[2,6,11,19,20]

In the present study, the strategy of nurse to communicate with a linguistically different patient was using family members or bilingual nurses. This finding is consistent with Cioffi and Kirkham.[1,6] In our study, the nurses proposed that when there is a linguistic barrier, the nurse gets confused. The studies of Murphy and Clark and Cioffi also showed that linguistic barriers create stress and feeling of despair among nurses.[6,11]

The third theme was it is not our fault. In this finding, nurses indicated that there are no facilities for such patients in the wards and the ground for suitable ground is not provided. Vydelingum also reports similar finding as “we are not guilty.” In Vydelingum's study, the minimum facilities were provided for migrant and minority patients, but it was not enough in the view of nurses such as interpreter, prayer saloon, special foods; however, in our study, no attention is paid to this issue, hence no facilities are provided.[2]

The final theme is lack of cultural knowledge. Vydelingum also reported lack of cultural competency as one of the themes, which can damage the relationship between patient and nurse.[2] This is consistent with our findings. However, our nurses are not even aware of the importance of this issue and not participated any class or course in this regard; however, in the United States, a course of cultural care is included in the educational curriculum of nursing.

This study has some limitations: One of the limitations is that personnel were very busy and had no time for interview. Some of them did not like to have interview beyond their job and in job environment (hospital, clinics, or office), they were very busy. Hence, we asked 20 nurses, but some of them did not accept our request. Despite the various cultures in Mashhad, it is the first study that works on caring of cultural diversity patients in Iran. It is very important subject in health area that should be considered by scholars and further research about this topic is necessary.

Conclusion

The experience of nurses in caring from culturally different patients in Mashhad shows that minorities and small cultures are not paid attention in hospitals, and there is no especial ground for hospitalization and caring of these patients in the medical system of Mashhad. As the final point, since Mashhad is rich with different local cultures and also hosts many pilgrims worldwide, this issue must be taken into account in hospital care. Paying attention to domestic and foreign cultures will promote the quality of nursing services. Hence, it is suggested that an educational curriculum about transcultural care is embedded in the nursing education. Training courses should also be held for the personnel of hospitals about cultural behavior and cultural care. Necessary facilities must be provided of people from different cultures. The rights of patients should be respected equally for all of them, and necessary information is given to them.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.