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Interpersonal communication as experienced by nurses working in culturally diverse Indian hospitals. Degree project in Nursing 15. Credits. Malmö University: ...
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Examensarbete i omvårdnad Malmö högskola 61 - 90hp Hälsa och samhälle Sjuksköterskeprogrammet 205 06 Malmö Januari 2018
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, Transkulturell omvårdnad, Språkbarriärer, Vårdkvalitet.
Communication and Culture Cultural competence Cultural competence in Swedish healthcare Theoretical framework Medical tourism India
Sample Data collection Pilot Data analysis
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
Method Discussion Data collection Sample Integrity Data analysis
Further research and value for the study
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 interpersonal skills is vast, and that understanding personal qualities are necessary
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
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
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
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.
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
