The Nurse’s Caring Behavior On Multicultural Hospital Settings: A Literature Review

Introduction: Cultural diversity means a different ethnic group in a country or region; these conditions bring different beliefs and understandings to health care and has an impact on the caring behaviour of nurses. Objective: To describe caring behaviour of nurses on patients in multicultural settings in hospitals. Methods: A Literature review and used 5 comprehensive electronic databases such as Google Scholar, PubMed, Science Direct, ProQuest and Garuda. Results: 10 articles used in this research, 3 themes were analysed, including: forms, barriers, and nursing care strategies for multicultural patients. Forms of nurse caring such as understanding and focus on patient, cultural sensitivity, and verbal and non-verbal communication. The caring barriers were ethnocentrism, conflicting perceptions, lack of cultural knowledge, language differences, inadequate hospital facilities, religious differences, patient family behaviour, ineffective coping, and body exposure. The strategies were providing translators, increasing education, organizational support, and improving coping strategies. Conclusion: The researcher concludes that when nurses do caring, they must pay close attention to the culture of the patient, and the strategies found in this study can be used to reduce the barriers that occur while nurses were caring for multicultural patients so that the patient does not feel different during health care. pada pasien dalam setting multikultural di rumah sakit. Metode: Metode yang digunakan adalah kajian literatur dan menggunakan 5 database elektronik yang komprehensif seperti Google Scholar, PubMed, Science Direct, ProQuest dan Garuda. Hasil: Dari 10 artikel yang digunakan dalam penelitian ini, dibagi menjadi 3 tema untuk dianalisis lebih lanjut, meliputi: bentuk, hambatan, dan strategi peningkatan caring perawat pada pasien multikultural. Bentuk caring perawat yang ditemukan antara lain: Saling pengertian dan memusatkan perhatian, peka budaya, serta komunikasi verbal dan nonverbal. Hambatan caring antara lain: etnosentrisme, persepsi yang bertentangan, kurangnya pengetahuan budaya, perbedaan bahasa, fasilitas rumah sakit yang tidak memadai, perbedaan agama, perilaku keluarga pasien, koping yang tidak efektif, dan eksposur tubuh. Strateginya adalah menyediakan penerjemah, meningkatkan pendidikan, dukungan organisasi, dan meningkatkan strategi koping. Kesimpulan: Peneliti menyimpulkan bahwa ketika perawat melakukan caring harus memperhatikan segala aspek budaya pasien, dan strategi yang ditemukan dalam penelitian ini dapat digunakan untuk mengurangi hambatan yang terjadi selama perawat merawat pasien multikultural sehingga pasien tidak merasa dibedakan selama perawatan kesehatan.


Introduction:
The cultural diversity of a society or multiculturalism comes from the coexistence of different ethnic groups in the same country or region, the growth of migration flows, social class, education, gender, language, age, religion and family structure (Murcia & Lopez, 2016). Høye & Severinsson (2010) stated that cultural diversity influences different beliefs and understandings to nursing situations which impact the nursing process.
The impacts of cultural diversity in health services are the failure of interaction, retardation in making decision quickly and appropriately, conflict, and discrimination against non-dominant cultures. Therefore, it is needed the capability to pay attention for others, intellectual skill, and technical and interpersonal skill which is reflected in caring behaviour (Dwidiyanti, 2007). Leininger in Sobo & Loustaunau (2010) revealed that caring practiced by nurses for patients with diverse cultures can affect their behaviour and well-being. Conditions which can limit nurses' caring behaviour such as poverty, powerlessness, and racism likely cause a gap among patients (Sobo & Loustaunau, 2010).
The gap in healthcare is influenced by two factors; interlanguage difference, culture, and environment; and socioeconomic factors including marginalization to health services (Tan & Li, 2016). This gap could continue, for ethnic differences spread out in the health care system. Therefore, it also often overlaps with discrimination against the poor, and it affects the adoption, development, and administration of health policies which limit aspects of life for low-income people (Sobo & Loustaunau, 2010).
The economic pressure and discrimination can disrupt the immune system, so it can increase stress on those who experience it, this contributes greatly to infant mortality, hypertension, and diabetes (Sobo & Loustaunau, 2010). The existence of cultural differences between patients and health workers might be a problem. It can decrease the quality of healthcare and a higher disease burden on patients and can accelerate mortality in patients with terminal illness (Tan & Li, 2016) According to research conducted by Goh (2017), there is a correlation between the caring behaviour of nurses based on the patient's culture and the level of patient satisfaction. The research also conducted by Murcia & Lopez (2016) stated that nurses' experience in caring multicultural patients was needed to improve the quality of nursing care. The purpose of this study is to describe caring behaviour of nurses on patients in multicultural settings in hospitals.

Methods:
This study implemented a literature review method, using 5 databases; Google Scholar, PubMed, Science Direct, ProQuest and Garuda, by entering keywords which were combined with Boolean operators. The articles selection is adjusted based on the inclusion and exclusion criteria which have been determined, such as: research conducted in Indonesia and abroad, written in English, published from 2010-2020, and using a qualitative research design, cross-sectional study, quasiexperimental studies, and randomized control and trial. Critical Appraisal Checklist was used to assess article quality. Jurnal Kesehatan dr. Soebandi Vol. 9, No. 2 http://journal.stikesdrsoebandi.ac.id/ Publisher : LP3M Universitas dr. Soebandi Jember Four steps used by the researchers in article selection using PRISMA Flowchart ( Figure 1).

Result:
The results of this study found 10 articles identified (Table 1) and published in 2013-2019, and there were no articles with publication years 2010, 2011, 2012, 2015 and 2020. The articles selected were from 9 different countries and the research methods used in the articles were 70% qualitative and 30% cross-sectional studies. The total respondents are 991, with an average of 99 respondents. The lowest number is 11 respondents and the highest is 374 respondents.
The caring behaviour of nurses in this study was divided into 3 categories: forms of caring, caring barriers and strategies to increase nurse caring for multicultural patients. Forms of nurse caring for patients in multicultural settings in hospitals such as: Mutual understanding and focus, cultural sensitivity, and practice verbal and nonverbal communication. Whereas ethnocentrism, conflicting perceptions, lack of cultural knowledge, language differences, inadequate hospital facilities, religion differences, patient family behaviour, ineffective coping, and body exposure can be barriers for nurses in caring for multicultural patients. Strategies to improve nurse caring for multicultural patients in hospitals can be done by providing translators or interpreters, increasing education through transcultural training and courses, organizational support such as equipment, facilities, staff and policies, and improving coping strategies. The result of this study is the extraction of 4 themes: Ethnocentrism, Ethnocentrism is divided into 3 sub-themes namely antipathy, controlling patients and mutual understanding. The second theme is contradictive perceptions about care, such as the easier care because of fewer demands and needs, and the difficult and challenging care. The third theme is that it is not our fault, and the last is the lack of cultural knowledge. The three themes discussed in this study are: First, Cultural awareness, in which the mean of cultural awareness level by nurses is 3.15 which means moderate. Second, knowledge and skills, it is known that the average participants have quite low knowledge and skills. The last, level of comfort. The participants reported a low level of comfort during meetings and cultural situations. 3 A phenomenological study of non-muslim nurses Experiences of caring for muslim patients in Saudi Arabia/ Alosaimi, D., S. Dyson, dan D. Antonius/ 2013 The results of the study are divided into 3 factors: Religion, culture, and language. (1) Religion factors in the experience of caring for Muslim patients are divided into 4 sub-themes, such as Ramadan fasting, prayer, politeness, and in maintaining professional. (2) The nurses' experience in cultural factors such as the behavior of the patient's family and fear of false accusations. (3) The language factor becomes an obstacle for nurses in caring. Those  The findings in the study are categorized into 4 themes: a large number of families takes the place and the family wants to be close to the patient. The second theme, Communication becomes a challenge such as Language barriers complicate already complicated care, families become translators, language barriers increase the workload, language barriers require new strategies to facilitate communication. The third theme is crisis reactions which cause problems such as foreign reactions to crises which create feelings of inadequacy and insecurity. And the last one is to provide equal care and adjust to each individual. 9 Sociocultural and

Discussion:
This study identifies how nurses' caring behaviour which consists of caring forms, barriers, and strategies to increase nurse caring for patients run in multicultural settings in hospitals. The articles in this study come from abroad with 9 different countries such as Arabia, Turkey, Iran, Spain, Ireland, America, Portugal, Europe and Korea. According to Potter & Perry (2005) Caring is a primary human need which refers to the activities, processes, and decisions that exist in care to help patients in an empathetic, compassionate, and supportive way. Caring is a process that provides opportunities for nurses and caregivers to identify themselves by empathizing with others and interacting through interpersonal relationships (Kusmiran, 2015).

Barriers to nurse caring for patients in a multicultural setting in a hospital.
According to Burtson and Stichler (2010), there are several factors which can affect nurse caring, including: Nurse workload, Work Environment and Knowledge and Training. Researchers found several obstacles which can occur in the care for multicultural patients in the hospitals, then the researchers divided them into 9 sub-themes barriers to caring for care, including: a. Ethnocentrism Researchers found 5 studies which discussed ethnocentrism as an obstacle to caring for nurses in a multicultural setting in hospitals. It is explained that ethnocentrism is one of the barriers for nurses in caring, nurses who have this attitude will usually ignore patient cultural differences, and nurses reluctant to treat patients with different cultures, therefore it will have a negative impact on patient care (Amiri Six of ten studies which have been analyzed by the researcher revealed that lack of cultural knowledge can have a negative impact on nurses' caring behavior. When nurses have a low level of cultural knowledge, it will negatively affect the cultural competence of nurses. This often makes nurses feel hopeless, worried and afraid, so nurses choose to avoid patients. The low level of knowledge is caused by a lack of education and training about cultural diversity in nurses (Amiri & Heydari, 2017;Mareno & Hart, 2016;Ahn, 2017;Alwahbi et al., 2014;Plaza del Pino et al., 2013;Markey et al., 2018). d. Language difference Seven of ten studies analyzed by researchers justify that language differences between patients and nurses can be an obstacle in caring for multicultural patients in hospitals. Language differences between nurses and patients are the main obstacles in all studies. Nurses consider that language differences caused by cultural differences can cause miscommunication in patient care and have an impact on their caring behavior (Amiri & Heydari, 2017;Alosaimi et al., 2013;Karabuga Yakar & Ecevit Alpar, 2018;de Almeida Monteiro & Mendes, 2013;Al-wahbi et al., 2014;Listerfelt et al., 2019;Plaza del Pino et al., 2013). e. Inadequate hospital facilities Three studies discuss inadequate hospital facilities. The lack of facilities in hospitals is an obstacle for nurses caring for multicultural patients. The lack of facilities is such as lack of wards for multicultural patients, lack of language training from hospitals and lack of physical space management from hospitals (Amiri & Heydari, 2017;Alosaimi et al., 2013;de Almeida Monteiro & Mendes, 2013). f. Religion differences The study conducted by Alosaimi et al. (2013) and Al-wahbi et al. (2014) mentioned that one of the obstacles to nurses' caring behavior is religious differences. It was stated that religious differences between nurses and patients can hinder the ability of nurses to provide care for multicultural patients. Religion differences also interfere with nurses' work routines. g. Patient's family Researchers found 2 studies that discussed the patient's family as an obstacle in caring for nurses, research conducted by Alosaimi et al. (2013) and Listerfelt et al. (2019) found that the behavior of the patient's family can inhibit caring behavior such as family behavior that is often disruptive and the patient's family take over and jostle the room so that nursing care activities and patient peace can be disturbed. h. Ineffective coping Researchers found 2 studies which discussed barriers to caring for nurses Jurnal Kesehatan dr. Soebandi Vol. 9, No. 2 http://journal.stikesdrsoebandi.ac.id/ Publisher : LP3M Universitas dr. Soebandi Jember due to ineffective coping, Research by Ahn (2017) and Markey et al. (2018) explained that poor coping strategies such as passive attitude towards patients will cause various emotions such as stress, guilt, sadness due to failure and feelings of uncertainty. i. Body exposure de Almeida Monteiro & Mendes (2013) mentions that the psychological aspects of patients implementing more invasive actions tend to be ignored, the nursing care process is not far from touching the patient directly. It can make patients worry and fear which their bodies will be touched by inappropriate treatment from health workers. Exposure or touch from nurses is limited by cultural ideas, values, and patient norms, so when nurses are not aware of these values in caring for patients, it will cause misunderstanding which influences the impact of the emotional aspects of patients.
3. Strategies which upgrade nurse caring for multicultural settings at hospital. 10 articles analysed by the researcher mentioned and discussed strategies to increase nurse caring for multicultural patients in hospitals, the researchers divided them into 4 subthemes, including: a. An interpreter Six of ten articles state that an interpreter, translator, or mediator is needed in dealing with language barriers, moreover nurses can also ask the patient's family as an interpreter when communicating with patients which have diverse cultures background (Amiri & Heydari, 2017;Karabuga Yakar & Ecevit Alpar, 2018;de Almeida Monteiro & Mendes, 2013;Al-wahbi et al., 2014;Listerfelt et al., 2019;Plaza del Pino et al., 2013). b. Enhancing education quality and access All studies which have been analyzed by the researchers discuss the importance of education in improving the health services quality. Additional curriculum and providing training and transcultural courses are strategies in enhancing education recommended by all researchers (Amiri & Heydari, 2017;Mareno & Hart, 2016;Alosaimi et al., 2013;Ahn, 2017;Karabuga Yakar & Ecevit Alpar, 2018;de Almeida Monteiro & Mendes, 2013;Al-wahbi et al., 2014;Listerfelt et al., 2019;Plaza del Pino et al., 2013). c. An organizational support Researchers found 3 studies which discussed organizational support. In this term, the organizational support is support from hospitals such as facilities, equipment, regulatory bodies, hospital policies which are provided to improve nurse cultural competence (Amiri & Heydari, 2017;Ahn, 2017;Al-wahbi et al., 2014). d. The increasing of coping strategy Only 1 study which argues the importance of increasing nurse coping is able to improve caring behavior in multicultural patients in hospitals, coping strategies can be carried out with active coping methods and actively attending workshops to enlarge cultural knowledge (Ahn, 2017).