523992
research-article2014
TCNXXX10.1177/1043659614523992Journal of Transcultural NursingAlmutairi et al.
Research Department
Understanding Cultural Competence in a Multicultural Nursing Workforce: Registered Nurses’ Experience in Saudi Arabia
Journal of Transcultural Nursing 2015, Vol. 26(1) 16–23 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614523992 tcn.sagepub.com
Adel F. Almutairi, Doctor of Healh Science, MSN, RN1,2,3, Alexandra McCarthy, PhD, RN1, and Glenn E. Gardner, PhD, RN, FACN1
Abstract Purpose: In Saudi Arabia, the health system is mainly staffed by expatriate nurses from different cultural and linguistic backgrounds. Given the potential risks this situation poses for patient care, it is important to understand how cultural diversity can be effectively managed in this multicultural environment. The purpose of this study was to explore notions of cultural competence with non-Saudi Arabian nurses working in a major hospital in Saudi Arabia. Design: Face-to-face, audio-recorded, semistructured interviews were conducted with 24 non-Saudi Arabian nurses. Deductive data collection and analysis were undertaken drawing on Campinha-Bacote’s cultural competence model. The data that could not be explained by this model were coded and analyzed inductively. Findings: Nurses within this culturally diverse environment struggled with the notion of cultural competence in terms of each other’s cultural expectations and those of the dominant Saudi culture. Discussion: The study also addressed the limitations of Campinha-Bacote’s model, which did not account for all of the nurses’ experiences. Subsequent inductive analysis yielded important themes that more fully explained the nurses’ experiences in this environment. Implications for Practice: The findings can inform policy, professional education, and practice in the multicultural Saudi setting. Keywords multicultural nursing workforce, cultural competence, qualitative analysis
Background The rapid development of the health care system in Saudi Arabia (Aldossary, While, & Barriball, 2008), coupled with chronic shortage of registered nurses and the increased mobility of the nursing workforce (Almalki, FitzGerald, & Clark, 2011), means that in Saudi Arabia the health care system is mainly staffed by non-Saudi health professionals who have been recruited from all over the world. For example, there are 110,858 nurses currently employed in Saudi hospitals. Of these, 67.7% are expatriates, with the remaining 32.3% being Saudi nationals (Ministry of Health, 2009). Expatriate nurses working in Saudi Arabia bring different cultural values, beliefs, customs, behaviors, and attitudes with them that can greatly differ from those of their patients, their Saudi Arabian employers and colleagues, and their nonSaudi colleagues. Many are employed, for example, without the Arabic language skills that might facilitate nurse–patient and nurse–employer interactions. Differences in interpretation can also occur because English is the standard medium of professional communication in this context. It is a second language for many of these nurses, who are not necessarily
native English speakers (Aldossary et al., 2008). Cultural norms can also be easily misunderstood in such a multicultural environment (Halligan, 2006). Hence, cultural and language difficulties both between patients and nurses and among the health care team have the potential to adversely affect nurses’ abilities to practice competently and safely (Boi, 2000; Cioffi, 2005). Given the potential risks this situation poses for patient care, it is important to understand how cultural diversity can be effectively managed in this multicultural environment. 1
Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia 2 School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada 3 King Abdullah International Medical Research Centre, and King Saud bin Abdulaziz University for health Sciences, Riyadh, Saudi Arabia Corresponding Author: Adel F. Almutairi, University of British Columbia, School of Nursing, T201-2211 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5. Email: [email protected] [email protected]
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
17
Almutairi et al. A number of theoretical frameworks to guide research and practice have been developed in response to cultural diversity in health environments. These frameworks are primarily Western in origin (Jirwe, Gerrish, & Emami, 2006). They have been used effectively in Western settings to develop and evaluate the cultural competence of health professionals (Brathwaite & Majumdar, 2006; Mahabeer, 2009) and students dealing with indigenous populations or patients from other cultures (Brathwaite, 2005; Dowell, Crampton, & Parkin, 2001; Smith, 2001). However, these frameworks tend to reflect the unique sociocultural, historical, and political dimensions of those generally Western settings (Jirwe et al., 2006). In addition, the notion of cultural competence has not been extensively examined in a multicultural nursing workforce where nurses are not only culturally diverse from the patients they care for but also culturally different from each other. Cultural competence aims to improve the quality of health care by reducing the cultural disparities that commonly arise when different cultures meet in the health care context. The precise definition of cultural competence that informed this study is that it is an “ongoing process in which the [individual] health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community)” (Campinha-Bacote, 2002, p. 181). Based on this view, Campinha-Bacote (2002) considers cultural competence as a lifelong learning endeavor rather than an endpoint or static outcome. CampinhaBacote’s (1999, 2002) model proposes that cultural competence is developed through an iterative and cumulative process of cultural awareness, knowledge, skill, encounter, and desire. These attributes are consistently identified in the literature as the main requirements for cultural competence (Campinha-Bacote, 2003; Cowan & Norman, 2006; Leininger, 2002; Suh, 2004); hence Campinha-Bacote’s model (2002) of cultural competence has been widely used in the literature, particularly in nursing research. It was used to guide data collection and analysis in this study because, despite its Western origin, it enables an investigation that is both systematic and comprehensive. This article reports the findings from the qualitative component of a larger mixed-methods study that investigated the influence of cultural diversity of the nursing workforce on the quality and safety of patient care in a Saudi tertiary hospital. The survey component consisted of the Safety Climate Survey, the results of which are reported in a separate paper (Almutairi, Gardner, & McCarthy, 2012). In summary, the results indicated that participants (n = 319) perceived the clinical safety climate as low, particularly non-Arabic participants. To illuminate why the challenges identified by the respondents arose, we collected qualitative data. In this article we present and analyze the qualitative data and in so doing critique the fit of Campinha-Bacote’s cultural competence framework to the Saudi Arabian setting.
Method Design A single-embedded case study design (Yin, 2009) enabled an in-depth exploration of the multicultural nursing workforce in a tertiary Saudi Arabian hospital.
Sample The nursing workforce in this setting consists largely of foreign nurses who are recruited from North America, South Africa, Europe, Asia, Australia, New Zealand, and the Middle East. A purposive sampling strategy was used to recruit participants to represent a variety of units in the hospital including the medical, surgical, pediatric, and gynecological wards. Eligibility criteria comprised registered expatriate or Saudi nurses who had worked in the hospital for a minimum of 12 months. To recruit participants, nurse unit managers identified nurses who met the selection criteria. The researcher then asked the nurses if they were willing to participate in the study. Twenty four nurses participated in the in-depth interviews.
Setting This study was conducted within an 800-bed teaching hospital that delivers primary, secondary, and tertiary health care services for Saudi Arabian National Guard employees and their families.
Instruments Table 1 outlines the interview stem questions and their correspondence to Campinha-Bacote’s framework of cultural competence.
Data Collection Procedures Individual semistructured interviews were undertaken at a time and place convenient to the participants. Audio-recorded interviews, undertaken in English, ranged from 30 to 60 minutes and were immediately transcribed by the researcher. All participants were assigned a pseudonym on transcription and are referred to by that pseudonym in this article.
Data Analysis Data were initially coded and analyzed deductively according to the five constructs underpinning the study: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. Data that did not fit into these predetermined categories were inductively analyzed. This inductive process was useful to help understand the phenomena apparent in the data that were not readily explained by
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
18
Journal of Transcultural Nursing 26(1)
Table 1. Constructs of Cultural Competence Model and Corresponding Interview Question. Constructs Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounter Cultural Desire
Initial interview questions Can you please tell me about the different cultural groups in the hospital? What is your experience of cultural differences within the Saudi population? How is it like to take care of patients who are different from your background? Can you tell me what you know about Saudi culture? Have you had a cultural training? Can you talk about it please? Can you tell me about the hospital orientation? Can you tell me whether all the patients are Saudi nationals or you have nursed patients from other cultures? In the situation when you do not understand the patient, what do you do? How do you handle that? Do you think the patients are comfortable with nursing care? Why? How important to meet the patients’ needs? Have you been able to access any resources about Saudi or other cultures?
the underpinning framework but were clearly valid in this particular context. This process has helped reformulate Campinha-Bacote’s model to a way that is appropriate in this non-Western setting.
Ethical Considerations Ethical approval to undertake the study was obtained from the Human Subject’s Committee of the Medical Center where the study was conducted and the Human Research Ethics Committee of the Principal Investigator’s university.
Results Demographics Most of the 24 participants were female and ranging in age from 26 years to 52 years. Their years of experience working in Saudi Arabia varied from 1 year to 25 years, with the majority having between 1 and 10 years’ experience. Table 2 provides a detailed outline of the participants’ demographic characteristics.
Deductive Analysis Cultural Awareness. This construct proposes that a person’s culturally mediated values, beliefs, and practices shape the way that they interpret the world around them and dictate the
way they relate to others (Adahl, 2009). In many situations, because their culture is the norm for them, it does not occur to the protagonist that there is another way of looking at the world or other points of view, although different, which are equally valid (Sullivan, 2009). Campinha-Bacote (1999), who refers to this tendency as cultural imposition, states that cultural awareness includes understanding one’s own cultural norms, behaviors, and biases and what these bring to a given cultural interaction. Only two participants demonstrated overt self-awareness in relation to their own cultural norms and what these brought to their interactions with Saudi patients. One participant stated, It’s quite challenging really, because you have to assess your own personality and how will you cope with this new environment. (Participant 4)
The ability to recognize cultural differences was not universal in this study, and it is clear from the interviews that some participants did impose their cultural norms on their patients with detrimental effects. One of the participants shared her thoughts about her perception of cultural sameness in her Saudi patients, which was echoed by many others in this study: I find them the same because they’re all Saudis, they’re all Muslims, so they practice the same most of the time. (Participant 4)
A number of participants exhibited their unconscious prejudices toward the practices of Saudi people, using their own cultural background as the yardstick for all behavior. One participant for example, applied a rigid Anglo perception of social etiquette as the standard for shopping and other street behavior, failing to comprehend the social roles these activities play in Saudi life and how time can have a different meaning to the one predicated by the Western world. Misunderstandings of the communal nature of illness, and of the importance of the family in health care among Saudis, were also common. One participant expressed a common nurse-centric viewpoint that was at odds with this Saudi norm and with the perspective of Saudi nurses: The visitors: They drive me crazy! They seem not to realize that nurses have a job to do and that me doing my job is possibly more important than getting coffee for their family member. (Participant 17)
Cultural Knowledge. The notion of cultural knowledge embraces the process of learning about the worldviews, languages, and the other components of cultures that are different from one’s own but which are essential for cultural competence (Campinha-Bacote, 1999; Suh, 2004). Campinha-Bacote (1999) suggests that the health care providers seek to understand three specific aspects of health and illness
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
19
Almutairi et al. Table 2. Description of the Demographic Characteristics of Participants. Age Less than 30 years 31 to 35 36 to 40 41 to 45 Over 45 Total Gender Female Male Total Countries of origin Philippines South Africa Malaysia Saudi Arabia Finland England Australia India Lebanon Jordan Total Educational level Diploma or a graduate certificate in nursing Bachelor degree Total
Frequency 5 6 4 4 5 24
4
% 20.8 25 16.66 16.66 20.8 100 95.8 4.2 100 33.33 16.66 12.5 8.33 8.33 4.16 4.16 4.16 4.16 4.16 100 20.8
18 24
79.2 100
23 1 24 8 4 3 2 2 1 1 1 1 1 24
in the target group: disease incidence and prevalence, healthrelated beliefs and values, and treatment efficacy (Campinha-Bacote, 2002). Despite probing, no participant discussed these aspects of Saudi health care. The participants also demonstrated limited knowledge about the philosophical beliefs underpinning the health and illness norms specific to the Saudi culture. Three of the participants were aware of some practices, such as using of ZamZam water and traditional burning, but emphasized their uncertainties about their use in practice. One participant illustrated the clinical safety risks she perceived were posed by Saudi gender beliefs, although she did not articulate why such beliefs existed: There’s quite few . . . male Saudis who don’t want a female nurse to be anywhere near their private parts . . . and sometimes we need to be near the private parts so, sometimes we just have to improvise so if you need to take the tube out of that area, you just have to sort of go in blind. (Participant 1)
The participants’ knowledge of Saudi culture was acquired through three avenues: predeparture preparation, hospitalbased information, and other information sources such as Saudi nurse interns, patients, and their families. With respect
to predeparture preparation, the information provided by recruiting agents concerning the cultural requirements of the host country was, for the majority of participants, limited or nonexistent. The nurses’ experiences were inconsistent, with variations in their impressions and perspectives regarding the adequacy of the general nursing orientation and the mandatory postorientation workshop. For Participant 2 orientation primarily focused on an introduction to the hospital, which she deemed essential but with what appeared to be limited coverage of cultural requirements. The sentiments were echoed by the majority of participants. Cultural Skill. Within the cultural competence framework, cultural skill is posited as the ability of health care providers to obtain patient health histories by performing culturally based physical assessments. Cultural skill is underpinned by cultural knowledge, that is, the nurses’ comprehension of the physical variations relevant to ethnic groups, such as differences in body structure, skin color, and other physical characteristics; but it takes this knowledge further by applying it in a way that conforms to cultural norms (Campinha-Bacote, 2002). The participants’ experiences indicated that some of them used critical thinking skills and tried to apply their cultural knowledge when they examined their patients. They reported, for example, that some Saudi nationals, especially the elderly, tend to withhold information about their pain due to cultural norms around pain. One of the participants described how knowledge of such aspects of the patient’s culture enables better care: You will know that the patients could have a pain and the patients may be saying “la la la ma feeh alam” [no, there is no pain]. And you see that because of his culture that he does not want to show that he is in pain. So for you just to say even if it is ok, I can give you something for pain even if it is shwayah [a little]. (Participant 23)
Several participants indicated the importance for patients of praying before any nursing task is performed for them, which is greatly appreciated by Saudi patients. Cultural Encounter. Cultural encounter is a process that encourages nurses to interact with those from other cultural backgrounds (Campinha-Bacote, 1999). Within the framework, this concept implies that “culture” is not a blanket term that can be applied without discrimination. There will always be intra-group variations between individuals that must be accounted for, as the individuals one interacts with are not necessarily representative of the group as a whole. Hence, the framework proposes that direct interaction with patients is vital, so that nurses can refine or modify their beliefs about the other’s culture and help nurses truly prevent stereotyping (Campinha-Bacote, 2002).
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
20
Journal of Transcultural Nursing 26(1)
The interview data indicated that when language difficulties are present, the ability of both parties to interact effectively is significantly diminished. The participants’ ability to converse in Arabic was either limited or absent, which they noted often adversely influenced the quality of communication and the resultant quality of care they could provide. For example, one participant explained, There was an incident where the patient wanted the towel, because towel, I am sorry, in our language (Futa) it means bad word like prostitute, and this baba said “ateeni Futa” (which means towel) . . . [the nurse] was almost fighting but she never fight back to that old man, she was crying she came to me and told me, I said no my dear, he is asking only a tissue paper and a towel. (Participant 3)
Many participants discussed how they tried to communicate with their patients by using sign language or other common body gestures. Like some words, gestures that are acceptable in one culture do not necessarily mean the same thing in another, and the participants here run the risk of giving offense. The following statement is a typical example of culturally unacceptable actions committed by many of the participants at one time or another: Ok for us, if there is somebody you care for, you say “how are you?” you touch the hand, “how are you mama or baba? Are you ok today?” Then they will respond, I’m fine. But if you tell somebody that if I’m talking to baba I must touch him, it’s not allowed. . . . I usually talk to my patient and say how are you? And touching them, showing that you are caring for them, you are a lovely person. (Participant 19)
The hospital recognized the risks associated with impaired linguistic communication and provided interpreter services to counteract these. However, access to this service was restricted not only in terms of time but also in relation to gender. Participants also spoke of eliciting the assistance of the colleagues, patient’s family and relatives, students, or another patient. This meant the service could not immediately respond to the needs of its clients or did not meet the nurses’ needs as the nurses reported that the unit assistants lacked interpreting skills. Cultural Desire. Cultural desire is the motivation of health care professionals to interact with people from different cultural backgrounds and to become culturally competent. Cultural desire overrides duty (“having to”) with motivation (“wanting to”; Campinha-Bacote, 1999). Many participants expressed a desire to learn the patient’s culture and language and were committed to providing culturally appropriate and safe care that met the needs of their Saudi client base. One way that some of them achieved this was to discard notions of overarching culture and tailor their care to the obvious needs of the individual.
Some participants were less committed to learning about their patients’ culture and did not actively seek to improve their cultural competence, expressing a preference for passive learning in this respect: Really I didn’t have the chance to read books or any other resources . . . much better if the hospital can provide like a workshop . . . to know about the culture of this country. (Participant 14)
Inductive Analysis Campinha-Bacote’s model of cultural competence did not account for all of the nurses’ experiences in this multicultural context. As a result, the data set that did not fit within the framework was analyzed inductively; this approach yielded important themes that more fully explained the nurses’ experiences in this multicultural environment. Culture Shock. Many of the participants spontaneously discussed their initial disturbing reactions to the Saudi culture, many of which were never resolved despite ongoing exposure. They reported an overwhelming and challenging experience, which was characterized by anxiety, insecurity, and an inability to conform to the Saudi cultural expectations that were so different from their own. Another participant described her shock in terms of the dissonance that was engendered by rules different to her own. She tried to follow these rules, yet the locals often flouted them for reasons she could not fathom: I had a cultural shock, because the visitors who come here they acting like they are in their homes, not in the hospital. They do not respect the rules of the hospital, I try to tell them these are the rules of the hospital, I am not the one who made these rules. Sometimes they complain because we told them the visiting time hours. (Participant 3)
For Participant 5, unfamiliarity with the local dress code for men and women in Saudi Arabia engendered a feeling of alienation, frustration, and depression. The participants also spoke of the many challenges they encountered in working with people from diverse cultures, each with their own patterns of behavior, personalities, value systems, and beliefs. The participants also revealed a high level of uncertainty regarding what practices were acceptable during care delivery within the Saudi culture, which often inhibited their nursing care or resulted in feelings that their care was not clinically safe. Disempowerment. Perceptions of a lack of control over their professional situations were a dominant theme in these data. For example, a number of participants reported that patients complained about them directly to the hospital management without raising the matter with the nurse first. While this
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
21
Almutairi et al. “pulling of rank” could have been a result of language barriers or cultural norms, it did result in profound feelings of inequity, discouragement, intimidation in this context, and perceptions of lack of support from the hospital management. One participant stated, I find it difficult working in an environment where the patients can go straight to the top. So no matter what you try, to put things into place to placate the patient, or make things easier for the patient, you then get a message from the top, the top saying you’re not doing this. . . . I find that a little bit discouraging. (Participant 2)
The participants were also acutely aware that the disempowerment caused by language barriers diminished patient safety. In this respect, one participant described the frequent absences of the unit assistants assigned as the interpreters, whose nonappearances seemed to be tolerated within the organization with no repercussions for the assistant but considerable inconvenience and distress for the non-Arabic speaking nurses: Work ethic is a very different thing [here]. Like our unit assistants never show up to work on time and things like that. . . . I mean at home you just get fired for that, you do it 2 or 3 times and you get fired, but here they do it all the time and nobody seems to care, and they wander off and go for a cigarette. (Participant 11)
Another participant described her frustration at an incident that exposed a group of her patients to harm, a result of what she perceived as nepotism. She could not move a highlyinfectious patient requiring isolation to a single room, because another (better connected) patient wanted that room. Participant 5 also evidenced disempowerment when she discussed the lack of social respect for nurses she experienced from Saudi nationals. Lack of respect in this complex environment, however, is not confined to the locals. The following quote from a Filipino nurse illustrates the social differences between health professionals of different nationalities in this environment, which resulted in feelings of intimidation and vulnerability: It’s not only from Saudi people . . . some nationalities also look down on the Filipinos as if they are stupid, less knowledge like that. Maybe because they thought that we Filipinos are working just for money . . . it’s unfair. (Participant 9)
Discussion and Conclusions The framework used in this study proposes that a multicultural nursing workforce can become culturally competent through the development of the five interdependent concepts of cultural awareness, knowledge, skill, encounter, and desire. This is the first time that this framework of cultural competence has tested the culturally diverse setting in Saudi
Arabia. In the course of the study the framework revealed both strengths and limitations. Analyzing the data deductively according to the constructs within the model revealed that the participants varied in their attainment of cultural competence. It also indicated that the barriers to the competence process were ethnocentric viewpoints, inadequate educational preparation, limited Arabic language skills, and the need to rely on a third party to convey health care messages. Enhancers of competence were the recognition of a common humanity, an appreciation of the value of another’s culture, and a desire to learn more about it. In this context, ethnocentrism could explain the attitude many of the participants consciously or unconsciously exhibited toward the Saudi people in their care, which resulted in cultural conflict. The term “ethnocentrism” refers to the way that people interpret the world around them and attach meaning to things according to their own cultural conditioning (Anyanwu, 2009; Axelrod & Hammond, 2003; DayerBerenson, 2011). Because they cannot or will not conceive of any other way of thinking or behaving, ethnocentric people assume that their own cultural values and belief systems are the yardstick for anything new that they encounter (Bailey & Peoples, 2010; Kendall, 2010). Many of the participants in this study appeared to unconsciously use their own cultural lens to evaluate and judge the behavior and culture of the Saudi people, without recognizing that their own culturally specific lens was just one way of approaching social life. This lack of awareness clearly was one way that frustration and discomfort were generated in this context. The cultural competence model that guided this study posits that cultural skill is the ability of health care providers to gather and process culturally relevant data from—and about—a patient (Campinha-Bacote, 2002). The results of this study showed the limitations of this conception of cultural skill, which confines such skill to the discrete tasks that occur during interactions between the nurse and the patient. These findings emphasize how cultural skill within a multicultural context is also related to the nurse’s ability to integrate and apply cultural knowledge that is not confined to interactions with patients; it is also dependent on skilful interactions with other health care professionals to ensure safe and effective care. Future versions of the framework might therefore acknowledge the interactions that occur in the context as a whole, rather than focusing exclusively on nurse–patient interactions. Campinha-Bacote’s framework also seems to assume that the process of attaining cultural competence is a result of the agency of the person who is new to the culture. The interview data indicated that agency on the part of the nurses did not account for everything that occurred in this study setting. Their cultural competence process was indeed active in many respects, but they were also subject to forces beyond their control. The framework does not account, for example, for the actual impact on the participants of their naive
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
22
Journal of Transcultural Nursing 26(1)
immersion in a new culture, which engendered feelings of shock and disempowerment; and these feelings were identified as having an impact on the cultural competence process as well as on the patient’s and nurse’s safety. According to Brown and Holloway (2008), culture shock is the “anxiety that results from losing the familiar signs and symbols of social intercourse, and their substitution by other cues that are strange” (p. 34). Language barriers play a pivotal role in generating culture shock (McLeod, 2008); in this study it was a barrier that was intensified because the common professional language used in the hospital (English) was not the native language of many of the participants. The literature highlights a number of negative outcomes of culture shock. Psychological problems such as anxiety, discomfort, feelings of helplessness, frustration, and depression are frequently reported (Brown & Holloway, 2008; Lin, 2006; McLeod, 2008). These psychological effects can culminate in physical outcomes such as illness and fatigue (Varner & Beamer, 2010). Cognitive effects, especially confusion during cultural interactions, are also common. For example, in this study, the participants revealed a high level of uncertainty regarding what practices were acceptable during care delivery within the Saudi culture, which often inhibited their nursing care or resulted in feelings that their care was not clinically safe. Such uncertainty resulted in the second new theme: disempowerment. The notion of disempowerment has been extensively explored in disciplines such as psychology, education, anthropology, and politics (Isokääntä & Johansson, 2006; Lincoln, Travers, Ackers, & Wilkinson, 2002). The literature generally agrees that disempowerment is a result of the discrimination, inequality, and negative attitudes (French & Swain, 2008; Goldberg & Solomos, 2002) as well as the language and cultural differences (Deegan & Simkin, 2010) that so many participants described during the interviews. The findings articulate common features associated with disempowerment—such as lack of self-efficacy, and limited feelings of control, confidence, and autonomy (Eckermann, Dowd, Chong, Nixon, & Gray, 2010; Hardina, Middleton, Montana, & Simpson, 2007). Consistent with the literature, disempowerment means the participants were often anxious and stressed, unable to challenge safety concerns, and felt intimidated and unsupported by the management as well as the representatives of the local culture (Kai et al., 2007).
Implications for Practice The findings clearly suggest that the cultural competence of the nursing workforce in this setting warrants enhancement and that this might best be achieved through continuous professional education and training programs at an individual level. Cultural competence might also be embodied or rolemodeled at the organizational level. The findings further emphasize that in this Saudi context, cultural competence requires a combination of individual desire and effort to
learn coupled with adequate organizational support and resources. It is recommended therefore that organizations that have a multicultural workforce in Saudi Arabia adopt the cultural competence model to guide education, induction, and continuing development of their workforce. The concepts embedded in this cultural competence model, in addition to consideration of the new themes elicited in this study, provide an ideal structure for educational programs. In addition, such an educational program should use and employ the best adult learning methods including case studies to ensure participation, comprehension, and understanding. The findings of this study also emphasize the importance of predeparture cultural preparation for nurses to mitigate the effect of cultural dissonance and so eliminate, or reduce, the potential for culture shock and disempowerment. Future iterations of the framework might usefully account for these themes and suggest how organizational support might be implemented to help nurses overcome the dissonance and disempowerment they often encounter. Acknowledgments This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN. The authors thank the National Guard Health Affairs, Chief Executive Officer, His Excellency, Dr. Bandar Al Knawy; Executive Director of King Abdullah International Medical Research Centre; the Associate Director of Nursing Services, Ms. Joan Murray; and Dr. Mustafa Bodrick, Director of Nursing Education; and all the Directors of Clinical Nursing for their support and facilitation to conduct this study. Our special thanks are extended to the nursing staff who participated in this study.
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.
References Adahl, S. (2009). Varying cultures in modern crisis management. Helsinki, Finland: Edita Prima Oy. Aldossary, A., While, A., & Barriball, L. (2008). Health care and nursing in Saudi Arabia. International Nursing Review, 55, 125-128. Almalki, M., FitzGerald, G., & Clark, M. (2011). The nursing profession in Saudi Arabia: An overview. International Nursing Review, 58, 304-311. Almutairi, A. F., Gardner, G., & McCarthy, A. (2013). Perceptions of clinical safety climate of the multicultural nursing workforce in Saudi Arabia: A cross-sectional survey. Collegian, 20, 187-194. Retrieved from http://dx.doi.org/10.1016/j. colegn.2012.08.002 Anyanwu, C. N. (2009). Creative strategies for conflict management & community building. Bloomington, IN: AuthorHouse.
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
23
Almutairi et al. Axelrod, R., & Hammond, R. A. (2003, April). The evolution of ethnocentric behavior. Paper presented at the Midwest Political Science Convention, Chicago, IL. Bailey, G., & Peoples, J. (2010). Essentials of cultural anthropology. Belmont, CA: Cengage Learning. Boi, S. (2000). Nurses’ experiences in caring for patients from different cultural backgrounds. Nursing Times Research, 5, 382389. Brathwaite, A. E. C. (2005). Evaluation of a cultural competence course. Journal of Transcultural Nursing, 16, 361-369. Brathwaite, A. C., & Majumdar, B. (2006). Evaluation of a cultural competence educational programme. Journal of Advanced Nursing, 53, 470-479. Brown, L., & Holloway, I. (2008). The initial stage of the international sojourn: Excitement or culture shock? British Journal of Guidance & Counselling, 36, 33-49. Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38, 203-207. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13, 181-184. Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of health care services: A culturally competent model of care. Cincinnati, OH: Transcultural C.A.R.E. Cioffi, J. (2005). Nurses’ experiences of caring for culturally diverse patients in an acute care setting. Contemporary Nurse, 20, 78-86. Cowan, D. T., & Norman, I. (2006). Cultural competence in nursing: New meanings. Journal of Transcultural Nursing, 17, 82-88. Dayer-Berenson, L. (2011). Cultural competencies for nurses: Impact on health and illness. Sudbury, MA: Jones & Bartlett Learning. Deegan, J., & Simkin, K. (2010). Expert to novice: Experiences of professional adaptation reported by non-English speaking nurses in Australia. Australian Journal of Advanced Nursing, 27(3), 31-37. Dowell, A., Crampton, P., & Parkin, C. (2001). The first sunrise: An experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Medical Education, 53, 242-249. Eckermann, A.-K., Dowd, T., Chong, E., Nixon, L., & Gray, R. (2010). Binan Goonj: Bridging cultures in aboriginal health. Chatswood, New South Wales, Australia: Elsevier. French, S., & Swain, J. (2008). Understanding disability: A guide for health professionals. Philadelphia, PA: Elsevier. Goldberg, D. T., & Solomos, J. (2002). A companion to racial and ethnic studies. Malden, MA: Wiley-Blackwell. Halligan, P. P. (2006). Caring for patients of Islamic denomination: Critical care nurses’ experiences in Saudi Arabia. Journal of Clinical Nursing, 15, 1565-1573.
Hardina, D., Middleton, J., Montana, S., & Simpson, R. (2007). An empowering approach to managing social service organizations. New York, NY: Springer. Isokääntä, V., & Johansson, A. (2006). Empowermental nursing: Experiences of empowerment and disempowerment made by patients in need of long term nursing. Gothenburg, Sweden: Göteborg University, Institute of Health and Care Sciences. Jirwe, M., Gerrish, K., & Emami, A. (2006). The theoretical framework of cultural competence. Journal of Multicultural Nursing and Health, 12(3), 6-16. Kai, J., Beavan, J., Faull, C., Dodson, L., Gill, P., & Beighton, A. (2007). Professional uncertainty and disempowerment responding to ethnic diversity in health care: A qualitative study. PLoS Medicine, 4(11), e323. Kendall, D. (2010). Sociology in our times: The essentials. Belmont, CA: Wadsworth Cengage Learning. Leininger, M. M. (2002). Culture care theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing, 13, 189-192. Lin, C. (2006). Culture shock and social support: An investigation of a Chinese student organization on a US campus. Journal of Intercultural Communication Research, 35, 117-137. Lincoln, N. D., Travers, C., Ackers, P., & Wilkinson, A. (2002). The meaning of empowerment: The interdisciplinary etymology of a new management concept. International Journal of Management Reviews, 4, 271-290. Mahabeer, S. A. (2009). A descriptive study of the cultural competence of hemodialysis nurses. Canadian Association of Nephrology Nurses and Technologists Journal, 19(4), 30-33. McLeod, K. D. (2008). A qualitative examination of culture shock and the influential factors affecting newly-arrived Korean students at Texas A&M university (Published dissertation). Texas A&M University, Texas. Ministry of Health. (2009). Health statistical year book 2009. Riyadh, Saudi Arabia: Author. Smith, L. (2001). Evaluation of an educational intervention to increase cultural competence among registered nurses. Journal of Cultural Diversity, 8(2), 50-63. Suh, E. E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15, 93-102. Sullivan, L. E. (2009). The Sage glossary of the social and behavioral sciences. Thousand Oaks, CA: Sage. Varner, I., & Beamer, L. (2010). Intercultural communication in the global workplace: New York, NY: McGraw-Hill. Yin, R. K. (2009). Case study research: Design and methods (4th ed.). Beverly Hills, CA: Sage.
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
research-article2014
TCNXXX10.1177/1043659614523992Journal of Transcultural NursingAlmutairi et al.
Research Department
Understanding Cultural Competence in a Multicultural Nursing Workforce: Registered Nurses’ Experience in Saudi Arabia
Journal of Transcultural Nursing 2015, Vol. 26(1) 16–23 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614523992 tcn.sagepub.com
Adel F. Almutairi, Doctor of Healh Science, MSN, RN1,2,3, Alexandra McCarthy, PhD, RN1, and Glenn E. Gardner, PhD, RN, FACN1
Abstract Purpose: In Saudi Arabia, the health system is mainly staffed by expatriate nurses from different cultural and linguistic backgrounds. Given the potential risks this situation poses for patient care, it is important to understand how cultural diversity can be effectively managed in this multicultural environment. The purpose of this study was to explore notions of cultural competence with non-Saudi Arabian nurses working in a major hospital in Saudi Arabia. Design: Face-to-face, audio-recorded, semistructured interviews were conducted with 24 non-Saudi Arabian nurses. Deductive data collection and analysis were undertaken drawing on Campinha-Bacote’s cultural competence model. The data that could not be explained by this model were coded and analyzed inductively. Findings: Nurses within this culturally diverse environment struggled with the notion of cultural competence in terms of each other’s cultural expectations and those of the dominant Saudi culture. Discussion: The study also addressed the limitations of Campinha-Bacote’s model, which did not account for all of the nurses’ experiences. Subsequent inductive analysis yielded important themes that more fully explained the nurses’ experiences in this environment. Implications for Practice: The findings can inform policy, professional education, and practice in the multicultural Saudi setting. Keywords multicultural nursing workforce, cultural competence, qualitative analysis
Background The rapid development of the health care system in Saudi Arabia (Aldossary, While, & Barriball, 2008), coupled with chronic shortage of registered nurses and the increased mobility of the nursing workforce (Almalki, FitzGerald, & Clark, 2011), means that in Saudi Arabia the health care system is mainly staffed by non-Saudi health professionals who have been recruited from all over the world. For example, there are 110,858 nurses currently employed in Saudi hospitals. Of these, 67.7% are expatriates, with the remaining 32.3% being Saudi nationals (Ministry of Health, 2009). Expatriate nurses working in Saudi Arabia bring different cultural values, beliefs, customs, behaviors, and attitudes with them that can greatly differ from those of their patients, their Saudi Arabian employers and colleagues, and their nonSaudi colleagues. Many are employed, for example, without the Arabic language skills that might facilitate nurse–patient and nurse–employer interactions. Differences in interpretation can also occur because English is the standard medium of professional communication in this context. It is a second language for many of these nurses, who are not necessarily
native English speakers (Aldossary et al., 2008). Cultural norms can also be easily misunderstood in such a multicultural environment (Halligan, 2006). Hence, cultural and language difficulties both between patients and nurses and among the health care team have the potential to adversely affect nurses’ abilities to practice competently and safely (Boi, 2000; Cioffi, 2005). Given the potential risks this situation poses for patient care, it is important to understand how cultural diversity can be effectively managed in this multicultural environment. 1
Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia 2 School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada 3 King Abdullah International Medical Research Centre, and King Saud bin Abdulaziz University for health Sciences, Riyadh, Saudi Arabia Corresponding Author: Adel F. Almutairi, University of British Columbia, School of Nursing, T201-2211 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5. Email: [email protected] [email protected]
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
17
Almutairi et al. A number of theoretical frameworks to guide research and practice have been developed in response to cultural diversity in health environments. These frameworks are primarily Western in origin (Jirwe, Gerrish, & Emami, 2006). They have been used effectively in Western settings to develop and evaluate the cultural competence of health professionals (Brathwaite & Majumdar, 2006; Mahabeer, 2009) and students dealing with indigenous populations or patients from other cultures (Brathwaite, 2005; Dowell, Crampton, & Parkin, 2001; Smith, 2001). However, these frameworks tend to reflect the unique sociocultural, historical, and political dimensions of those generally Western settings (Jirwe et al., 2006). In addition, the notion of cultural competence has not been extensively examined in a multicultural nursing workforce where nurses are not only culturally diverse from the patients they care for but also culturally different from each other. Cultural competence aims to improve the quality of health care by reducing the cultural disparities that commonly arise when different cultures meet in the health care context. The precise definition of cultural competence that informed this study is that it is an “ongoing process in which the [individual] health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community)” (Campinha-Bacote, 2002, p. 181). Based on this view, Campinha-Bacote (2002) considers cultural competence as a lifelong learning endeavor rather than an endpoint or static outcome. CampinhaBacote’s (1999, 2002) model proposes that cultural competence is developed through an iterative and cumulative process of cultural awareness, knowledge, skill, encounter, and desire. These attributes are consistently identified in the literature as the main requirements for cultural competence (Campinha-Bacote, 2003; Cowan & Norman, 2006; Leininger, 2002; Suh, 2004); hence Campinha-Bacote’s model (2002) of cultural competence has been widely used in the literature, particularly in nursing research. It was used to guide data collection and analysis in this study because, despite its Western origin, it enables an investigation that is both systematic and comprehensive. This article reports the findings from the qualitative component of a larger mixed-methods study that investigated the influence of cultural diversity of the nursing workforce on the quality and safety of patient care in a Saudi tertiary hospital. The survey component consisted of the Safety Climate Survey, the results of which are reported in a separate paper (Almutairi, Gardner, & McCarthy, 2012). In summary, the results indicated that participants (n = 319) perceived the clinical safety climate as low, particularly non-Arabic participants. To illuminate why the challenges identified by the respondents arose, we collected qualitative data. In this article we present and analyze the qualitative data and in so doing critique the fit of Campinha-Bacote’s cultural competence framework to the Saudi Arabian setting.
Method Design A single-embedded case study design (Yin, 2009) enabled an in-depth exploration of the multicultural nursing workforce in a tertiary Saudi Arabian hospital.
Sample The nursing workforce in this setting consists largely of foreign nurses who are recruited from North America, South Africa, Europe, Asia, Australia, New Zealand, and the Middle East. A purposive sampling strategy was used to recruit participants to represent a variety of units in the hospital including the medical, surgical, pediatric, and gynecological wards. Eligibility criteria comprised registered expatriate or Saudi nurses who had worked in the hospital for a minimum of 12 months. To recruit participants, nurse unit managers identified nurses who met the selection criteria. The researcher then asked the nurses if they were willing to participate in the study. Twenty four nurses participated in the in-depth interviews.
Setting This study was conducted within an 800-bed teaching hospital that delivers primary, secondary, and tertiary health care services for Saudi Arabian National Guard employees and their families.
Instruments Table 1 outlines the interview stem questions and their correspondence to Campinha-Bacote’s framework of cultural competence.
Data Collection Procedures Individual semistructured interviews were undertaken at a time and place convenient to the participants. Audio-recorded interviews, undertaken in English, ranged from 30 to 60 minutes and were immediately transcribed by the researcher. All participants were assigned a pseudonym on transcription and are referred to by that pseudonym in this article.
Data Analysis Data were initially coded and analyzed deductively according to the five constructs underpinning the study: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. Data that did not fit into these predetermined categories were inductively analyzed. This inductive process was useful to help understand the phenomena apparent in the data that were not readily explained by
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
18
Journal of Transcultural Nursing 26(1)
Table 1. Constructs of Cultural Competence Model and Corresponding Interview Question. Constructs Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounter Cultural Desire
Initial interview questions Can you please tell me about the different cultural groups in the hospital? What is your experience of cultural differences within the Saudi population? How is it like to take care of patients who are different from your background? Can you tell me what you know about Saudi culture? Have you had a cultural training? Can you talk about it please? Can you tell me about the hospital orientation? Can you tell me whether all the patients are Saudi nationals or you have nursed patients from other cultures? In the situation when you do not understand the patient, what do you do? How do you handle that? Do you think the patients are comfortable with nursing care? Why? How important to meet the patients’ needs? Have you been able to access any resources about Saudi or other cultures?
the underpinning framework but were clearly valid in this particular context. This process has helped reformulate Campinha-Bacote’s model to a way that is appropriate in this non-Western setting.
Ethical Considerations Ethical approval to undertake the study was obtained from the Human Subject’s Committee of the Medical Center where the study was conducted and the Human Research Ethics Committee of the Principal Investigator’s university.
Results Demographics Most of the 24 participants were female and ranging in age from 26 years to 52 years. Their years of experience working in Saudi Arabia varied from 1 year to 25 years, with the majority having between 1 and 10 years’ experience. Table 2 provides a detailed outline of the participants’ demographic characteristics.
Deductive Analysis Cultural Awareness. This construct proposes that a person’s culturally mediated values, beliefs, and practices shape the way that they interpret the world around them and dictate the
way they relate to others (Adahl, 2009). In many situations, because their culture is the norm for them, it does not occur to the protagonist that there is another way of looking at the world or other points of view, although different, which are equally valid (Sullivan, 2009). Campinha-Bacote (1999), who refers to this tendency as cultural imposition, states that cultural awareness includes understanding one’s own cultural norms, behaviors, and biases and what these bring to a given cultural interaction. Only two participants demonstrated overt self-awareness in relation to their own cultural norms and what these brought to their interactions with Saudi patients. One participant stated, It’s quite challenging really, because you have to assess your own personality and how will you cope with this new environment. (Participant 4)
The ability to recognize cultural differences was not universal in this study, and it is clear from the interviews that some participants did impose their cultural norms on their patients with detrimental effects. One of the participants shared her thoughts about her perception of cultural sameness in her Saudi patients, which was echoed by many others in this study: I find them the same because they’re all Saudis, they’re all Muslims, so they practice the same most of the time. (Participant 4)
A number of participants exhibited their unconscious prejudices toward the practices of Saudi people, using their own cultural background as the yardstick for all behavior. One participant for example, applied a rigid Anglo perception of social etiquette as the standard for shopping and other street behavior, failing to comprehend the social roles these activities play in Saudi life and how time can have a different meaning to the one predicated by the Western world. Misunderstandings of the communal nature of illness, and of the importance of the family in health care among Saudis, were also common. One participant expressed a common nurse-centric viewpoint that was at odds with this Saudi norm and with the perspective of Saudi nurses: The visitors: They drive me crazy! They seem not to realize that nurses have a job to do and that me doing my job is possibly more important than getting coffee for their family member. (Participant 17)
Cultural Knowledge. The notion of cultural knowledge embraces the process of learning about the worldviews, languages, and the other components of cultures that are different from one’s own but which are essential for cultural competence (Campinha-Bacote, 1999; Suh, 2004). Campinha-Bacote (1999) suggests that the health care providers seek to understand three specific aspects of health and illness
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
19
Almutairi et al. Table 2. Description of the Demographic Characteristics of Participants. Age Less than 30 years 31 to 35 36 to 40 41 to 45 Over 45 Total Gender Female Male Total Countries of origin Philippines South Africa Malaysia Saudi Arabia Finland England Australia India Lebanon Jordan Total Educational level Diploma or a graduate certificate in nursing Bachelor degree Total
Frequency 5 6 4 4 5 24
4
% 20.8 25 16.66 16.66 20.8 100 95.8 4.2 100 33.33 16.66 12.5 8.33 8.33 4.16 4.16 4.16 4.16 4.16 100 20.8
18 24
79.2 100
23 1 24 8 4 3 2 2 1 1 1 1 1 24
in the target group: disease incidence and prevalence, healthrelated beliefs and values, and treatment efficacy (Campinha-Bacote, 2002). Despite probing, no participant discussed these aspects of Saudi health care. The participants also demonstrated limited knowledge about the philosophical beliefs underpinning the health and illness norms specific to the Saudi culture. Three of the participants were aware of some practices, such as using of ZamZam water and traditional burning, but emphasized their uncertainties about their use in practice. One participant illustrated the clinical safety risks she perceived were posed by Saudi gender beliefs, although she did not articulate why such beliefs existed: There’s quite few . . . male Saudis who don’t want a female nurse to be anywhere near their private parts . . . and sometimes we need to be near the private parts so, sometimes we just have to improvise so if you need to take the tube out of that area, you just have to sort of go in blind. (Participant 1)
The participants’ knowledge of Saudi culture was acquired through three avenues: predeparture preparation, hospitalbased information, and other information sources such as Saudi nurse interns, patients, and their families. With respect
to predeparture preparation, the information provided by recruiting agents concerning the cultural requirements of the host country was, for the majority of participants, limited or nonexistent. The nurses’ experiences were inconsistent, with variations in their impressions and perspectives regarding the adequacy of the general nursing orientation and the mandatory postorientation workshop. For Participant 2 orientation primarily focused on an introduction to the hospital, which she deemed essential but with what appeared to be limited coverage of cultural requirements. The sentiments were echoed by the majority of participants. Cultural Skill. Within the cultural competence framework, cultural skill is posited as the ability of health care providers to obtain patient health histories by performing culturally based physical assessments. Cultural skill is underpinned by cultural knowledge, that is, the nurses’ comprehension of the physical variations relevant to ethnic groups, such as differences in body structure, skin color, and other physical characteristics; but it takes this knowledge further by applying it in a way that conforms to cultural norms (Campinha-Bacote, 2002). The participants’ experiences indicated that some of them used critical thinking skills and tried to apply their cultural knowledge when they examined their patients. They reported, for example, that some Saudi nationals, especially the elderly, tend to withhold information about their pain due to cultural norms around pain. One of the participants described how knowledge of such aspects of the patient’s culture enables better care: You will know that the patients could have a pain and the patients may be saying “la la la ma feeh alam” [no, there is no pain]. And you see that because of his culture that he does not want to show that he is in pain. So for you just to say even if it is ok, I can give you something for pain even if it is shwayah [a little]. (Participant 23)
Several participants indicated the importance for patients of praying before any nursing task is performed for them, which is greatly appreciated by Saudi patients. Cultural Encounter. Cultural encounter is a process that encourages nurses to interact with those from other cultural backgrounds (Campinha-Bacote, 1999). Within the framework, this concept implies that “culture” is not a blanket term that can be applied without discrimination. There will always be intra-group variations between individuals that must be accounted for, as the individuals one interacts with are not necessarily representative of the group as a whole. Hence, the framework proposes that direct interaction with patients is vital, so that nurses can refine or modify their beliefs about the other’s culture and help nurses truly prevent stereotyping (Campinha-Bacote, 2002).
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
20
Journal of Transcultural Nursing 26(1)
The interview data indicated that when language difficulties are present, the ability of both parties to interact effectively is significantly diminished. The participants’ ability to converse in Arabic was either limited or absent, which they noted often adversely influenced the quality of communication and the resultant quality of care they could provide. For example, one participant explained, There was an incident where the patient wanted the towel, because towel, I am sorry, in our language (Futa) it means bad word like prostitute, and this baba said “ateeni Futa” (which means towel) . . . [the nurse] was almost fighting but she never fight back to that old man, she was crying she came to me and told me, I said no my dear, he is asking only a tissue paper and a towel. (Participant 3)
Many participants discussed how they tried to communicate with their patients by using sign language or other common body gestures. Like some words, gestures that are acceptable in one culture do not necessarily mean the same thing in another, and the participants here run the risk of giving offense. The following statement is a typical example of culturally unacceptable actions committed by many of the participants at one time or another: Ok for us, if there is somebody you care for, you say “how are you?” you touch the hand, “how are you mama or baba? Are you ok today?” Then they will respond, I’m fine. But if you tell somebody that if I’m talking to baba I must touch him, it’s not allowed. . . . I usually talk to my patient and say how are you? And touching them, showing that you are caring for them, you are a lovely person. (Participant 19)
The hospital recognized the risks associated with impaired linguistic communication and provided interpreter services to counteract these. However, access to this service was restricted not only in terms of time but also in relation to gender. Participants also spoke of eliciting the assistance of the colleagues, patient’s family and relatives, students, or another patient. This meant the service could not immediately respond to the needs of its clients or did not meet the nurses’ needs as the nurses reported that the unit assistants lacked interpreting skills. Cultural Desire. Cultural desire is the motivation of health care professionals to interact with people from different cultural backgrounds and to become culturally competent. Cultural desire overrides duty (“having to”) with motivation (“wanting to”; Campinha-Bacote, 1999). Many participants expressed a desire to learn the patient’s culture and language and were committed to providing culturally appropriate and safe care that met the needs of their Saudi client base. One way that some of them achieved this was to discard notions of overarching culture and tailor their care to the obvious needs of the individual.
Some participants were less committed to learning about their patients’ culture and did not actively seek to improve their cultural competence, expressing a preference for passive learning in this respect: Really I didn’t have the chance to read books or any other resources . . . much better if the hospital can provide like a workshop . . . to know about the culture of this country. (Participant 14)
Inductive Analysis Campinha-Bacote’s model of cultural competence did not account for all of the nurses’ experiences in this multicultural context. As a result, the data set that did not fit within the framework was analyzed inductively; this approach yielded important themes that more fully explained the nurses’ experiences in this multicultural environment. Culture Shock. Many of the participants spontaneously discussed their initial disturbing reactions to the Saudi culture, many of which were never resolved despite ongoing exposure. They reported an overwhelming and challenging experience, which was characterized by anxiety, insecurity, and an inability to conform to the Saudi cultural expectations that were so different from their own. Another participant described her shock in terms of the dissonance that was engendered by rules different to her own. She tried to follow these rules, yet the locals often flouted them for reasons she could not fathom: I had a cultural shock, because the visitors who come here they acting like they are in their homes, not in the hospital. They do not respect the rules of the hospital, I try to tell them these are the rules of the hospital, I am not the one who made these rules. Sometimes they complain because we told them the visiting time hours. (Participant 3)
For Participant 5, unfamiliarity with the local dress code for men and women in Saudi Arabia engendered a feeling of alienation, frustration, and depression. The participants also spoke of the many challenges they encountered in working with people from diverse cultures, each with their own patterns of behavior, personalities, value systems, and beliefs. The participants also revealed a high level of uncertainty regarding what practices were acceptable during care delivery within the Saudi culture, which often inhibited their nursing care or resulted in feelings that their care was not clinically safe. Disempowerment. Perceptions of a lack of control over their professional situations were a dominant theme in these data. For example, a number of participants reported that patients complained about them directly to the hospital management without raising the matter with the nurse first. While this
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
21
Almutairi et al. “pulling of rank” could have been a result of language barriers or cultural norms, it did result in profound feelings of inequity, discouragement, intimidation in this context, and perceptions of lack of support from the hospital management. One participant stated, I find it difficult working in an environment where the patients can go straight to the top. So no matter what you try, to put things into place to placate the patient, or make things easier for the patient, you then get a message from the top, the top saying you’re not doing this. . . . I find that a little bit discouraging. (Participant 2)
The participants were also acutely aware that the disempowerment caused by language barriers diminished patient safety. In this respect, one participant described the frequent absences of the unit assistants assigned as the interpreters, whose nonappearances seemed to be tolerated within the organization with no repercussions for the assistant but considerable inconvenience and distress for the non-Arabic speaking nurses: Work ethic is a very different thing [here]. Like our unit assistants never show up to work on time and things like that. . . . I mean at home you just get fired for that, you do it 2 or 3 times and you get fired, but here they do it all the time and nobody seems to care, and they wander off and go for a cigarette. (Participant 11)
Another participant described her frustration at an incident that exposed a group of her patients to harm, a result of what she perceived as nepotism. She could not move a highlyinfectious patient requiring isolation to a single room, because another (better connected) patient wanted that room. Participant 5 also evidenced disempowerment when she discussed the lack of social respect for nurses she experienced from Saudi nationals. Lack of respect in this complex environment, however, is not confined to the locals. The following quote from a Filipino nurse illustrates the social differences between health professionals of different nationalities in this environment, which resulted in feelings of intimidation and vulnerability: It’s not only from Saudi people . . . some nationalities also look down on the Filipinos as if they are stupid, less knowledge like that. Maybe because they thought that we Filipinos are working just for money . . . it’s unfair. (Participant 9)
Discussion and Conclusions The framework used in this study proposes that a multicultural nursing workforce can become culturally competent through the development of the five interdependent concepts of cultural awareness, knowledge, skill, encounter, and desire. This is the first time that this framework of cultural competence has tested the culturally diverse setting in Saudi
Arabia. In the course of the study the framework revealed both strengths and limitations. Analyzing the data deductively according to the constructs within the model revealed that the participants varied in their attainment of cultural competence. It also indicated that the barriers to the competence process were ethnocentric viewpoints, inadequate educational preparation, limited Arabic language skills, and the need to rely on a third party to convey health care messages. Enhancers of competence were the recognition of a common humanity, an appreciation of the value of another’s culture, and a desire to learn more about it. In this context, ethnocentrism could explain the attitude many of the participants consciously or unconsciously exhibited toward the Saudi people in their care, which resulted in cultural conflict. The term “ethnocentrism” refers to the way that people interpret the world around them and attach meaning to things according to their own cultural conditioning (Anyanwu, 2009; Axelrod & Hammond, 2003; DayerBerenson, 2011). Because they cannot or will not conceive of any other way of thinking or behaving, ethnocentric people assume that their own cultural values and belief systems are the yardstick for anything new that they encounter (Bailey & Peoples, 2010; Kendall, 2010). Many of the participants in this study appeared to unconsciously use their own cultural lens to evaluate and judge the behavior and culture of the Saudi people, without recognizing that their own culturally specific lens was just one way of approaching social life. This lack of awareness clearly was one way that frustration and discomfort were generated in this context. The cultural competence model that guided this study posits that cultural skill is the ability of health care providers to gather and process culturally relevant data from—and about—a patient (Campinha-Bacote, 2002). The results of this study showed the limitations of this conception of cultural skill, which confines such skill to the discrete tasks that occur during interactions between the nurse and the patient. These findings emphasize how cultural skill within a multicultural context is also related to the nurse’s ability to integrate and apply cultural knowledge that is not confined to interactions with patients; it is also dependent on skilful interactions with other health care professionals to ensure safe and effective care. Future versions of the framework might therefore acknowledge the interactions that occur in the context as a whole, rather than focusing exclusively on nurse–patient interactions. Campinha-Bacote’s framework also seems to assume that the process of attaining cultural competence is a result of the agency of the person who is new to the culture. The interview data indicated that agency on the part of the nurses did not account for everything that occurred in this study setting. Their cultural competence process was indeed active in many respects, but they were also subject to forces beyond their control. The framework does not account, for example, for the actual impact on the participants of their naive
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
22
Journal of Transcultural Nursing 26(1)
immersion in a new culture, which engendered feelings of shock and disempowerment; and these feelings were identified as having an impact on the cultural competence process as well as on the patient’s and nurse’s safety. According to Brown and Holloway (2008), culture shock is the “anxiety that results from losing the familiar signs and symbols of social intercourse, and their substitution by other cues that are strange” (p. 34). Language barriers play a pivotal role in generating culture shock (McLeod, 2008); in this study it was a barrier that was intensified because the common professional language used in the hospital (English) was not the native language of many of the participants. The literature highlights a number of negative outcomes of culture shock. Psychological problems such as anxiety, discomfort, feelings of helplessness, frustration, and depression are frequently reported (Brown & Holloway, 2008; Lin, 2006; McLeod, 2008). These psychological effects can culminate in physical outcomes such as illness and fatigue (Varner & Beamer, 2010). Cognitive effects, especially confusion during cultural interactions, are also common. For example, in this study, the participants revealed a high level of uncertainty regarding what practices were acceptable during care delivery within the Saudi culture, which often inhibited their nursing care or resulted in feelings that their care was not clinically safe. Such uncertainty resulted in the second new theme: disempowerment. The notion of disempowerment has been extensively explored in disciplines such as psychology, education, anthropology, and politics (Isokääntä & Johansson, 2006; Lincoln, Travers, Ackers, & Wilkinson, 2002). The literature generally agrees that disempowerment is a result of the discrimination, inequality, and negative attitudes (French & Swain, 2008; Goldberg & Solomos, 2002) as well as the language and cultural differences (Deegan & Simkin, 2010) that so many participants described during the interviews. The findings articulate common features associated with disempowerment—such as lack of self-efficacy, and limited feelings of control, confidence, and autonomy (Eckermann, Dowd, Chong, Nixon, & Gray, 2010; Hardina, Middleton, Montana, & Simpson, 2007). Consistent with the literature, disempowerment means the participants were often anxious and stressed, unable to challenge safety concerns, and felt intimidated and unsupported by the management as well as the representatives of the local culture (Kai et al., 2007).
Implications for Practice The findings clearly suggest that the cultural competence of the nursing workforce in this setting warrants enhancement and that this might best be achieved through continuous professional education and training programs at an individual level. Cultural competence might also be embodied or rolemodeled at the organizational level. The findings further emphasize that in this Saudi context, cultural competence requires a combination of individual desire and effort to
learn coupled with adequate organizational support and resources. It is recommended therefore that organizations that have a multicultural workforce in Saudi Arabia adopt the cultural competence model to guide education, induction, and continuing development of their workforce. The concepts embedded in this cultural competence model, in addition to consideration of the new themes elicited in this study, provide an ideal structure for educational programs. In addition, such an educational program should use and employ the best adult learning methods including case studies to ensure participation, comprehension, and understanding. The findings of this study also emphasize the importance of predeparture cultural preparation for nurses to mitigate the effect of cultural dissonance and so eliminate, or reduce, the potential for culture shock and disempowerment. Future iterations of the framework might usefully account for these themes and suggest how organizational support might be implemented to help nurses overcome the dissonance and disempowerment they often encounter. Acknowledgments This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN. The authors thank the National Guard Health Affairs, Chief Executive Officer, His Excellency, Dr. Bandar Al Knawy; Executive Director of King Abdullah International Medical Research Centre; the Associate Director of Nursing Services, Ms. Joan Murray; and Dr. Mustafa Bodrick, Director of Nursing Education; and all the Directors of Clinical Nursing for their support and facilitation to conduct this study. Our special thanks are extended to the nursing staff who participated in this study.
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.
References Adahl, S. (2009). Varying cultures in modern crisis management. Helsinki, Finland: Edita Prima Oy. Aldossary, A., While, A., & Barriball, L. (2008). Health care and nursing in Saudi Arabia. International Nursing Review, 55, 125-128. Almalki, M., FitzGerald, G., & Clark, M. (2011). The nursing profession in Saudi Arabia: An overview. International Nursing Review, 58, 304-311. Almutairi, A. F., Gardner, G., & McCarthy, A. (2013). Perceptions of clinical safety climate of the multicultural nursing workforce in Saudi Arabia: A cross-sectional survey. Collegian, 20, 187-194. Retrieved from http://dx.doi.org/10.1016/j. colegn.2012.08.002 Anyanwu, C. N. (2009). Creative strategies for conflict management & community building. Bloomington, IN: AuthorHouse.
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
23
Almutairi et al. Axelrod, R., & Hammond, R. A. (2003, April). The evolution of ethnocentric behavior. Paper presented at the Midwest Political Science Convention, Chicago, IL. Bailey, G., & Peoples, J. (2010). Essentials of cultural anthropology. Belmont, CA: Cengage Learning. Boi, S. (2000). Nurses’ experiences in caring for patients from different cultural backgrounds. Nursing Times Research, 5, 382389. Brathwaite, A. E. C. (2005). Evaluation of a cultural competence course. Journal of Transcultural Nursing, 16, 361-369. Brathwaite, A. C., & Majumdar, B. (2006). Evaluation of a cultural competence educational programme. Journal of Advanced Nursing, 53, 470-479. Brown, L., & Holloway, I. (2008). The initial stage of the international sojourn: Excitement or culture shock? British Journal of Guidance & Counselling, 36, 33-49. Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38, 203-207. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13, 181-184. Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of health care services: A culturally competent model of care. Cincinnati, OH: Transcultural C.A.R.E. Cioffi, J. (2005). Nurses’ experiences of caring for culturally diverse patients in an acute care setting. Contemporary Nurse, 20, 78-86. Cowan, D. T., & Norman, I. (2006). Cultural competence in nursing: New meanings. Journal of Transcultural Nursing, 17, 82-88. Dayer-Berenson, L. (2011). Cultural competencies for nurses: Impact on health and illness. Sudbury, MA: Jones & Bartlett Learning. Deegan, J., & Simkin, K. (2010). Expert to novice: Experiences of professional adaptation reported by non-English speaking nurses in Australia. Australian Journal of Advanced Nursing, 27(3), 31-37. Dowell, A., Crampton, P., & Parkin, C. (2001). The first sunrise: An experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Medical Education, 53, 242-249. Eckermann, A.-K., Dowd, T., Chong, E., Nixon, L., & Gray, R. (2010). Binan Goonj: Bridging cultures in aboriginal health. Chatswood, New South Wales, Australia: Elsevier. French, S., & Swain, J. (2008). Understanding disability: A guide for health professionals. Philadelphia, PA: Elsevier. Goldberg, D. T., & Solomos, J. (2002). A companion to racial and ethnic studies. Malden, MA: Wiley-Blackwell. Halligan, P. P. (2006). Caring for patients of Islamic denomination: Critical care nurses’ experiences in Saudi Arabia. Journal of Clinical Nursing, 15, 1565-1573.
Hardina, D., Middleton, J., Montana, S., & Simpson, R. (2007). An empowering approach to managing social service organizations. New York, NY: Springer. Isokääntä, V., & Johansson, A. (2006). Empowermental nursing: Experiences of empowerment and disempowerment made by patients in need of long term nursing. Gothenburg, Sweden: Göteborg University, Institute of Health and Care Sciences. Jirwe, M., Gerrish, K., & Emami, A. (2006). The theoretical framework of cultural competence. Journal of Multicultural Nursing and Health, 12(3), 6-16. Kai, J., Beavan, J., Faull, C., Dodson, L., Gill, P., & Beighton, A. (2007). Professional uncertainty and disempowerment responding to ethnic diversity in health care: A qualitative study. PLoS Medicine, 4(11), e323. Kendall, D. (2010). Sociology in our times: The essentials. Belmont, CA: Wadsworth Cengage Learning. Leininger, M. M. (2002). Culture care theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing, 13, 189-192. Lin, C. (2006). Culture shock and social support: An investigation of a Chinese student organization on a US campus. Journal of Intercultural Communication Research, 35, 117-137. Lincoln, N. D., Travers, C., Ackers, P., & Wilkinson, A. (2002). The meaning of empowerment: The interdisciplinary etymology of a new management concept. International Journal of Management Reviews, 4, 271-290. Mahabeer, S. A. (2009). A descriptive study of the cultural competence of hemodialysis nurses. Canadian Association of Nephrology Nurses and Technologists Journal, 19(4), 30-33. McLeod, K. D. (2008). A qualitative examination of culture shock and the influential factors affecting newly-arrived Korean students at Texas A&M university (Published dissertation). Texas A&M University, Texas. Ministry of Health. (2009). Health statistical year book 2009. Riyadh, Saudi Arabia: Author. Smith, L. (2001). Evaluation of an educational intervention to increase cultural competence among registered nurses. Journal of Cultural Diversity, 8(2), 50-63. Suh, E. E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15, 93-102. Sullivan, L. E. (2009). The Sage glossary of the social and behavioral sciences. Thousand Oaks, CA: Sage. Varner, I., & Beamer, L. (2010). Intercultural communication in the global workplace: New York, NY: McGraw-Hill. Yin, R. K. (2009). Case study research: Design and methods (4th ed.). Beverly Hills, CA: Sage.
Downloaded from tcn.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on June 18, 2015
