A meta-synthesis of qualitative research

Cultural caring in nursing practice: a meta-synthesis of qualitative research

Maren J. Coffman

Abstract: The number of qualitative studies regarding the experience of nurses caring for patients from cultures other than their own has increased, yet there remains a limited understanding of the meanings derived from this work. Using the methodology of Noblit and Hare’s meta-ethnographic comparative method, the main themes and concepts from 13 qualitative studies are reduced to six overall themes that describe over 1,000 nurses’ experience caring for patients from other cultures. The themes include: (a) connecting with the client, (b) cultural discovery, (c) the patient in context, (d) in their world, not mine, (e) road blocks, and (f) the cultural lens.

Keywords: Nursing Practice, Cultural Caring, Meta-Synthesis Qualitative Research

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Minority populations continue to grow at an unprecedented rate in the U.S. The Hispanic population is the fastest growing minority with over 35.3 million (12.5%) persons residing in the U.S. This largely Spanish speaking group as become the majority minority as of the year 2000 census. The African American population is slightly less than the Hispanic population at 34.6 million persons or 12.3%. In addition, there are 10 million Asian Americans or about 3.6% of the total U.S. population and 2.4 million American Indians that comprise 0.9% of the population (U.S. Bureau of the Census, 2002).

While the U.S. population has become increasingly diverse, nurses have remained a homogeneous group. Approximately 90% of all Registered Nurses are Caucasian; 4.2% are African American; 3.4% are Asian or Pacific Islander; and 1.6% are Hispanic (Minority Nursing Statistics, 2001). The only nurse population that mirrors the U.S. population is Asian American. The degree of uniformity of nurses compared to the U.S. population begs the question: Are we prepared to care for the increasingly multicultural patient?

Definition and purpose

According to Leininger, culture is a process of “learned, shared, and transmitted values, beliefs, norms, and life practices of a particular group that guides thinking, decisions and actions in patterned ways” (1988, p. 156). This article focuses on the experience of providing care to patients from other cultures. More specifically, other cultures refers to the experience of health care providers caring fro a patient from a culture that is perceived as different than their own. This may include the patient having a different language, ethnicity, religion or any other life practice.

As society becomes increasingly diverse, transcultural care has become an important aspect of health care. The need for clinicians to become more sensitive to cultural differences and gain an understanding of transcultural concepts has been repeatedly stressed by Leininger (1988)who stated the use of transcultural care knowledge is essential for accurate, reliable health care” (p. 159). As the health care community recognizes the need for increased cultural understanding, the number of qualitative studies regarding the experience of clinicians caring for different cultural groups has increased. Though there is increased interest and research, there remains a limited understanding of the meanings derived from this work since the work that has been done has not been summarized in a meaningful way. To further the applicability of the work, it is essential to synthesize individual studies into more concise findings. Further, a review of the literature revealed no published meta-synthesis on health care clinicians” experience caring for patients from other cultures. This represents a gap in the knowledge and need for synthesis of studies that address health care provider’s views. The aim of this article is to closely examine and integrate the qualitative work in this area of study through meta-synthesis.

Meta-synthesis can be defined as the theories, grand narratives, generalizations, or interpretive translations produced from the integration or comparison of findings from qualitative studies” (Sandelowski, Docherty & Emden, 1997, p. 366). According to Jensen and Allen (1996, p. 553), meta-synthesis is essential in order to advance knowledge and influence practice.” A meta-synthesis that summarizes the experience of clinicians caring for patients from a variety of cultural backgrounds will enhance the overall understanding of the issues and concerns. By utilizing a comprehensive synthesis of information, limitations in the research emerge and future research can be fine-tuned and applied to practice.

METHOD

The methodology chosen for the meta-synthesis is Noblit and Hare’s (1988) meta-ethnographic comparative method. This method allows for substantive interpretations” that can be derived from ethnographic and interpretive studies (Noblit & Hare, 1988, p.9). This approach allows the researcher to “compare and analyze text, creating new interpretations in the process” (Noblit & Hare, 1988,p. 9). The seven step process is outlined throughout the article and in Table 1.

Phase one and two involved deciding on a research topic of interest and locating a sample. The content +of the research articles selected for inclusion in the analysis must be related to each other and directly comparable. Initially, research articles were subject to two criteria for inclusion in the meta-synthesis: first, the focus of the research was on health care providers caring for patients from different cultural backgrounds and second, the research design was qualitative. The studies included in this meta-synthesis were located through an extensive search of literature databases including CINAHL, Medline, PsychINFO, ERIC, Sociological Abstracts and Dissertation Abstracts Online for all available dates. Key words used in the literature search included; culture, cultural bias, minority, cultural competence, experiences, as well as providers, nurses, clinicians, physicians, therapists, health care professionals and socials workers. Initially, all studies found from any health discipline were within the predetermined inclusion criteria. An effort was made to include a variety of qualitative methods, as well as other cultural backgrounds, settings and participant experiences.

Following the literature review, the next phase of the comparative method consisted of meticulous reading and re-reading the studies selected for possible inclusion. Originally, 18 studies were found in the literature related to the overall phenomenon of health care provider’s experience caring for patients from other cultures. The initial objective was to include a wide variety of health care providers. Examination of the research revealed 3 studies that focused on the physician’s experience and 14 studies on the nurse’s experience. As a result, the inclusion criteria were narrowed to the experience of nurses as there was not adequate research involving other health care providers.

The final sample consisted of 13 articles published between 1990 and 2001. One study was eliminated (Bates, Rankin-Hill & Sanchez-Ayendez, 1997) as the researcher interviewed the patients but used observation methods only to study the providers. Eleven of the studies were published in nursing journals, one (Lipton et al., 1998) was published in a multi-disciplinary health journal and the remaining study was an unpublished doctoral dissertation (Emerson, 1995). All were published in English, nine were conducted in the U.S. while the remaining four were conducted in the U.K. and Canada. Sample size of the studies included in the meta-synthesis ranged from 7 to 767 participants, the large numbers resulting from two studies using triangulated methods though the quantitative data was not included in the current analysis. A total of 1054 nurses participated in the studies (noting that one study accounted for 767 of the total number of participants). The ethnicity of the nurses as well as the patients they cared for varied, however, five studies did not report the ethnicity of the nurses. Study settings, where specified, included nurses that worked in hospitals, clinics and community health settings. Research methods ranged from descriptive qualitative, exploratory and grounded theory. A synopsis of the studies used in the metasynthesis can be viewed in Table 2.

RESULTS

Phase four of Noblit and Hare’s (1988) seven step method included looking at how the ideas and concepts in the sample are related. To do this, a detailed table was constructed that included all of the key metaphors, phrases, idea, themes and concepts that emerged from the research articles. As a result of the large quantity of data extracted from the pool of articles, the most central data from each of the studies is summarized in Table 3.

The fifth phase of the process involved translating the key concepts from the pool of studies into one another and then synthesizing these translations into an encompassing whole. This is done while maintaining the central themes from each of the original studies. The themes can be related as either reciprocal translations, meaning they are similar and can be compared directly, as a refutation or opposites of each other, or in a line of argument.

In phase six of the method, the research brings the clustered data together to make a whole. Through this process, an initial clustering of metaphors into 13 categories were reduced to 6 overall themes that described the nurses’ experience caring for patients from other cultures. The six reciprocal translations as outlined in Table 3 include: (a) connecting with the client, (b) cultural discovery, (c) the patient in context, (d) in their world, not mine, (e) road blocks, and (f) the cultural lens. Step seven involved expressing the findings in written format.

Connecting with the Client

Communication was seen as an over-encompassing issue and emerged in all but two of the studies included in the synthesis. Communication included both spoken language, the use of interpreters, body language as well as other issues. Nurses often felt that cultural and language barriers made it difficult to relate to the patient. Kirkham (1998) stated that “cultural beliefs and practices of the culturally diverse client, along with the language barrier, presented the nurse with variables not typically encountered in the development of a helping relationship (p.133). Language was one of the most widely recognized barriers to delivery of quality health care. Without effective communication, the nurse found that only a superficial nurse-patient relationship was formed (Boi, 2000).

The nurses described the process of connecting with the client through the use of translators and their own communication efforts (Boi, 2000; Kirkham, 1998). Nurses used such methods as “hand signs” and tried to show objects to the patient to attempt to convey a message (Murphy & Clark, 1993). Other nurses stated that body language techniques such as touching, pointing and smiling helped them to connect with their patients (Baldonado et al., 1998). Emerson’s (1995) study of public health nurses described the impact of verbal and non-verbal communication patterns the nurse used while caring for patients in the community. The nurses observed the consequence that cultural knowledge and awareness had on communication effectiveness to improve the care of ethnic clients.

Too often, the resources nurses felt were needed to communicate with the client, such as interpreters, were not available. One nurse described seeing her client “really upset and crying and his wife crying and him looking so worried. You can’t get an interpreter in time when you need them most (Murphy & Clark, 1993, p. 444). A nurse working to prepare patients for surgery stated, The interpreters would arrive after the patients have already been sent down for surgery limiting the amount of preoperative teaching that can be completed” (Boi, 2000, Pg 386).

Nurses felt that inadequate literacy of ethnic patients and lack of resources made minority patients more difficult to teach. One study noted the lack of educational materials in Spanish (Lipton et al., 1998). Nurses indicated that the patients would nod, agree or would even say yes even when they did not understand what they were being told (Baldonado et al., 1998). A student nurse reported an experience she had with a non-English speaking client stating, Language barriers are difficult. I was discharging a Vietnamese woman who spoke very little English. She wanted to be taught how to change the dressing over her breast which was from what she thought was a biopsy When the dressing was removed, she was shocked to find out that she had a mastectomy” (Baldonado et al., 1998, p. 21)

Several of the articles presented the experience of nurse participants that spoke foreign languages. These nurses felt that they benefited from speaking foreign languages in their ability to connect with and develop relationships with patients (Baldonado et al., 1998; Bernal, Pardue & Kramer, 1990; Emerson, 1995). The benefits of having a bilingual staff was expressed by a Spanish speaking nurse who stated, “You need to understand the language for that particular group. A Spanish speaking woman told me ‘I have ants on my face’ during labor. I knew she meant tingling because she was hyperventilating. But what if a non-Spanish speaking person were taking care of her? How would they find out that problem she was having?” (Baldonado et al., 1998, p. 21). Fortunately for this client, her nurse was able to understand the symptoms that the patient was describing and intervene appropriately.

Cultural Discovery

Nurses expressed that they lack the education necessary to effectively care for a diverse mix of patients from other cultures. The nurses verbalized a desire to continue to gain knowledge and “expand their horizons” (Labun, 2001) with regard to other cultures in order to practice effectively. All but two of the studies referred to education as a major theme within the experience of caring for patients from other cultures.

Many nurses expressed a need for transcultural knowledge to enable them to deliver culturally sensitive nursing care (Baldonado et al., 1998). The participants felt that their own educational training did not give them the foundation that they needed (Baldonado et al; Boi, 2000; Kirkham, 1998). This sentiment was expressed by one participant who felt she was not at all [prepared in training to care for culturally different patients]. When I came to England I had never actually cared for anyone from a different background.” (Boi, p. 386).

The nurses stated that they enjoyed learning about different cultures from the patients themselves. “I learnt so much from looking after people. I found it, so interesting and would want to know more” (Murphy & Clark, 1993, p. 448). Bernal et al. (1990), reported that nurses felt rewarded by working with Hispanic patients and listed the “nurse’s opportunity to learn from a generous population” (p. 22) as a benefit of their work.

Not all of the participants in the studies demonstrated as much interest in learning about other cultures. One student nurse described the resistance she perceived from the nurses ,she had observed during shift reports. She felt that with an increasing number of patients with different ethnic backgrounds, I have found that many people in the health care field are not aware of different belief systems and do not really care to learn” (Baldonado et al., 1998, p. 20).

The study participants save the researchers suggestions to improve cultural understanding. The participants wanted to learn the specific skills and facts needed to care for other cultures. However, as well as learning the facts, the nurses expressed a need to gain an understanding of strategies such as collaboration and working with translators (Kirkham, 1998). One respondent paraphrased, “a need I perceive as being unique to groups of different cultures is religion. Religion is so important to many of the different cultures we encounter during our health care career, yet we get very little of it in our educational experience. I know very little about other religions and don’t believe I could be much help to anyone outside the Catholic religion.” (Baldonado et al., 1998, p. 20). Additional methods to increase transcultural knowledge were the need for inservices regarding other cultures, taking time to learn from the patients themselves and the value of being exposed to a variety of clients in the clinical setting (Kirkham, 1998; Murphy & Clark, 1993).

Two studies described the impact that living in another country had on their cultural knowledge and nursing practice. These studies (Ryan et al.. 2000: St. Clair & McKenry, 1999) reported that students who had participated in cultural immersion experiences were able to learn about cultural practices and gain an understanding about cultural sensitivity by living outside of the U.S. St. Clair and McKenry (1999) analyzed the journals of nursing students who lived abroad. An overall sentiment expressed by the students was that they were able to learn more by living in foreign communities than by studying transcultural nursing in the classroom. One student wrote regarding living in another country, “this experience has made me rethink what is important in life, what I value, how I relate to others, how I understand and am sensitive to others, what I need to do to be culturally competent.” (p. 232).

Patients in Context

Families and relatives emerged as a theme in nine of the studies. Families were seen as both a positive and negative influence on the care of the patient and affected the patient’s health. The importance of understanding the meaning and role of the family was essential in order to build a caring relationship.

Families provided a great deal of support, assurance and caring to an individual who was ill and in need of healthcare services. One nurse expressed that “our concept of family is a lot different than their concept of family” (Ryan et al., 2000, p. 405). In addition to the distinction of familial concepts between cultures, patients from other cultural backgrounds were described by the nurses as having a “strong sense of family” (Bernal et al., 1990, pp. 21-22).

Nurses agreed it was helpful to have family members present when the patient had little or no understanding of English. Families were often used as a source of information for nurses gathering patient histories (Boi, 2000). Astute nurses stated that they could learn about the patient’s background just by meeting the family members. “They are a sign of what the patient’s environment is actually like at home … watching them interact with the family can often show quite a few different things” (Boi, p. 386). Families were also useful when translators were not available though this practice was not always seen as the ideal circumstance when sensitive information needed to be shared (Murphy & Clark, 1993). Nurses also relied on family members to provide cultural food or diets to clients could not be accommodated by the hospital (Boi).

Support from family was not always seen as positive by the nursing staff. Only one nurse stated that having the family at the bedside for long periods of time in the hospital was useful (Murphy & Clark, 1993). The overwhelming majority of nurses (Baldonado et al., 1998; Boi, 2000; Lipton et al., 1998; Murphy & Clark, 1993) however felt that the large number of visitors that came in with minority patients was difficult to deal with and impacted patient care. “..When they visited, they came in large numbers. I did find it hard to deal with 10 visitors and the patient” (Boi, p. 386). Another nurse stated that there would often be so many visitors, that she “felt apprehensive going into the patient’s room. There would be a whole crowd of people in there and it was hard everybody looking at you trying to get through to (the client)” (Murphy & Clark, p. 446).

Nursing staff who gained a deeper understanding of family accommodated their practice to meet the needs of the patriarchal and matriarchal order to ]provide cultural care. One nurse stated that as she began to learn about family dynamics, she taught the patient’s husband, who then gave me permission to teach the patient” (Baldonado et al., 1998, p. 23). Another nurse reports, One black patient I had was younger and had no questions regarding his condition. When his mother visited, she had many. From then on, I would wait for his mother to come in and talk with them together, understanding how the mother in black families is often dominant and the center of the family (Baldonado, p. 23).”

More experienced nurses who adapted their care treated family more respectfully in order to gain trust (Kirkham, 1998). The nurses did this by allowing the family to actively participate in the care of the patient (Baldonado et al., 1998), as well as provide health care service, when appropriate, to family members free of charge in order to gain needed respect and trust (Lipton et al., 1999). As nurses learned to modify their nursing practice to meet the needs of the patient, they found that they were able to build trusting relationships with families and foster improved outcomes with the patients.

In Their World, Not Mine

The title of this theme was borrowed from Ryan et al. (2000) as strategies nurses used to care for clients “in their world, not mine” (p. 403). Kirkham (1998) discussed three levels of nurses in her study. She found that nurses were either resistant, meaning that they ignored or resented the cultural diversity of their patients, generalist nurses who were respectful but ad not given a lot of thought to the issue of culture and last, the most experienced nurses who were impassioned. These impassioned nurses expressed a high degree of personal commitment to providing culturally sensitive care. Many of these nurses described having had an “awakening” to the importance of culturally sensitive care through having lived in another country or being a minority themselves at some time in their life. The impassioned nurses were those who were most effectively able to accommodate for the cultural needs of the patient and see beyond their own worlds into that of the patient.

Concern about the cultural needs of patients included gaining an understanding and accommodating for non-medicinal therapies, rituals, home remedies and religious practices. “The Vietnamese culture has its own way of looking at health and looking at appropriate treatment and the whole concept of Eastern and Western medicines very much an issue and that can easily be misinterpreted” (Labun, 2001, p. 878). Native Americans were described as having very specific rituals that were meaningful to them. These patients expected that nurses be knowledgeable of the local cultural beliefs and traditions, any currently practiced health care rituals, and/or medicine men or women in conjunction with Western alternative health practices.” (Weaver, 1999, p. 200).

Nurses spoke of the influence of folk medicine on health beliefs. The health care providers in the clinics felt that their Latino patients would seek care from folk remedies and curanderos first, and then if those remedies were not successful, the patients would come to the clinic for care. This would often mean a delay in treatment as the client did not access care until complications had set in (Lipton et al., 1998). Accommodating nurses who worked with American Indian patients recognized the role of medicine woman and men in providing health care to their clients (Weaver, 1999).

Religious and spiritual rituals were considered an essential element in providing culturally sensitive care. Many nurses spoke of the importance of accommodating for these practices in terms of providing privacy, respect and taking the time to understand the issues. Nurses and student nurses reported remarkable outcomes with regards to these aspects of nursing care. For example, one student stated “I had a Mormon patient, an 18 year old woman with little hope for survival, at best total paralysis. Church members came to the ICU late one night to say a blessing. The patient not only survived but has only slight short-term memory loss (Baldonado et al., 1998, p. 22).

Road Blocks

Areas that have an impact on the quality of patient care that is given to patients from other cultures include; being an outsider, the socioeconomic status of the patients, adherence and health beliefs of the patients. Also included are factors that contribute to whether patients receive the health care they need and how they view the health care system.

Unfortunately, many of the most vulnerable members of our society are also are the most economically at risk. Nurses were aware of the impact that one s socioeconomic status has on individual health status and expressions and meanings of care. One student nurse felt that “it is the failure of society to accept the socioeconomic diversity among people, that causes most of our problems today. We fear that which we do not understand. If people would just take time to learn and explore the differences maybe they would appreciate each and every individual” (Bengiamin, Downey & Heuer, 1999, p. 63).

An example from the studies involved the impact poverty had on the patient as they fear having to ask for help. Patients who have a lot of pride and self-reliance are sometimes unwilling to accept the help offered to them in the form of government subsidized medications and medical care. Some patients believed that if they accepted help, they would someday, be required to pay for the costs. Immigrant patients, who did not have the proper U.S. visas and paperwork, feared seeking medical care believing that accepting free medical care would jeopardize their chances of gaining U.S. Citizenship. This seemed to contribute to delays in accessing care and choosing to use home remedies (Lipton et al., 1998).

Many cultural groups were viewed by health care providers as failing to maintain prescribed medical treatments. While some nurses in outpatient clinics understood the need to allow patients to continue with home remedies as a means to improve adherence to prescribed treatments (Lipton et al., 1998), other nurses found the use of healer and alternative health practices to be a source of frustration.

Cultural Lens

The “cultural lens” related to the way nurses, institutions, colleagues and the health care system at large view patients from other cultures. These areas include the positive and negative attitudes of nurses, support from nurses’ colleagues, the role of the institution and stereotyping that made care inequitable. An essential characteristic that nurses needed in order to care for culturally different patients was a non-judgmental attitude. This quality was noted in an overwhelming portion of the studies. Most of the nurses that were interviewed felt that they were in the process of learning to care for patients without being biased. One student who took a course on culture stated “I now feel more open toward diversity not only in health care but in life itself. Because of this class I have been exposed to a great variety of alternative health practices and ideas” (Bengiamin, Downey & Heuer, 1999, p. 64).

Many nurses still seemed to maintain biases against culturally different patients. Though none of the nurses in the studies stated that they were biased, they indicated that many of their nurse colleagues held negative attitudes towards some patients that influenced care. One nurse described having to work with a group of negative, complaining nurses that discouraged others in their efforts to care for culturally different patients (Kirkham, 1998). One student perceived that more than once on shift reports, nurses have criticized patients and families for differences rather than conveying understanding and accepting differences” (Baldonado et al., 1998, p. 20). It was suggested by some nurses, that a diverse group of colleagues and experience working with clients with different cultural backgrounds was helpful as it increased flexibility and openness in nurses (Bernal et al., 1990; Kirkham, 1998).

The health care setting was included in several studies as an issue in caring for patients. Many nurses felt that the heavy workloads they were expected to carry prevented them from spending the time that they needed to meet special needs of diverse patients. The nurses felt that they did not have the time to communicate effectively or build rapport with the patients from other cultures (Kirkham, 1998). Other nurses reported feeling frustrated at the circumstance that they were in regarding limited support from the institution.

The nurses perceived that many minority clients were stereotyped and often received inequitable treatment when compared to non-minority populations. Though the nurses didn’t always claim to understand why, many made suggestions. One student nurse stated that “the care minorities receive is below standard perhaps because the nurses providing the care are the majority (Baldonado et al., 1998, p. 21). Another student agreed stating that some patients (Hispanics, blacks) are treated as if they cannot under, stand or are inferior in intelligence when they are not (Baldonado et al., 1998, p. 21).

DISCUSSION

A strength as well as a limitation of this meta-synthesis was the diversity of the participants sampled and the wide variety of cultural groups that they care for. The diversity of experiences allowed for a wide variety of experiences but also made direct comparison more difficult. Another limitation was the lack of reporting in many of the studies related to the demographics of the study participants. Adherence to the research methodology allows for credibility of the findings despite these limitations. Mixing the experience of nursing students with nurses provided an etic perspective of the nurses’ weaknesses. Many students described their interpretations of nurses actions related to cultural caring. The students were able to observe the nurses’ behaviors, reluctance and resistance related to caring for patients from other cultures. This finding was confirmed by other nurses in the studies who felt that they were able to care for all patients, but described their colleagues biases.

Suggestions for further research include continued meta-synthesis of more narrow topics as the body of qualitative research continues to expand. Given an adequate number of studies in the future, separate meta-synthesis could be conducted related to specific practice settings, cultural groups and practice concerns. In addition, further qualitative studies are needed not just on the experience of nurses and nursing students caring for patient from other cultures, but on that of others who work within the health care system.

Meta-synthesis of the qualitative articles that have been completed regarding nurses caring for minority cultures have shown the positive and negative impact that diversity has on the health care system. A meaningful summary of the studies demonstrates the experience of nurses caring for diverse cultures and allows for expression of the nurse’s issues. Overall, nurses voiced concern related to the barriers, lack of support and resources encountered when caring for cultural groups. Nurses stated that they did benefit from learning about other cultures and found satisfaction in caring for gracious ethnic patients. On the other hand, nurses were concerned that due to limited resources including teaching materials and translators, they were challenged with finding other ways to overcome barriers to best meet the client’s health care needs.

Culture is an essential element of the human race and will continue to be an enduring part of the health care system. Leininger (1991) identified the genuinely interested practitioner as one who has a positive interest as well as a sincere desire to know and serve a variety of people. Since nurses are in a position where they are expected to provide intimate and individualized care to individuals, it is essential that nurses and other health care professionals come to understand and respond to the patient’s cultural needs. The most effective way to accomplish this is to increase awareness and become enlightened to the cultural differences of those we serve.

Implications for practice

The qualitative findings outlined through this meta-synthesis mirror those of quantitative findings suggesting that nurses lack a level of comfort and ability to perform transcultural skills and tasks when caring for patients from other cultures. The information contained in prior quantitative studies suggests that nurses lack confidence when caring for all ethnic minorities and are the least comfortable caring for Asians and Hispanics, due primarily to the language barriers that are present (Bernal & Froman, 1987, 1991; Jeffries & Smodlaka, 1999; Lipton et al., 1996; Rooda, 1993).

In fact, communication has been cited as the primary barrier to providing culturally sensitive care and without adequate and meaningful interaction, only superficial relationships are developed between clinicians and clients. In addition, communication is not only language, but encompasses all of the methods we use to share information with each other. Nurses are a critical element in quality health care and communication is essential in order for the nurse to advocate and care for their patients in a meaningful way.

Many nurses in the studies perceived that they lack the necessary training to adequately care for their patients cultural needs. Nurses recommend additional education and inservices on culture in order to increase their level of confidence and knowledge of transcultural skills. Other ways that nurses can improve cultural competence is through immersion experiences, living in another country or learning another language. Nurses and students reported the effect this type of experience has on their ability to relate to and care for diverse patient populations.

Cultural competence has become a new imperative in a world that is looking more like a salad bowl than a melting pot. It is interesting to note that the majority of the studies used in the sample have been completed since 1995. This alone speaks for the urgent need for health care clinicians to expand their care practices. Continued research needs to be done in order to enhance the knowledge base of nurses and others and qualitative work and intervention studies are needed to determine approaches and experiences that are effective and meaningful.

Table 1. Noblit and Hare’s Meta-Ethnographic Comparative Method

Phase 1: Getting started. This step involves finding an

area of interest in need of synthesis.

Phase 2: Deciding what is relevant to the initial interest.

This phase involves conducting a literature

search based on sample criteria.

Phase 3: Reading the studies. This involves reading and

re-reading the studies and noting interpretive

metaphors in each.

Phase 4: Determine how the studies are related. In this

step, the studies are “put together” and relation-

ships between the studies are forged. It is

suggested that a list of key metaphors, phrases,

ideas and concepts are made for each study.

The metaphors are then compared and juxta-

posed. Three different relationships are pos-

sible: a direct comparison using reciprocal

translations; a refutational comparison where

studies oppose each other; and a grouping of

studies that represent a line of argument.

Phase 5: Translating the studies into one another, Simply

stated, the metaphors and themes are compared

with each other while leaving the central meta-

phors intact.

Phase 6: Synthesizing translations. This step requires the

researcher to make the parts of each study into a

whole through synthesis of the information

Phase 7: Expressing the synthesis. The final step requires

the researcher to write up and report the results.

(Noblit &Hare, 1988, pp. 26-29)

Table 2. Demographic Characteristics of the participants of the

Individual Studies Included in the Meta-Synthesis

Study Country Sample Ethnicity

of nurses

Boi, 2000 UK 7 Not specified

Murphy & Clark, 1993 UK 18 Not specified

Kirkham, 1998 Canada 8 1 Asian,

7 Caucasian

Bernal, Pardue & USA 12 RNs caring for

Kramer, 1990 Hispanic patients

Bengiamin, Downey & USA 22 Caucasian, Asian

Heuer, 1999 & Native American

Labum, 2001 USA 27 RNs caring for

& Canada Vietnamese

Lipton of al., 1998 USA 24 total, 13 Hispanic,

7 RN’s Caucasian &

Asian American

Weaver, 1999 USA 40 Native American

RN’s and students

St. Clarr & McKenry, USA 80 Not specified

1999

Baldonado et al., USA 767 70% Caucasian

1998

Canales & Bowers, USA 10 Hispanic

2001

Ryan et al., 2000 USA 9 Not specified

Emerson, 1995 USA 30 Not specified

(dissertation)

Study Study Research

setting design

Boi, 2000 Hospital Descriptive

Murphy & Clark, 1993 Hospital Descriptive

Kirkham, 1998 Hospital Interpretive

descriptive

Bernal, Pardue & VNA Descriptive

Kramer, 1990

Bengiamin, Downey & Students Descriptive

Heuer, 1999

Labum, 2001 Clinics, Hospital Grounded

Theory

Lipton of al., 1998 Clinics Descriptive

Weaver, 1999 Not specified Exploratory

St. Clarr & McKenry, Students Exploratory,

1999 triangulated

Baldonado et al., 250 Students Exploratory,

1998 517 RN’s triangulated

Canales & Bowers, Nursing Grounded

2001 professors theory

Ryan et al., 2000 Varied Grounded

theory

Emerson, 1995 Community Descriptive

(dissertation) health

Study Data Data

collection analyais

Boi, 2000 Interview None specified

Murphy & Clark, 1993 Interview None specified

Kirkham, 1998 Interview Lincoln and Guba

Bernal, Pardue & Questionnaire None specified

Kramer, 1990

Bengiamin, Downey & Questionnaire None specified

Heuer, 1999

Labum, 2001 Interview, Dimensional

theoretical memos analysis

Lipton of al., 1998 Focus groups None specified

Weaver, 1999 Questionnaire None specified

St. Clarr & McKenry, Analysis of None specified

1999 journal entries

Baldonado et al., Questionnaire Lincoln and Guba

1998

Canales & Bowers, Interviews Constant comparative

2001 method, dimensional

analysis

Ryan et al., 2000 Interviews, Constant comparative

focus group method, dimensional

analysis

Emerson, 1995 Interviews, None specified

(dissertation) observation

Table 3. Individual study metaphors as related to six themes

Boi, 200 Murphy &

Clark,1993

Connecting with Communication Communication

the Client

Cultural Nurses’ lack Nurses’ lack of

Discovery of knowledge knowledge

of cultural differences

Nurses’ education

and training

Patient in Patient’s relatives Issues relating

Context to relatives

In Their World,

Not Mine

Road Blocks

The Cultural Nurses’ feeling

Lens stressed and

frustrated

working with other

cultures

Kirkham, 1998 Bernal, 1990

Connecting with Connecting with the Limitation–

the Client client–overcome nurses’ limited

through communication Spanish

Reward–nurses able

to use/learn Spanish

Cultural Importance of Reward–nurses able

Discovery oundation of education to learn about

and from another

culture

Patient in Working with Strong sense

Context the family of family

In Their World, Three steps to

Not Mine accommodate practice

Road Blocks Client’s non-

compliance

Over-reliance on

the nurse for care

Poverty of the pts.

The Cultural Nurses’ lack of High demand

Lens commitment to caring on nurses

–resistant or generalist Through experience

care nurses less willing

Presence of racism to stereotype

Negative colleagues

Lack of support from

institutions

Bengiamin, Labun, 2001

Downey & Heuer,

1999

Connecting with Connecting

the Client though the use

of interpreters

Cultural Nursing students Process of

Discovery able to learn cultural discovery

rom experience –Nurses

“expanded their

horizons”

Patient in Seeing the patients

Context in context of family

In Their World, Accommodating Changing views of

Not Mine meanings of care health to

within cultures accommodate

patients views of

health

Road Blocks Poor socio-

economic

status of the

patients

The Cultural Students able to Discovering

Lens become open- that other

minded through cultures are not

exprience so different

Bonding with the

patients you are

taking care of

Lipton Weaver,

1999 1998

Connecting with Communication Communication

the Client as a barrier to skills and

care understanding

language

Cultural Nurses’ need

Discovery to know about

cultural issues

Know culture

to gain trust,

“Go slow.”

Patient in Treating family Seeing patients

Context members. within their

Pts take nations/history

recommendations

of family/friends

In Their World, Use of folk Cultural health

Not Mine remedies beliefs, healing

practices,

medicine men

Road Blocks Patients resisting

treatment

Poverty and low

literacy of pts.

The Cultural Nurses able to Nurses open-

Lens develop trusting minded and

relationship non-judgmental

Importance of

caring and

compassion

St. Clair Baldonado

& Mckenry, et al., 1998

2001

Connecting with Communication Language and

the Client communication a

challenge

Cultural Students’ Nurses’ need

Discovery increased for transcultural

awareness of knowledge

cultures through

immersion

Patient in Gender and

Context family roles

In Their World, Nurses’ need to

Not Mine accept and allow

for pt differences

Nurses need to

modify care.

Hot/cold, diet

Road Blocks Patients are

stereotyped

Minority patients

get different care

The Cultural Nurses’ cultural

Lens bias & ignorance

Canales Ryan et al.,

& Bowers, 2000

2001

Connecting with Connecting Learning to

the Client students to communicate

multiple differently

communities

Cultural Teaching Nurses’

Discovery students to learning about

connect with differences in

minority patients cultures

Patient in

Context

In Their World, Caring for Strategies to

Not Mine others from the provide care

others “in their world,

perspective not mine.”

Road Blocks Minorities are

oppressed,

marginalized

and discredited

The Cultural Being a voice

Lens for the

community

Emerson,

1995

Connecting with Verbal and

the Client non-verbal

communication

Use of interpreters

Cultural Nurses’

Discovery commitment to

learning

Patient in Knowledge of

Context family roles

& relationships

In Their World, Nurses’ need to

Not Mine respond to cultural

differences, flexible,

open

Road Blocks

The Cultural Nurses’ attitude

Lens of empathy

for the clients

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Maren J. Coffman teaches at the University of North Carolina-Charlotte School of Nursing. She is a doctoral candidate at the University of CT School of Nursing. She may be contacted via email at: mjcoffma@email.uncc.edu.

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