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research-article2014
TCNXXX10.1177/1043659614524794Journal of Transcultural NursingGoodman et al.
Research Department
Cultural Awareness: Nursing Care of Iraqi Patients
Journal of Transcultural Nursing 2015, Vol. 26(4) 395–401 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524794 tcn.sagepub.com
Petra Goodman, PhD, WHNP1, Bethany Edge, BSN, RN2, Janice Agazio, PhD, CRNP, FAANP, FAAN1, and Kathy Prue-Owens, PhD, RN3
Abstract Purpose: The aim of this study was to describe the cultural factors that have an impact on military nursing care for Iraqi patients. The results were part of a larger study in which the purpose was to understand nurses’ experiences of delivery of care for Iraqi patients. Method: Three focus groups, consisting of military registered nurses and licensed practical nurses, were used to generate rich descriptions of experiences in a military combat support hospital in Iraq. Data were analyzed using thematic analysis methods. Findings: Culturally, the differences between the Iraqi patients and the nurses included variations in communication, diet, and beliefs and values in reference to gender and patient dependency. Conclusion: The findings indicated that the nurses need language skills and cultural customs and beliefs training to provide care to culturally diverse patients. In addition, support services, such as dieticians, need to be involved in the plan of care to address applicable cultural issues. Implications: Implementation of learning to provide nurses language skills and cultural awareness of the diet, customs and beliefs of Iraqi people as well as the economic, political, and social factors that have an impact on their lives will promote quality nursing care and optimal health outcomes. Keywords cultural awareness, nursing care, military nursing, Iraqi patients, critical care, transcultural health, focus group analysis, deployment During military operations in Iraq, not only did service members sustain physical and psychological injuries, but so too did the Iraqi people. Estimates from 2004 through 2010 range from 110,000 to 147,195 (Associated Press, 2010; National Counterterrorism Center, 2011; Todd, 2009). The Iraqi patients, which included pediatric patients, were primarily injured by gunshot wounds, explosions, fragments, crush injuries, falls, and burns (Filliung & Bower, 2010; McGuigan et al., 2007; Schreiber et al., 2008; Smith, 2008). Most of the orthopedic injuries were fractures, followed by lacerations, joint dislocations, amputations, and stump infections (Filliung & Bower, 2010; Schreiber et al., 2008). Soft tissue injuries, burns, and fragmentation wounds were also common (Filliung & Bower, 2010; Schreiber et al., 2008; Smith, 2008). Surgical procedures included wound washouts and debridements, bone grafts, amputations, application of external fixator devices, nerve repair, skin grafting, thoracotomies, and colostomies (Filliung & Bower, 2010; McGuigan et al., 2007; Schreiber et al., 2008). Moreover, the Iraqi patients had higher mean injury severity scores (ranging from 7–11.6), longer length of stays (mean length of 4.8–8 days), and more surgeries per person than injured coalition or U.S. service members (Filliung & Bower, 2010; McGuigan et al., 2007; Schreiber et al., 2008; Smith, 2008).
Many of these patients were cared for by U.S. military nurses, who were challenged by not only the complex and multiple injuries but also by diverse cultural factors. Iraqi people are a heterogeneous group. Among the differentiating factors are place of residence (urban versus rural), ethnic (Arab or Kurd), and religious (Shiite, Sunni, and Christian) backgrounds and social class (Al-Ali, 2005). The people have experienced wars or military operations, political oppression, and impoverishment for several decades. During these times, Iraq’s infrastructure collapsed under extensive destruction. There was little or no electricity, shortages of food and clean water, limited supplies and communication, high morbidity and mortality, and little health care. The exposure to such devastation has resulted in psychological 1
The Catholic University of America, Washington, DC, USA Oregon Health and Science University, Portland, OR, USA 3 Deputy Commander of Nursing, Department of Nursing, Landstuhl Regional Army Medical Center, Landstuhl, Germany 2
Corresponding Author: Petra Goodman, PhD, WHNP, COL (Ret), Nurse Corps, U.S. Army, Associate Professor, Director of Research, School of Nursing, The Catholic University of America, Gowan Hall, Room 201, 620 Michigan Avenue, NE, Washington, DC 20064, USA. Email: [email protected]
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trauma for many Iraqis and has led many people to become hopeless and fatalistic (Al-Ali, 2005; Cainkar, 1993). Islam is the religion of the majority of Iraqi people. Due to the current state of tribal and Shiite–Sunni sectarianism, there has been a religious revival within Iraq and the rise of extremist Islamist forces (Al-Ali, 2005; Moaddel, de Jong, & Dagher, 2011). After years of brutal suppression by Saddam Hussein, the Shiites were determined to give Islam a central role in Iraq’s society and political system (Coleman, 2006). Today, the processes related to Islamization are dominating Iraqi political power struggles (Al-Ali, 2005). The incorporation of Islam into Iraqi law has also led to increased conservatism in gender relations. The interpretation of these laws by patriarchal leaders and Islamic teachings of tribal traditions has led to the marginalization of women (Coleman, 2006). Although over the latter half of the 20th century Iraqi women experienced an expansion in their opportunities and rights, the return to tribalism and sectarianism has caused a demise in the status of Iraqi women back into an inferior and subordinate status to men. Today, extremists are imposing restrictions such as requiring women to veil their faces and to cover the body and are enforcing strict segregation of the sexes in public (Coleman, 2006; Ismael & Ismael, 2007). Islam also influences the diet of the Iraqi people. Halal (meaning “permitted or lawful”) foods are foods that are allowed under Islamic dietary guidelines (Rahman, Admad, Mohamad, & Ismail, 2011). Eating halal foods is good for physical and spiritual health. The Quran instructs Muslims to eat and drink only permitted foods as an indication of their submission and obedience to Allah (Rahman et al., 2011). According to these guidelines, Muslims cannot consume pork or pork by-products, animals not slaughtered properly or not slaughtered in the name of Allah, blood and blood by-products, and carnivorous animals (Rahman et al. 2011). Two prominent features of health care practices in Iraq are the dominant role of the physician and health beliefs based on primitive ancient religious practices (Sultan, 2007). Physicians are regarded as high in status and as authoritative figures who are not challenged. During physician and patient encounters, discussions are limited as the physician is in the superior role informing the patient and family of the diagnosis and plan of treatment while the patient and the family accept a passive role of listening and complying with instructions. In terms of health beliefs, many trace back to Sumerians, some as old as 4,000 years ago (Sultan, 2007). Certain diseases are thought to occur due to supernatural powers, a form of punishment for sins and for disobeying gods (Sultan, 2007). However, the persistence of such beliefs may also be due to other factors such as inadequate health services, illiteracy, and poverty (Sultan, 2007). To provide quality of care and to promote recovery and healing, the nurses had to be knowledgeable of the cultural implications of that care and understand how to incorporate
the implications in their plans of care. However, to date, little research has focused on understanding the cultural awareness of nursing care for Iraqi patients, and nurses may feel ill prepared for incorporating cultural aspects into their care. The aim of this article is to describe the cultural factors that have an impact on military nursing care of Iraqi patients. The results were part of a study in which the purpose was to understand the meaning of “nursing care of Iraqi patients” for military nurses who served in Iraq from 2008 to 2009.
Method Design and Research Question This study was a phenomenological inquiry—the study of human experience from the perspective of those experiencing a particular phenomenon. The purpose was to understand the phenomenon of nursing care of Iraqi patients as told from the perspective of the nurses experiencing the delivery of care. Two general questions were posed: (a) Tell me about your experience of providing nursing care for Iraqi patients? and (g) How did your experience transform your nursing practice?
Sample and Setting The sample consisted of military registered nurses and licensed practical nurses. To be included, the nurse must have been assigned to either the inpatient ward or the intensive care unit providing direct inpatient nursing care to Iraq patients. The study did not include the nurses assigned to the emergency room, the operating room, or the ward and intensive care unit in which the U.S. and coalition service members and civilian contract personnel were housed. Following institutional review board approval, the investigators initiated recruitment. The investigators e-mailed the nurses a recruitment letter informing them of the study and posted flyers advertising the study. When a nurse contacted the principal investigator (PI) to volunteer, the PI determined if the nurse met the inclusion criteria. On confirmation of a nurse’s eligibility, the PI, in collaboration with the nurse, scheduled the dates and times for completing the consent form process and the focus group participation. The sample consisted of three focus groups. the mean respondent age was 30 with a range of 24 to 42 years. The mean years in the military were 5, with a range of 2 to 14 years, and the mean years in nursing were 6, with a range of 2 to 15 years. At the time of the study, all participants were assigned to a combat support hospital in Iraq and were serving a 6- to 12-month tour. Most were medical-surgical nurses followed by intensive care nurses. The setting was a military combat support hospital in Iraq. The hospital could be characterized as austere with limited medical equipment, supplies, medications, diagnostic and therapeutic technologies, and communication systems.
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Data Collection
Findings
Focus groups were used rather than individual interviews to generate richer descriptions of experiences. Three focus groups (N = 15) were conducted. The first group consisted of four participants, the second had eight participants, and the third had three participants. All focus groups were conducted by the investigators after obtaining informed consent from each participant. Each focus group interview took place in a private and quiet room, lasted 1.5 to 2 hours, and was conducted using an interview guide. Before beginning the interviews, nurses were instructed not to discuss the interview with others. No names were used during the interviews. Data-generating open-ended questions guided the interview process. Follow-up questions were asked to clarify thoughts, feelings, and meanings of what was expressed and to gain a deeper understanding. Interviews were audiorecorded. One investigator annotated field notes related to participants’ behaviors for additional clarification or context to the data.
Culturally, the differences between the Iraqi patients and the military nurses were widespread and included variations in diet, values in reference to gender and patient dependency, and, most problematic, communication.
Data Analysis Data were analyzed using thematic analysis methods. First, the investigators read the transcription of each focus group interview. Second, the investigators highlighted and extracted significant words, phrases, and statements from the transcripts and categorized them into themes. In order to corroborate the themes, the investigators compared themes with previously extracted items and refined them to reflect the intent of the participants’ experiences. All significant statements and themes were validated by the investigators. Rigor was maintained by attending to credibility, confirmability, dependability, and transferability (Guba & Lincoln, 1994; Lincoln & Guba, 1985). Credibility and confirmability of results were enhanced by keeping comprehensive field notes during data collection and analysis, by audio-taping the interviews and transcribing them verbatim, and by collaboration among the investigators on data collection and analytical decisions. Two of the investigators were military nurses who were deployed with the participants of the study. A third investigator was also a military nurse who had previously deployed to Iraq as well, and the fourth investigator was a retired military nurse. The military service and deployments of the investigators enhanced the credibility. The outcomes of the independent analyses were compared to assure as much bias-free description of the participants’ experiences as possible for confirmability. Transferability was enhanced by a thick description using vivid quotes. Dependability was accomplished by the verbatim transcriptions and a list of analytical decisions. In addition, data saturation ensured that the findings were dependable. The same content and themes emerged from all of the groups.
Communication Language was a barrier to communication for the nurses did not speak Arabic. The language difficulties hampered the nurses’ abilities to acquire accurate and complete assessment information on which to base nursing diagnoses and interventions, to implement procedures and treatments, and to provide education and emotional support. Based on the language barriers, nurses were compelled to use Iraqi interpreters to interact with the patients. Most of the nurses expressed that the interpreters were a definite asset. As one nurse expressed, “I think it is really good that we have all of these interpreters, for without them we would not get nearly as much done as we do. For that was my biggest fear about coming here - how am I going to communicate.” Another nurse commented, “My experience is that it is pretty easy as long as we have the interpreters here. So I am not stressed about communicating because they are always right there.” Others commented that with the interpreters, the communication was suboptimal due to the inability to verify the accuracy of the translation, the modification of the translations based on the interpreters’ own beliefs and values, and the loss of the emotional intent associated with the translation. As one nurse stated, “When you are telling them about one thing, you never know what they are passing on. And even when they are passing it on, exactly what are they saying and does the patient understand. Even if you have them verbalize it back to you, you don’t know what the patient actually said.” One nurse described an incident in which he believed that the interpreter was not telling the patient about the poor prognosis for the interpreter felt that this was “Allah’s wish” and that therefore the patient did not need to know about his poor outcome. The translator would not translate what the doctor was saying about the patient’s poor outcome. It didn’t look like he would have a good quality of life and he wouldn’t be able to talk. The translator would not tell the patient because the translator believes this is what Allah wants. If it is God’s will, it is going to happen, so he would not translate and tell the patient; he would leave off the negative stuff.
Some nurses expressed that the interpreters translated what they believed the patient should know based on the interpreters’ professional affiliation or health beliefs. As one nurse commented, “Sometimes, I prefer not to have the doctors [interpreters who are former Iraqi doctors]
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translate, because they feel that the patient doesn’t need to know certain information.” Conversely, some nurses indicated that the medical background of the interpreters was an asset and that translations were more problematic with the interpreters that did not have a medical background. As one nurse stated, “It is more of a problem with the female interpreters, who are not medically trained. With the male interpreters, it is not so much of a problem. Our male interpreters are medical doctors, things like that.” The nurses also expressed frustration at the loss of the exact meaning and intent in the translation secondary to differences in voice inflections, emotional emphasis, and body language. As one nurse commented, “Sometimes, I feel like the interpreters . . . they translate but they do not translate the feeling in your voice. There are inflections that they are not translating.” Another one stated, “The issue with the interpreters is that they don’t translate the inflection in your voice . . . Sometimes, they will translate well with the inflection, but it varies. It gets infuriating when you can’t get your point across.” Adding to this dilemma was the need for immediate and frequent access to the interpreters. Although the interpreters were present in the hospital, they were not located directly on the patient units. Therefore, if the nurse needed to immediately attend to a patient and did not have time to call the interpreter; she would do the best in terms of communicating to the patient. In addition, the high frequency of needing an interpreter also significantly inhibited communication. One nurse described this in relation to patient teaching: “I usually communicate a lot more with my patients. But, even if I know the interpreters are available, I am hesitant for I do not want to call them every five seconds. . . . So, I don’t necessarily educate my patients as much as I would normally because of the fact that there are language barriers.”
Diet In addition, the nurses confronted dietary issues. They spoke of the differences in food and the dislike of the American food by the Iraqis. The patients, particularly the children, would not eat the food. Consequently, malnutrition, weight loss, and compromised wound healing could become potential issues. As one nurse stated,
food provided by family members. “The nutrition is a pain. The patient will not eat any of our food. The family will bring in food, but it is not the right nutrient for wound healing. It is so frustrating.” Another nurse described how the food provided by family members could be more problematic if the patient was on a special diet and how invasive means may be needed to ensure that the patient received adequate nutrition: They get a nasograstic tube and we force-feed them. We let the family bring them food some of the time. However, if they are on a special diet such as soft or pureed, it becomes a problem if the family brings them food. They are barely progressing from a liquid diet to real food, and they have big chunks of lamb.
However, many nurses, who were exasperated with the dietary difficulties, would indicate that any food was better than none as long as the patients were eating something to minimize the detriments on their health. This was particularly relevant for the pediatric patients. Sometimes, the family will bring in food. It may not be as totally nutritious as that protein shake, but they are not drinking that anyway. So you might as well let them eat the food their families are bringing in. Again, it may not have many nutrients, but, at least, it’s something. Because you can try all you want and they will not eat our food. Nothing that we give them is what they are used to.
Gender Another cultural issue confronted by the nurses was related to gender. Issues centered on same-gender care and the status of men versus women. Some of the Iraqi female patients would not expose their bodies to other men, even if the men were health care providers. Therefore, they requested that only women provide care for them. To respect this custom, the charge nurse would attempt to assign male patients to male nurses and vice versa. However, this was not always possible based on patient census or required procedures. One male nurse articulated his difficulty in trying to complete a procedure on a female patient: I have a female coming in with chest pain. I couldn’t even do an EKG because she did not want me to see her chest because of her religion or whatever. So I am here to respect their culture. . . . But the whole female–female, male–male thing. I am not used to that, but here it is a learning experience, to respect cultural ways and everything.
You are not going to get your patients to eat the food. They do not like our food. They hate it. I know from taking care of all of these burn kids who need all of these proteins and calories, so they can heal properly. They won’t eat the food because it doesn’t look the same and it is not what they are used to. Even if it is meat and potatoes—something that they are used to eating; if it is not prepared the same or look the same, they will not eat it. Especially, the little kids.
Conversely, the female nurses expressed the difficulty they encountered providing care to male Iraqi patients. As one nurse commented,
One nurse described her frustration at the patients’ dislike of the American food as well as the lack of nutrition in the
Some [Iraqi males] believe females do not belong here and will seek out the male nurse for questions. They are not even taking
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Goodman et al. care of the patient. The older men have it ingrained in them that they are to be waited on; a woman is supposed to take care of them, she is supposed to wait on them. Women are raised to take care of men. That is the ultimate thing—no matter what.
Fortunately, this was not consistent, for some of the female nurses indicated that they encountered no problems with taking care of male Iraqi patients and that these patients were respectful, receptive to their care and instructions, and appreciative of the care. This change may have been due to the fact that military nurses had already been in Iraq for several years providing care to Iraqi patients, in which time the Iraqi population had been exposed to American customs and traditions. Therefore, the population may have been more familiar with and accepting of American traditions and respect for female nurses. Differences in family participation in care were also noted to be related to gender. Female and younger family members appeared to be more actively involved in the care of their family member, whereas males were not. As one nurse expressed, “Some family members want to do everything. Like with this mother of a nine-year-old, we were all like completely hands-off because she wanted to do everything. And we had an elderly woman that had an MI and her son wanted to do as much as he could to help her.” Conversely, men, particularly, older male family members, did not participate in care. As one nurse stated, One night, I had a 3-year-old who was awake and crying and the uncle, who brought him to the hospital, was sleeping and didn’t want to take care of the child. The uncle would get up and come to get us to take care of the child. He did not want to hold the child. I felt like he thought it was not his job.
Patient Dependency Another cultural challenge was the lack of autonomy and decision making exercised by the patient. The nurses expressed that they were accustomed to having patients participate in decisions relative to their care. As one nurse expressed, I think the hardest thing for me, personally, is I am used to giving so much power to the patient as far as deciding their own care. I try to give them as many options as possible. Here, I don’t know if it is the language barrier or because of the cultural barrier, but I feel like those decisions are being made by other people because for whatever reason, they are not ready to make those decisions themselves.
The passive and dependent role of Iraqi patients in their relationship with healthcare providers may have been due to their perceptions of physicians as authoritative figures. Iraqis view doctors as paternal or fatherlike and place the patient in the role of a child (Sultan, 2007). Treatment decisions are usually left in the doctor’s hands and the patient may not ask questions
about diagnosis, treatment, or complication (Sultan, 2006). However, another reason for the dependency may be due to the effects of the economic, political, and social changes and the daily struggles for survival. Political repression, increased unemployment, scarce resources, and increased crime and violence may have forced Iraqis into dependent roles in which they are governed and directed by others.
Discussion The nurses highlighted the difficulties encountered due to the lack of awareness of cultural norms and lack of language fluency. Lack of awareness could result in patient and family anger, dissatisfaction, and noncompliance potentially contributing to compromised care. In addition, the differences in language often made interactions difficult. Other studies of Vietnam nurse veterans and military nurses deployed to Honduras, Bosnia, Iraq, and Afghanistan reported similar findings in which the nurses described the lack of knowledge about the culture and customs and the language barrier (Agazio, 2010; Scannell-Desch, 2005). The nurses expressed that their cultural learning was acquired through “on-the-job” experiences and in cultural awareness classes prior to deployment. However, they also reported that the amount and type of classes were insufficient. As one nurse stated, “I don’t think two classes are enough, for each class has so much information that you couldn’t retain it. So things like propping your leg and not showing the bottom of your shoe, types of gestures, things like that, you forget about all of that.” Based on the findings, it was evident that language was a significant dilemma. Although the military has made efforts to provide language training through classes and self-learning with flashcards, which were considered by the nurses to be very important, additional language learning needs to be addressed. The availability of varied methods such as online courses in addition to direct classroom instruction should be considered. In addition, nurses need to be aware of the patient’s and family’s health beliefs. Nurses should ask the patient and the family how they view the illness, what they consider to be the cause, what treatments they have already tried, and what treatments they hope nurses will use. Doing so may go a long way toward building a therapeutic relationship. Knowledge of these values and beliefs can be used to plan for nursing actions and behaviors consistent with the patient’s and the family’s norms. Such care will not only demonstrate respect for the patients and their families but will also improve patient and family compliance and satisfaction. As with language, diet was a major cultural challenge for the nurses. The Iraqi patients disliked the American food and frequently refused to eat it. Diet was a critical factor related to the necessity of nutrition for healing particularly for the burn patients. Nurses need to inquire about the dietary habits of the patient and have a good knowledge on halal foods,
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including the ways it is processed and prepared. This also includes their awareness on food products considered to be harmful or questionable. Moreover, invasive measures such as “force-feeding by gastric tubes” should be used as last mean efforts. Less aggressive measures such as provision of food that the patient will eat should be pursued first. Dieticians should consult with nurses, patients, and their families to plan meals consisting of foods that the patient will eat. Dietary departments should also be knowledgeable of the dietary habits of patients. Although rules concerning halal food are relatively difficult to adhere to, efforts to use appropriate methods of preparation should be implemented to the extent possible. In addition, the patient and his or her family should be informed regarding the methods of food preparation such as avoidance of cross-contamination between halal and non-halal dishes to reassure the patient and family that preservation of traditional dietary habits related to religious values are being complied with based on the availability of resources. The nurses highlighted other cultural factors related to gender and norms in reference to family support and patient dependency. The issue of gender centered on same-gender care and the status of men versus women. Nurses need to be aware that Iraqi women have experienced a number of profound social and cultural changes linked to gender relations and ideologies, and need to be knowledgeable of cultural norms explicating the differences in the care of and role expectations of Iraqi men versus Iraqi women. Based on the dominant role of men, women may display fearful, subservient, protective, or noncompliant behaviors when approached by male healthcare providers. Conversely, when providing care to male patients, nurses need to acknowledge men’s conservative and patriarchal values in reference to women. Iraqi beliefs regarding gender relations may also impact family support in reference to participation in care of the patient. In Iraq, women have the primary responsibility for taking care of the family and the household, and men are responsible for working and earning wages (Cainkar, 1993). In addition, the elderly generation is honored by the younger family members. Therefore, male family members may not participate in care unless providing care for an elderly family member. Nurses’ ignorance of such beliefs could have a significant impact on the nurses’ relationships with the patient and his or her family. Nurses need to have an understanding of the patient’s or the family’s beliefs that would allow nurses to reach compromises and show respect for the family’s and patient’s beliefs and values. In addition, cultural customs need to be analyzed in the context of social, economic and political factors in Iraq. Economic sanctions, political repression, increased unemployment, increased crime and violence, scarce resources, and a religious revival within Iraqi society have led to fatalistic views, conservative and restrictive values, and dependent behaviors (Al-Ali, 2003). Again, nurses need to be cognizant of these influential factors and comprehensively assess patients and their families to have a full understanding of how these factors impact patients’
and families’ behaviors. Plans of care need to incorporate nursing actions and behaviors that demonstrate alignment with patient and family factors and behaviors. Such efforts will promote the facilitation of optimum health outcomes.
Conclusion Through experiential learning and personal experiences, these nurses developed situated knowledge needed for particular cultural challenges faced when providing care for Iraqi patients. Findings indicated that the nurses felt ill prepared for the cultural aspects of nursing care confirming existing research and extending knowledge about nursing care of various cultures. However, the implementation of learning to provide nurses with cultural awareness of the customs and beliefs of Iraqi people will promote quality nursing care and optimal health outcomes. Acknowledgment This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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research-article2014
TCNXXX10.1177/1043659614524794Journal of Transcultural NursingGoodman et al.
Research Department
Cultural Awareness: Nursing Care of Iraqi Patients
Journal of Transcultural Nursing 2015, Vol. 26(4) 395–401 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524794 tcn.sagepub.com
Petra Goodman, PhD, WHNP1, Bethany Edge, BSN, RN2, Janice Agazio, PhD, CRNP, FAANP, FAAN1, and Kathy Prue-Owens, PhD, RN3
Abstract Purpose: The aim of this study was to describe the cultural factors that have an impact on military nursing care for Iraqi patients. The results were part of a larger study in which the purpose was to understand nurses’ experiences of delivery of care for Iraqi patients. Method: Three focus groups, consisting of military registered nurses and licensed practical nurses, were used to generate rich descriptions of experiences in a military combat support hospital in Iraq. Data were analyzed using thematic analysis methods. Findings: Culturally, the differences between the Iraqi patients and the nurses included variations in communication, diet, and beliefs and values in reference to gender and patient dependency. Conclusion: The findings indicated that the nurses need language skills and cultural customs and beliefs training to provide care to culturally diverse patients. In addition, support services, such as dieticians, need to be involved in the plan of care to address applicable cultural issues. Implications: Implementation of learning to provide nurses language skills and cultural awareness of the diet, customs and beliefs of Iraqi people as well as the economic, political, and social factors that have an impact on their lives will promote quality nursing care and optimal health outcomes. Keywords cultural awareness, nursing care, military nursing, Iraqi patients, critical care, transcultural health, focus group analysis, deployment During military operations in Iraq, not only did service members sustain physical and psychological injuries, but so too did the Iraqi people. Estimates from 2004 through 2010 range from 110,000 to 147,195 (Associated Press, 2010; National Counterterrorism Center, 2011; Todd, 2009). The Iraqi patients, which included pediatric patients, were primarily injured by gunshot wounds, explosions, fragments, crush injuries, falls, and burns (Filliung & Bower, 2010; McGuigan et al., 2007; Schreiber et al., 2008; Smith, 2008). Most of the orthopedic injuries were fractures, followed by lacerations, joint dislocations, amputations, and stump infections (Filliung & Bower, 2010; Schreiber et al., 2008). Soft tissue injuries, burns, and fragmentation wounds were also common (Filliung & Bower, 2010; Schreiber et al., 2008; Smith, 2008). Surgical procedures included wound washouts and debridements, bone grafts, amputations, application of external fixator devices, nerve repair, skin grafting, thoracotomies, and colostomies (Filliung & Bower, 2010; McGuigan et al., 2007; Schreiber et al., 2008). Moreover, the Iraqi patients had higher mean injury severity scores (ranging from 7–11.6), longer length of stays (mean length of 4.8–8 days), and more surgeries per person than injured coalition or U.S. service members (Filliung & Bower, 2010; McGuigan et al., 2007; Schreiber et al., 2008; Smith, 2008).
Many of these patients were cared for by U.S. military nurses, who were challenged by not only the complex and multiple injuries but also by diverse cultural factors. Iraqi people are a heterogeneous group. Among the differentiating factors are place of residence (urban versus rural), ethnic (Arab or Kurd), and religious (Shiite, Sunni, and Christian) backgrounds and social class (Al-Ali, 2005). The people have experienced wars or military operations, political oppression, and impoverishment for several decades. During these times, Iraq’s infrastructure collapsed under extensive destruction. There was little or no electricity, shortages of food and clean water, limited supplies and communication, high morbidity and mortality, and little health care. The exposure to such devastation has resulted in psychological 1
The Catholic University of America, Washington, DC, USA Oregon Health and Science University, Portland, OR, USA 3 Deputy Commander of Nursing, Department of Nursing, Landstuhl Regional Army Medical Center, Landstuhl, Germany 2
Corresponding Author: Petra Goodman, PhD, WHNP, COL (Ret), Nurse Corps, U.S. Army, Associate Professor, Director of Research, School of Nursing, The Catholic University of America, Gowan Hall, Room 201, 620 Michigan Avenue, NE, Washington, DC 20064, USA. Email: [email protected]
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trauma for many Iraqis and has led many people to become hopeless and fatalistic (Al-Ali, 2005; Cainkar, 1993). Islam is the religion of the majority of Iraqi people. Due to the current state of tribal and Shiite–Sunni sectarianism, there has been a religious revival within Iraq and the rise of extremist Islamist forces (Al-Ali, 2005; Moaddel, de Jong, & Dagher, 2011). After years of brutal suppression by Saddam Hussein, the Shiites were determined to give Islam a central role in Iraq’s society and political system (Coleman, 2006). Today, the processes related to Islamization are dominating Iraqi political power struggles (Al-Ali, 2005). The incorporation of Islam into Iraqi law has also led to increased conservatism in gender relations. The interpretation of these laws by patriarchal leaders and Islamic teachings of tribal traditions has led to the marginalization of women (Coleman, 2006). Although over the latter half of the 20th century Iraqi women experienced an expansion in their opportunities and rights, the return to tribalism and sectarianism has caused a demise in the status of Iraqi women back into an inferior and subordinate status to men. Today, extremists are imposing restrictions such as requiring women to veil their faces and to cover the body and are enforcing strict segregation of the sexes in public (Coleman, 2006; Ismael & Ismael, 2007). Islam also influences the diet of the Iraqi people. Halal (meaning “permitted or lawful”) foods are foods that are allowed under Islamic dietary guidelines (Rahman, Admad, Mohamad, & Ismail, 2011). Eating halal foods is good for physical and spiritual health. The Quran instructs Muslims to eat and drink only permitted foods as an indication of their submission and obedience to Allah (Rahman et al., 2011). According to these guidelines, Muslims cannot consume pork or pork by-products, animals not slaughtered properly or not slaughtered in the name of Allah, blood and blood by-products, and carnivorous animals (Rahman et al. 2011). Two prominent features of health care practices in Iraq are the dominant role of the physician and health beliefs based on primitive ancient religious practices (Sultan, 2007). Physicians are regarded as high in status and as authoritative figures who are not challenged. During physician and patient encounters, discussions are limited as the physician is in the superior role informing the patient and family of the diagnosis and plan of treatment while the patient and the family accept a passive role of listening and complying with instructions. In terms of health beliefs, many trace back to Sumerians, some as old as 4,000 years ago (Sultan, 2007). Certain diseases are thought to occur due to supernatural powers, a form of punishment for sins and for disobeying gods (Sultan, 2007). However, the persistence of such beliefs may also be due to other factors such as inadequate health services, illiteracy, and poverty (Sultan, 2007). To provide quality of care and to promote recovery and healing, the nurses had to be knowledgeable of the cultural implications of that care and understand how to incorporate
the implications in their plans of care. However, to date, little research has focused on understanding the cultural awareness of nursing care for Iraqi patients, and nurses may feel ill prepared for incorporating cultural aspects into their care. The aim of this article is to describe the cultural factors that have an impact on military nursing care of Iraqi patients. The results were part of a study in which the purpose was to understand the meaning of “nursing care of Iraqi patients” for military nurses who served in Iraq from 2008 to 2009.
Method Design and Research Question This study was a phenomenological inquiry—the study of human experience from the perspective of those experiencing a particular phenomenon. The purpose was to understand the phenomenon of nursing care of Iraqi patients as told from the perspective of the nurses experiencing the delivery of care. Two general questions were posed: (a) Tell me about your experience of providing nursing care for Iraqi patients? and (g) How did your experience transform your nursing practice?
Sample and Setting The sample consisted of military registered nurses and licensed practical nurses. To be included, the nurse must have been assigned to either the inpatient ward or the intensive care unit providing direct inpatient nursing care to Iraq patients. The study did not include the nurses assigned to the emergency room, the operating room, or the ward and intensive care unit in which the U.S. and coalition service members and civilian contract personnel were housed. Following institutional review board approval, the investigators initiated recruitment. The investigators e-mailed the nurses a recruitment letter informing them of the study and posted flyers advertising the study. When a nurse contacted the principal investigator (PI) to volunteer, the PI determined if the nurse met the inclusion criteria. On confirmation of a nurse’s eligibility, the PI, in collaboration with the nurse, scheduled the dates and times for completing the consent form process and the focus group participation. The sample consisted of three focus groups. the mean respondent age was 30 with a range of 24 to 42 years. The mean years in the military were 5, with a range of 2 to 14 years, and the mean years in nursing were 6, with a range of 2 to 15 years. At the time of the study, all participants were assigned to a combat support hospital in Iraq and were serving a 6- to 12-month tour. Most were medical-surgical nurses followed by intensive care nurses. The setting was a military combat support hospital in Iraq. The hospital could be characterized as austere with limited medical equipment, supplies, medications, diagnostic and therapeutic technologies, and communication systems.
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Data Collection
Findings
Focus groups were used rather than individual interviews to generate richer descriptions of experiences. Three focus groups (N = 15) were conducted. The first group consisted of four participants, the second had eight participants, and the third had three participants. All focus groups were conducted by the investigators after obtaining informed consent from each participant. Each focus group interview took place in a private and quiet room, lasted 1.5 to 2 hours, and was conducted using an interview guide. Before beginning the interviews, nurses were instructed not to discuss the interview with others. No names were used during the interviews. Data-generating open-ended questions guided the interview process. Follow-up questions were asked to clarify thoughts, feelings, and meanings of what was expressed and to gain a deeper understanding. Interviews were audiorecorded. One investigator annotated field notes related to participants’ behaviors for additional clarification or context to the data.
Culturally, the differences between the Iraqi patients and the military nurses were widespread and included variations in diet, values in reference to gender and patient dependency, and, most problematic, communication.
Data Analysis Data were analyzed using thematic analysis methods. First, the investigators read the transcription of each focus group interview. Second, the investigators highlighted and extracted significant words, phrases, and statements from the transcripts and categorized them into themes. In order to corroborate the themes, the investigators compared themes with previously extracted items and refined them to reflect the intent of the participants’ experiences. All significant statements and themes were validated by the investigators. Rigor was maintained by attending to credibility, confirmability, dependability, and transferability (Guba & Lincoln, 1994; Lincoln & Guba, 1985). Credibility and confirmability of results were enhanced by keeping comprehensive field notes during data collection and analysis, by audio-taping the interviews and transcribing them verbatim, and by collaboration among the investigators on data collection and analytical decisions. Two of the investigators were military nurses who were deployed with the participants of the study. A third investigator was also a military nurse who had previously deployed to Iraq as well, and the fourth investigator was a retired military nurse. The military service and deployments of the investigators enhanced the credibility. The outcomes of the independent analyses were compared to assure as much bias-free description of the participants’ experiences as possible for confirmability. Transferability was enhanced by a thick description using vivid quotes. Dependability was accomplished by the verbatim transcriptions and a list of analytical decisions. In addition, data saturation ensured that the findings were dependable. The same content and themes emerged from all of the groups.
Communication Language was a barrier to communication for the nurses did not speak Arabic. The language difficulties hampered the nurses’ abilities to acquire accurate and complete assessment information on which to base nursing diagnoses and interventions, to implement procedures and treatments, and to provide education and emotional support. Based on the language barriers, nurses were compelled to use Iraqi interpreters to interact with the patients. Most of the nurses expressed that the interpreters were a definite asset. As one nurse expressed, “I think it is really good that we have all of these interpreters, for without them we would not get nearly as much done as we do. For that was my biggest fear about coming here - how am I going to communicate.” Another nurse commented, “My experience is that it is pretty easy as long as we have the interpreters here. So I am not stressed about communicating because they are always right there.” Others commented that with the interpreters, the communication was suboptimal due to the inability to verify the accuracy of the translation, the modification of the translations based on the interpreters’ own beliefs and values, and the loss of the emotional intent associated with the translation. As one nurse stated, “When you are telling them about one thing, you never know what they are passing on. And even when they are passing it on, exactly what are they saying and does the patient understand. Even if you have them verbalize it back to you, you don’t know what the patient actually said.” One nurse described an incident in which he believed that the interpreter was not telling the patient about the poor prognosis for the interpreter felt that this was “Allah’s wish” and that therefore the patient did not need to know about his poor outcome. The translator would not translate what the doctor was saying about the patient’s poor outcome. It didn’t look like he would have a good quality of life and he wouldn’t be able to talk. The translator would not tell the patient because the translator believes this is what Allah wants. If it is God’s will, it is going to happen, so he would not translate and tell the patient; he would leave off the negative stuff.
Some nurses expressed that the interpreters translated what they believed the patient should know based on the interpreters’ professional affiliation or health beliefs. As one nurse commented, “Sometimes, I prefer not to have the doctors [interpreters who are former Iraqi doctors]
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translate, because they feel that the patient doesn’t need to know certain information.” Conversely, some nurses indicated that the medical background of the interpreters was an asset and that translations were more problematic with the interpreters that did not have a medical background. As one nurse stated, “It is more of a problem with the female interpreters, who are not medically trained. With the male interpreters, it is not so much of a problem. Our male interpreters are medical doctors, things like that.” The nurses also expressed frustration at the loss of the exact meaning and intent in the translation secondary to differences in voice inflections, emotional emphasis, and body language. As one nurse commented, “Sometimes, I feel like the interpreters . . . they translate but they do not translate the feeling in your voice. There are inflections that they are not translating.” Another one stated, “The issue with the interpreters is that they don’t translate the inflection in your voice . . . Sometimes, they will translate well with the inflection, but it varies. It gets infuriating when you can’t get your point across.” Adding to this dilemma was the need for immediate and frequent access to the interpreters. Although the interpreters were present in the hospital, they were not located directly on the patient units. Therefore, if the nurse needed to immediately attend to a patient and did not have time to call the interpreter; she would do the best in terms of communicating to the patient. In addition, the high frequency of needing an interpreter also significantly inhibited communication. One nurse described this in relation to patient teaching: “I usually communicate a lot more with my patients. But, even if I know the interpreters are available, I am hesitant for I do not want to call them every five seconds. . . . So, I don’t necessarily educate my patients as much as I would normally because of the fact that there are language barriers.”
Diet In addition, the nurses confronted dietary issues. They spoke of the differences in food and the dislike of the American food by the Iraqis. The patients, particularly the children, would not eat the food. Consequently, malnutrition, weight loss, and compromised wound healing could become potential issues. As one nurse stated,
food provided by family members. “The nutrition is a pain. The patient will not eat any of our food. The family will bring in food, but it is not the right nutrient for wound healing. It is so frustrating.” Another nurse described how the food provided by family members could be more problematic if the patient was on a special diet and how invasive means may be needed to ensure that the patient received adequate nutrition: They get a nasograstic tube and we force-feed them. We let the family bring them food some of the time. However, if they are on a special diet such as soft or pureed, it becomes a problem if the family brings them food. They are barely progressing from a liquid diet to real food, and they have big chunks of lamb.
However, many nurses, who were exasperated with the dietary difficulties, would indicate that any food was better than none as long as the patients were eating something to minimize the detriments on their health. This was particularly relevant for the pediatric patients. Sometimes, the family will bring in food. It may not be as totally nutritious as that protein shake, but they are not drinking that anyway. So you might as well let them eat the food their families are bringing in. Again, it may not have many nutrients, but, at least, it’s something. Because you can try all you want and they will not eat our food. Nothing that we give them is what they are used to.
Gender Another cultural issue confronted by the nurses was related to gender. Issues centered on same-gender care and the status of men versus women. Some of the Iraqi female patients would not expose their bodies to other men, even if the men were health care providers. Therefore, they requested that only women provide care for them. To respect this custom, the charge nurse would attempt to assign male patients to male nurses and vice versa. However, this was not always possible based on patient census or required procedures. One male nurse articulated his difficulty in trying to complete a procedure on a female patient: I have a female coming in with chest pain. I couldn’t even do an EKG because she did not want me to see her chest because of her religion or whatever. So I am here to respect their culture. . . . But the whole female–female, male–male thing. I am not used to that, but here it is a learning experience, to respect cultural ways and everything.
You are not going to get your patients to eat the food. They do not like our food. They hate it. I know from taking care of all of these burn kids who need all of these proteins and calories, so they can heal properly. They won’t eat the food because it doesn’t look the same and it is not what they are used to. Even if it is meat and potatoes—something that they are used to eating; if it is not prepared the same or look the same, they will not eat it. Especially, the little kids.
Conversely, the female nurses expressed the difficulty they encountered providing care to male Iraqi patients. As one nurse commented,
One nurse described her frustration at the patients’ dislike of the American food as well as the lack of nutrition in the
Some [Iraqi males] believe females do not belong here and will seek out the male nurse for questions. They are not even taking
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Goodman et al. care of the patient. The older men have it ingrained in them that they are to be waited on; a woman is supposed to take care of them, she is supposed to wait on them. Women are raised to take care of men. That is the ultimate thing—no matter what.
Fortunately, this was not consistent, for some of the female nurses indicated that they encountered no problems with taking care of male Iraqi patients and that these patients were respectful, receptive to their care and instructions, and appreciative of the care. This change may have been due to the fact that military nurses had already been in Iraq for several years providing care to Iraqi patients, in which time the Iraqi population had been exposed to American customs and traditions. Therefore, the population may have been more familiar with and accepting of American traditions and respect for female nurses. Differences in family participation in care were also noted to be related to gender. Female and younger family members appeared to be more actively involved in the care of their family member, whereas males were not. As one nurse expressed, “Some family members want to do everything. Like with this mother of a nine-year-old, we were all like completely hands-off because she wanted to do everything. And we had an elderly woman that had an MI and her son wanted to do as much as he could to help her.” Conversely, men, particularly, older male family members, did not participate in care. As one nurse stated, One night, I had a 3-year-old who was awake and crying and the uncle, who brought him to the hospital, was sleeping and didn’t want to take care of the child. The uncle would get up and come to get us to take care of the child. He did not want to hold the child. I felt like he thought it was not his job.
Patient Dependency Another cultural challenge was the lack of autonomy and decision making exercised by the patient. The nurses expressed that they were accustomed to having patients participate in decisions relative to their care. As one nurse expressed, I think the hardest thing for me, personally, is I am used to giving so much power to the patient as far as deciding their own care. I try to give them as many options as possible. Here, I don’t know if it is the language barrier or because of the cultural barrier, but I feel like those decisions are being made by other people because for whatever reason, they are not ready to make those decisions themselves.
The passive and dependent role of Iraqi patients in their relationship with healthcare providers may have been due to their perceptions of physicians as authoritative figures. Iraqis view doctors as paternal or fatherlike and place the patient in the role of a child (Sultan, 2007). Treatment decisions are usually left in the doctor’s hands and the patient may not ask questions
about diagnosis, treatment, or complication (Sultan, 2006). However, another reason for the dependency may be due to the effects of the economic, political, and social changes and the daily struggles for survival. Political repression, increased unemployment, scarce resources, and increased crime and violence may have forced Iraqis into dependent roles in which they are governed and directed by others.
Discussion The nurses highlighted the difficulties encountered due to the lack of awareness of cultural norms and lack of language fluency. Lack of awareness could result in patient and family anger, dissatisfaction, and noncompliance potentially contributing to compromised care. In addition, the differences in language often made interactions difficult. Other studies of Vietnam nurse veterans and military nurses deployed to Honduras, Bosnia, Iraq, and Afghanistan reported similar findings in which the nurses described the lack of knowledge about the culture and customs and the language barrier (Agazio, 2010; Scannell-Desch, 2005). The nurses expressed that their cultural learning was acquired through “on-the-job” experiences and in cultural awareness classes prior to deployment. However, they also reported that the amount and type of classes were insufficient. As one nurse stated, “I don’t think two classes are enough, for each class has so much information that you couldn’t retain it. So things like propping your leg and not showing the bottom of your shoe, types of gestures, things like that, you forget about all of that.” Based on the findings, it was evident that language was a significant dilemma. Although the military has made efforts to provide language training through classes and self-learning with flashcards, which were considered by the nurses to be very important, additional language learning needs to be addressed. The availability of varied methods such as online courses in addition to direct classroom instruction should be considered. In addition, nurses need to be aware of the patient’s and family’s health beliefs. Nurses should ask the patient and the family how they view the illness, what they consider to be the cause, what treatments they have already tried, and what treatments they hope nurses will use. Doing so may go a long way toward building a therapeutic relationship. Knowledge of these values and beliefs can be used to plan for nursing actions and behaviors consistent with the patient’s and the family’s norms. Such care will not only demonstrate respect for the patients and their families but will also improve patient and family compliance and satisfaction. As with language, diet was a major cultural challenge for the nurses. The Iraqi patients disliked the American food and frequently refused to eat it. Diet was a critical factor related to the necessity of nutrition for healing particularly for the burn patients. Nurses need to inquire about the dietary habits of the patient and have a good knowledge on halal foods,
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including the ways it is processed and prepared. This also includes their awareness on food products considered to be harmful or questionable. Moreover, invasive measures such as “force-feeding by gastric tubes” should be used as last mean efforts. Less aggressive measures such as provision of food that the patient will eat should be pursued first. Dieticians should consult with nurses, patients, and their families to plan meals consisting of foods that the patient will eat. Dietary departments should also be knowledgeable of the dietary habits of patients. Although rules concerning halal food are relatively difficult to adhere to, efforts to use appropriate methods of preparation should be implemented to the extent possible. In addition, the patient and his or her family should be informed regarding the methods of food preparation such as avoidance of cross-contamination between halal and non-halal dishes to reassure the patient and family that preservation of traditional dietary habits related to religious values are being complied with based on the availability of resources. The nurses highlighted other cultural factors related to gender and norms in reference to family support and patient dependency. The issue of gender centered on same-gender care and the status of men versus women. Nurses need to be aware that Iraqi women have experienced a number of profound social and cultural changes linked to gender relations and ideologies, and need to be knowledgeable of cultural norms explicating the differences in the care of and role expectations of Iraqi men versus Iraqi women. Based on the dominant role of men, women may display fearful, subservient, protective, or noncompliant behaviors when approached by male healthcare providers. Conversely, when providing care to male patients, nurses need to acknowledge men’s conservative and patriarchal values in reference to women. Iraqi beliefs regarding gender relations may also impact family support in reference to participation in care of the patient. In Iraq, women have the primary responsibility for taking care of the family and the household, and men are responsible for working and earning wages (Cainkar, 1993). In addition, the elderly generation is honored by the younger family members. Therefore, male family members may not participate in care unless providing care for an elderly family member. Nurses’ ignorance of such beliefs could have a significant impact on the nurses’ relationships with the patient and his or her family. Nurses need to have an understanding of the patient’s or the family’s beliefs that would allow nurses to reach compromises and show respect for the family’s and patient’s beliefs and values. In addition, cultural customs need to be analyzed in the context of social, economic and political factors in Iraq. Economic sanctions, political repression, increased unemployment, increased crime and violence, scarce resources, and a religious revival within Iraqi society have led to fatalistic views, conservative and restrictive values, and dependent behaviors (Al-Ali, 2003). Again, nurses need to be cognizant of these influential factors and comprehensively assess patients and their families to have a full understanding of how these factors impact patients’
and families’ behaviors. Plans of care need to incorporate nursing actions and behaviors that demonstrate alignment with patient and family factors and behaviors. Such efforts will promote the facilitation of optimum health outcomes.
Conclusion Through experiential learning and personal experiences, these nurses developed situated knowledge needed for particular cultural challenges faced when providing care for Iraqi patients. Findings indicated that the nurses felt ill prepared for the cultural aspects of nursing care confirming existing research and extending knowledge about nursing care of various cultures. However, the implementation of learning to provide nurses with cultural awareness of the customs and beliefs of Iraqi people will promote quality nursing care and optimal health outcomes. Acknowledgment This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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