Global migration has increased dramatically in this century. During the period from 2000 to 2017, the total number of international migrants increased from 173 to 258 million people, an increase of 85 million (49%) (United Nations, 2017). According to a policy statement from the American Academy of Pediatrics (2004), by 2020, it is predicted that 44.5% of children aged 0 to 19 years in the USA will be from a racial or ethnic minority group. This rapid change in the demographic structure makes the concepts of ethnicity and culture even more important in health care.
In 2017, Turkey became the largest refugee-hosting country worldwide, with 3.1 million refugees (United Nations, 2017). Turkey hosts families from many different cultural backgrounds. A large number of people migrate to Turkey from Middle Eastern countries.
Although the decision to migrate is taken by parents, children are the ones most affected by the migration decision. Migration leads to serious impoverishment of children. Children may be separated from their parents due to migration, they may not be able to attend school, and they face many risks such as social exclusion, discrimination and even homelessness. Poor living conditions experienced by migrants can affect children's health adversely to varying degrees (UNICEF, 2007).
Migrant children from various cultures are frequently admitted to children's clinics and undergo inpatient treatment. The role nurses play in the provision of holistic care to a child in the clinical setting is vital. The basic mission of paediatric nurses is to improve and maintain the physical, mental and social wellbeing of children, whether they are infants, children or adolescents, and their families. Provision of truly holistic care by paediatric nurses is closely related to their respect for or awareness of cultural/traditional beliefs and having cultural competence and sensitivity (Berlin et al, 2010; Renzaho et al, 2013; Suk et al, 2015).
Race and ethnicity are often seen as the most important signs of a person's culture (Rice and O'Donohue, 2002). However, other aspects have been identified by the American Academy of Pediatrics as follows:
‘The term ‘culture’ is used to signify the full spectrum of values, behaviors, customs, language, race, ethnicity, gender, sexual orientation, religious beliefs, socioeconomic status, and other distinct attributes of population groups.’
From this perspective, it is necessary for paediatric nurses to perform a multidimensional cultural assessment and then to provide care. In one study of nurses in Taiwan, the ‘cultural competence’ of the participants was in the low-to-moderate range, with relatively higher mean scores for the subscales of ‘cultural awareness’ and ‘cultural sensitivity’ and relatively lower scores for the subscales of ‘cultural knowledge’ and ‘cultural skills’. Most of the nurses did not think they had cultural competence (Lin et al, 2015).
In a study of nurses in four children's hospitals in the USA, Hart (1999) reported that paediatric nurses did not routinely perform cultural assessments of patients and frequently experienced cultural conflicts. Berlin et al (2006) reported that 84% of the 270 Swedish paediatric nurses who responded to a questionnaire had difficulty communicating with patients, especially with children, born in other countries.
Cultural competence, an important part of patient-centred care, has been on the nursing agenda for many years (Heitzler, 2017). To be culturally competent, intercultural effectiveness is required (Chen and Starosta, 2000). The three factors contributing to intercultural effectiveness are effective communication skills, the ability to establish interpersonal relationships, and the ability to cope with stress (Fisher and Hartel, 2003). Intercultural effectiveness enables individuals to achieve communication targets within intercultural interaction through appropriate and effective performance. Portalla and Chen (2010) defined five components of interculturally effective behaviours:
Although there are several studies in the literature investigating the cultural awareness and sensitivities of paediatric nurses (Berlin et al, 2010; Hendson et al, 2015; Heitzler, 2017), no researchers have quantitatively measured the intercultural effectiveness of paediatric registered nurses. In recent years, nurses in Turkey have nursed patients from different cultures and provided care for them. However, the level of intercultural effectiveness of practising paediatric nurses in Turkey was unknown, and led to the idea for this study.
Study aim
The aim of this study was to measure the intercultural effectiveness of paediatric nurses in a Turkish hospital and to explore relationships between the level of intercultural effectiveness and some sociodemographic variables in paediatric nurses.
Method
Type
The study had a descriptive and correlational research design.
Setting
The study was conducted at the İzmir Tepecik Training and Research Hospital's children's clinics in Turkey. The hospital is a state hospital and serves patients from all socioeconomic groups. It was chosen because children whose families had migrated from Syria and other countries were frequently admitted to this hospital.
Sampling
There were 196 nurses working in the paediatric clinics of the hospital when the study was carried out. A non-probability sample of 98 paediatric registered nurses practising at the hospital was evaluated. The participation rate was 50% because the nurses worked shifts, and because some of them were on annual leave or sick leave. There were no specific exclusion criteria.
Ethical approval
Ethical approval was obtained from the administration of the hospital where the study data were to be collected. The data were collected between June 2016 and September 2016. After the nurses were informed about the purpose of the study, their written consent was obtained.
Procedure
The data were collected during working hours through face-to-face interviews.
Data collection tools
To collect the study data, two questionnaires and the Intercultural Effectiveness Scale (IES) were used (Portalla and Chen, 2010).
A sociodemographic characteristics questionnaire was prepared, including items requesting nurses' gender, educational status, marital status, place of residence and length of service.
The Cultural Approach in Nursing Care questionnaire was prepared by the researchers in light of the pertinent literature and similar studies (Bayık Temel, 2008; Tanrıverdi et al, 2009; Bulduk et al, 2011; Tanrıverdi, 2015). The questionnaire was then reviewed by five experts (three academic nurses and two clinical nurses). The resulting questionnaire included questions on whether nurses have taken intercultural nursing courses, their culture-related thoughts, their self-assessment regarding their cultural skills, and their knowledge levels of cultural approaches to nursing interventions and practices. The questionnaire also included questions related to cultural issues and to practical applications of cultural care (see Table 2 and Table 3).
| Sociodemographic characteristic | n | % |
|---|---|---|
| Gender | ||
| Female | 94 | 95.9 |
| Male | 4 | 4.1 |
| Marital status | ||
| Married | 52 | 53.6 |
| Single | 46 | 47.4 |
| Education | ||
| High school | 14 | 14.3 |
| Associate's degree | 19 | 19.4 |
| Bachelor's degree | 56 | 57.1 |
| Postgraduate degree | 9 | 9.2 |
| Length of service | ||
| 0−5 years | 48 | 49.0 |
| 6−10 years | 24 | 24.5 |
| 11−15 years | 12 | 12.2 |
| 16−20 years | 13 | 13.3 |
| Place of residence | ||
| District | 27 | 27.6 |
| City | 31 | 31.6 |
| Metropolis | 40 | 40.8 |
| Characteristics related to cultural issues | n | % |
|---|---|---|
| Can you speak a foreign language? | ||
| No | 64 | 65.3 |
| Yes | 34 | 34.7 |
| Do you believe that there is a relationship between your profession and culture? | ||
| No | 25 | 25.5 |
| Yes | 73 | 74.5 |
| Do you think that the patient's culture affects his/her communication? (n=97) | ||
| No | 17 | 17.5 |
| Yes | 80 | 82.5 |
| Do you think that understanding your patients' cultures would be effective in their treatment and care? | ||
| No | 17 | 17.3 |
| Yes | 81 | 82.7 |
| How do you assess your cultural knowledge skills in communicating with children? | ||
| Very adequate | 17 | 17.3 |
| Adequate | 24 | 24.5 |
| Partly adequate | 42 | 42.9 |
| Inadequate | 11 | 11.2 |
| Very inadequate | 4 | 4.1 |
| How do you assess your cultural knowledge skills in communicating with parents? | ||
| Very adequate | 11 | 11.2 |
| Adequate | 22 | 22.5 |
| Partly adequate | 49 | 50.0 |
| Inadequate | 12 | 12.2 |
| Very inadequate | 4 | 4.1 |
| Applications | n | % |
|---|---|---|
| How often do you meet patients who are foreigners or do not speak the same language you speak? | ||
| One in two patients | 27 | 27.6 |
| One in three patients | 39 | 39.8 |
| One in four patients | 32 | 32.7 |
| Do you observe the parents' traditional/ethnic practices regarding children's care? | ||
| No | 13 | 13.3 |
| Yes | 50 | 51.0 |
| Sometimes | 34 | 34.7 |
| Do you observe the parents' traditional/ethnic practices regarding improvements in children's health? | ||
| No | 19 | 19.4 |
| Yes | 52 | 53.1 |
| Sometimes | 27 | 27.6 |
| Did you take the intercultural nursing course during your nursing education? | ||
| No | 45 | 45.9 |
| Yes | 53 | 54.1 |
| Have you ever received in-service training in cultural care? | ||
| No | 54 | 55.1 |
| Yes | 44 | 44.9 |
| Would you like to participate in a training programme to better know the culture of the community you live in? | ||
| No | 26 | 26.5 |
| Yes | 72 | 73.5 |
| What are the most common problems/difficulties arising during caregiving?* | ||
| Not being able to speak a foreign language | 57 | 58.2 |
| Parents' low educational level | 52 | 53.1 |
| Patients' age | 32 | 33.7 |
| Health perception | 31 | 31.6 |
Nurses were asked to rate their cultural skills in communication with children and their parents as ‘very inadequate,’ ‘inadequate’, ‘partially adequate’, ‘adequate’ or ‘very adequate’.
The Turkish version of the Intercultural Effectiveness Scale (IES), developed by Portalla and Chen (2010) consists of three subscales and 15 items. The three subscales are:
Items were rated on a 5-point Likert-type scale (ranging from 1=strongly disagree to 5=strongly agree). The higher the score, the higher the intercultural effectiveness. The minimum and maximum possible scores to be obtained from the scale are 15 and 75 respectively. The Cronbach's alpha value, which was 0.79 for the original scale, was 0.74 in the present study. The results are shown in Table 4.
| Subscale | χ± SS |
|---|---|
| Behavioural flexibility (7 items) | 22.20±3.6 |
| Interactant respect (4 items) | 13.30±2.1 |
| Interactant relaxation (4 items) | 12.04±2.4 |
| Total | 47.60±4.7 |
Data analysis
Statistical analyses were performed using SPSS 20.0. In the analysis of descriptive data, numbers, percentage distribution and mean values were used. Because the IES scores showed normal distribution, the t test and one-way ANOVA (F value) were used to compare some sociodemographic characteristics and the IES scores (Portalla and Chen, 2010). P values of <0.05 were accepted as statistically significant at a 95% confidence interval.
Results
The mean age of the participating paediatric nurses was 29.8 ± 5.8 (20–46) years. Of those, 95.9% were women, 53.6% were married, 57.1% had an undergraduate degree, and 40.8% had spent the vast majority of their lives in a large metropolitan area. Their mean length of service was 6 years (minimum: 6 months, maximum: 20 years) (Table 1).
Of the participating nurses, 65.3% did not speak any foreign languages, 74.5% believed that there is a relationship between their profession and culture, 82.5% thought that the patient's culture influences communication and 82.7% thought that the awareness of the patient's culture would affect the treatment and care to be given (Table 2).
In establishing cultural skills in communication with children, 24.5% of participants regarded themselves as adequate, 42.9% as partially adequate and 11.2% as inadequate (Table 2).
In establishing cultural skills in communication with parents, 50% of them regarded themselves as partially adequate, 22.5% as adequate and 12.2% as inadequate (Table 2).
Some 27.6% of participants were nursing one in two patients who were foreigners and/or who did not speak the same language as the participants; 39.8% were nursing one in three such patients and 32.7% were nursing one in four such patients (Table 3).
Of the participants, 51% always witnessed parents' traditional/cultural practices regarding their children's care, and 34.7% observed them sometimes. Some 53.1% always observed that parents believed that their traditional/cultural practices had improved their children's health, and 27.6% observed this sometimes. An example of a traditional cultural practice would be a parent swaddling an infant or giving a child an amulet to wear (in some cultures traditionally believed to ward off evil or illness).
Of the participants, 54.1% had taken the Intercultural Nursing Course during their nursing education, and 44.9% had received in-service training in cultural care during their professional life; 73.5% wanted to participate in a training programme to better know the culture of the communities they lived among.
Table 3 shows the most common cultural problems experienced by nurses: not being able to speak a foreign language, parents' low educational level, patients' age and health perceptions.
Table 4 shows that the intercultural effectiveness level of the paediatric nurses is 47.60 ± 4.7, which is moderate. They obtained the lowest score from the interactant relaxation subscale (12.04 ± 2.4).
The analysis of the distribution of intercultural effectiveness scores according to sociodemographic characteristics revealed that the interactant respect scores of the university graduates (t=-2.07 P=0.04) and of those living in metropolitan areas (F =7.48, P=0.001) were found to be at a higher than were the scores of the nurses of other education levels.
The total intercultural effectiveness scores of the nurses who believed that nursing and culture were related was higher than those of the participants who did not (t=-2.54; P=0.01). Interaction relaxation and total IES scores of the nurses who thought that the patient's culture would affect communication were higher than those of the participants who thought that it would not (t=-2.53; P=0.013) (t=-2.93; P=0.006). Those who had taken the intercultural nursing course and received the in-service training on cultural care had higher interactant respect scores (t=3.26; P=0.002). Both the total scale scores (F=4.29; P=0.016) and the behavioural flexibility scores of the participants who observed the traditional/cultural practices of the parents were higher than those who did not (F=3.16; P=0.04).
Discussion
To the authors' knowledge, this is the first study to measure the level of intercultural effectiveness of paediatric nurses in Turkey. Intercultural effectiveness is one of the three main components of the intercultural communication competence model. Although there have been studies conducted on cultural sensitivity and cultural awareness, the number of studies performed on cultural effectiveness is limited. In order for a nurse to have cultural competence, he or she should not only be aware of and sensitive to the patient's culture but also interculturally effective. In this present study, the participating paediatric nurses' intercultural effectiveness levels were moderate. There is no cut-off score for the IES, but the analysis found that the university graduate nurses' IES scores were higher. Nurses living in a city had lower IES scores.
Several factors have been found to influence nurses' cultural competence. The cultural competence assessment levels of obstetric neonatal nurses in one study were negatively correlated with age, but positively correlated with their specialty area, previous training, and self-ranked cultural competence (Heitzler, 2017). Cultural competence has been positively correlated with number of years of nursing experience, receiving cultural nursing training, providing care for patients whose culture and ethnicity were different and providing care for special patient groups (Lin et al, 2015; Cruz et al, 2016). In Cruz et al's study (2017), gender, academic level, clinical exposure, prior diversity training, the experience of taking care of culturally diverse patients and patients belonging to special population groups were significant factors that were likely to influence cultural competence.
As is seen in Table 3, the most common problem experienced by the nurses was that of language. Arabic was the foreign language most often mentioned by study participants because most of their foreign patients and their families were Syrian. Language-related inadequacies are among the factors that reduce the use of health services by immigrant communities (Pehlivan et al, 2013). Interactions where what the healthcare provider says is misinterpreted by the patient will negatively affect not only that interaction, but also the diagnosis and treatment process of the disease (Pehlivan et al, 2013).
In a qualitative study conducted in a paediatric stem cell transplant setting by Calza et al (2016), communication was seen as a barrier in caring for foreign patients. Hendson et al (2015) reported that communication problems with immigrant families of infants admitted to the neonatal intensive care unit negatively affected the decision-making process at times of crisis. The language problem can lead to stereotyped behaviours and lack of intuitive perceptions that nurses use to identify the needs of families (Hendson et al, 2015).
In the interviews, many nurses indicated that one of the difficulties they experienced was low educational levels among Syrian families, which affected their understanding of some health conditions and treatments, even when an interpreter was present. However, because no comparison was made between foreign patients and native patients, such judgements could not be supported. The correlation between the perception of health and the level of education is similar in native patients. Yilmaz et al (2017) categorised the problems experienced by nurses as language barriers, patients' education level, health perception about disease and religious beliefs when providing health care.
The vast majority of the nurses in the present study were aware of the importance of cultural issues, and only around 11% considered their cultural competence inadequate. In another study, the vast majority of the paediatric nurses who responded to a questionnaire stated that they did not feel that they were culturally competent enough (Berlin et al, 2006). In a survey conducted with student nurses, Cruz et al (2016) found that although their competence in general cultural communication skills was high, their competence in health/disease-related cultural communication skills was low. Nearly half of the nurses in the present study stated that they had not received any training in cultural care (Table 5), and 73.5% wanted to have training or further training. The 27% of nurses who did not want cultural training may have felt they had gained enough experience of cultural care during their clinical practice.
| Behavioural flexibility | Interactant respect | Interactant relaxation | Total | |
|---|---|---|---|---|
| Believing that nursing is related to culture | ||||
| No | 21.4± 3.5 | 12.6±1.9 | 11.6± 2.2 | 45.6±2.7 |
| Yes | 22.5±3.6 | 13.5±2.1 | 12.2±2.4 | 48.3±5.0 |
| t, P | P>0.05 | P>0.05 | P>0.05 | t=-2.54; P=0.01 |
| Does the patient's culture affect communication? | ||||
| No | 21.5± 3.6 | 13.1±1.9 | 10.7± 1.9 | 45.4±0.8 |
| Yes | 22.4±3.5 | 13.4 ±2.1 | 12.3±2.4 | 48.1±0.5 |
| t, P | P>0.05 | P>0.05 | t=-2.53; P=0.013 | t=-2.93, P=0.006 |
| Taking the intercultural nursing course | ||||
| Yes | 22.2± 3.6 | 14.0±1.5 | 12.1± 2.6 | 48.3±4.5 |
| No | 22.2±3.5 | 12.7 ±2.4 | 12.1±2.2 | 46.9±4.8 |
| t, P | P>0.05 | t=3.26; P=0.002 | P>0.05 | P>0.05 |
| Receiving in-service training in cultural care | ||||
| Yes | 22.6± 3.8 | 13.7±1.9 | 11.7± 2.4 | 48.1±5.2 |
| No | 21.7±3.2 | 12.2 ±2.2 | 12.4±2.3 | 46.9±4.0 |
| t, P | P>0.05 | t=2.32; P=0.02 | P>0.05 | P>0.05 |
| Observing traditional/ethnic practices | ||||
| Noa | 22.0± 2.5 | 12.8±2.7 | 10.7± 1.9 | 45.4±3.6 |
| Rarelyb | 21.4±3.8 | 13.3±2.1 | 12.2±2.4 | 46.9±4.6 |
| Oftenc | 23.4±3.3 | 13.6±1.9 | 12.3±2.4 | 49.3±4.7 |
| F, P | F=3.16; P=0.04 (b<c) | P>0.05 | P>0.05 | F=4.29; P=0.016 (a<b<c) |
Berlin et al (2006) found that most of the paediatric nurses in their study did not receive formal cultural competence training. Similarly, Lin et al (2015) stated that nurses identified themselves as culturally competent, but their cultural skills were found to be low. In Calza et al's (2016) study, the nurses stated that their training and knowledge were not sufficient to provide care for foreign patients. Providing nurses with training on cultural competence can provide a self-evaluation opportunity. According to Campinha-Bacote (2002), achieving competence is an ongoing process; thus, training programmes aiming to increase nurses' cultural competence levels may be useful. Berlin et al (2010) stated that the cultural knowledge, cultural skills, cultural encounters and cultural desire levels of paediatric nurses increased after they received cultural competence training.
Although the nurses who participated in the present study often received interpreter support, they stated that they frequently had to deal with patients and families with whom they could not communicate adequately since they did not speak the same language. However, while half of the nurses said that they always saw families carry out traditional cultural practices, the other half said that they only sometimes saw families carrying out traditional cultural practices. Tanrıverdi (2015) stated that approximately 65% of the nurses fulfilled cultural practices. Hisama (2000) found that nurses' recognition of the cultures of the individuals for whom they provided care was positively reflected in nursing care.
Limitations
A non-probability convenience sample was used. Due to the difference in gender distribution, the change in the nurses' IES scores was not investigated by gender.
Conclusion and recommendations
In the present study, the participating paediatric nurses' intercultural effectiveness levels were moderate. The problem they experienced most was the language barrier and although half of them did not have adequate training in intercultural care, based on their experiences, the majority regarded themselves as culturally competent.
Intercultural competence is an essential skill in nursing. Therefore, nurses should first question their perspectives on culture and improve their communication skills using empathy and reflective thinking. Nurses who provide care to patients in multicultural and multi-ethnic societies should also learn the cultural characteristics of the groups they care for. Paediatric nurses working in such societies should perform a multidimensional cultural assessment in their daily routines. This is also important in offering family-centred care. Language is an important problem in providing culturally sensitive care.
As countries become more multicultural and multi-ethnic, cultural competence among nurses has becoming increasingly important and should be reflected in undergraduate education and in-service training. Clinical case studies and role playing may be used in training and education to help improve cultural awareness. Guidelines on providing culturally appropriate care are required and should be distributed widely.