EMPIRICAL STUDIES
doi: 10.1111/scs.12051
Ethnic Swedish Parents’ experiences of minority ethnic nurses’ cultural competence in Swedish paediatric care Azar G. Tavallali MSc, RN (PhD Candidate), Zarina Nahar Kabir PhD (Associate Professor of Public Health) and Maria Jirwe PhD, RN (Senior Lecturer) Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Scand J Caring Sci; 2013 Ethnic Swedish Parents’ experiences of minority ethnic nurses’ cultural competence in Swedish paediatric care
Background: Sweden has a population of a little more than 9.4 million. The rapid growth of immigration in Sweden has resulted in an increased number of minority ethnic patients and minority ethnic nurses in the Swedish healthcare system. This also applies to paediatric care. Aim: The purpose of this study was to explore how parents with ethnic Swedish backgrounds experience minority ethnic nurses’ cultural competence and the care the nurses provide in a Swedish paediatric care context. Method: This exploratory qualitative study is of 14 parents with an ethnic Swedish background whose child was in a ward at a children’s hospital in Stockholm County Council. Data were collected using semi-structured interviews to identify parents’ perceptions and experiences of
Introduction Sweden has a population of a little more than 9.4 million. It is gradually becoming a multiethnic society, with almost 20% of its total population comprising a variety of various nationalities from almost 200 countries. This multiethnic and multicultural composition of Swedish society shows its impact on the composition of healthcare providers. Currently, about 9% of the nurses in the country and 14% in the capital, Stockholm, have an immigrant background (1). The rapid growth of immigration in Sweden has resulted in an increased number of minority ethnic patients and also minority ethnic nurses in the Swedish healthcare system. This increase also applies to paediatric care (1). In Sweden, about 100 000 children are
Correspondence to: Azar G. Tavallali, Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels All e 23, 23 300, SE 141 83 Huddinge, Stockholm, Sweden. E-mail:
[email protected] © 2013 Nordic College of Caring Science
minority ethnic nurses’ cultural competence. The interviews were analysed by qualitative content analysis. Results: The analyses of the interviews led to four main categories: influence of nurses’ ethnicity; significance of cross-cultural communication; cross-cultural skills; and the importance of nursing education. Conclusions: Nurses’ ethnicity did not have much impact on parents’ satisfaction with their child’s care. The parents attached importance to nurses’ language skills and to their adaptation and awareness of Swedish culture. They also attached weight to nurses’ professional knowledge and personal attributes. The role of nursing education to increase nurses’ cultural awareness was highlighted too. Keywords: Minority ethnic nurse, cultural competence, parents’ experiences, paediatric, Content analysis. Submitted 17 January 2013, Accepted 17 April 2013
hospitalised every year (2). It is common for parents to stay in the hospital with their child and participate in their child’s care (3,4). Child hospitalisation is a very stressful process that affects the child and the family and also affects the interaction between the parents and the care providers (5–7). A trusting relationship, the staff’s attitude and the parents’ involvement in care and information about their child’s illness are factors that play a major role in parents’ satisfaction related to their child’s care (8, 9). These factors and other factors such as clear communication, culturally sensitive care, transcultural caring relationships and nurses’ cultural competence impact patient satisfaction in a multiethnic society (10– 13). The above factors are also important for the present study that focuses on the interaction and care relationship between the parents and nurses who do not share the same ethnic background and first language. According to previous research, minority ethnic nurses’ difficulties in adjusting to the new environment/culture and difficulties in communication can affect nurses’ skills to meet the needs of patients/relatives and affect the interaction between them (14), which is the focus of the this study. 1
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The multiethnic issues in health care The term ethnicity is used in different ways in health care. Usually, ethnicity represents a form of group or social identity that draws on a nation’s shared background or ancestry (15). The multiethnic issues in health care have been studied from different perspectives. Several studies have explored the experiences of minority ethnic nurses working in a multiethnic society. For example, some researchers (16) have studied African American and Hispanic nurses’ experiences of the influence of their race and ethnicity on the quality of health care and on their own professional careers. The results of these studies demonstrated that minority ethnic nurses experienced racism and prejudice (16). Other researchers have studied the experiences of Black and minority ethnic nurses in the National Health Service in the south of England. These studies reported that the minority ethnic nurses experienced fear and discrimination (14,17). These experiences coupled with the lack of opportunities to develop adequate skills to meet the needs of the patients/relatives create an unpleasant feeling negatively affecting the interaction between the nurse and patient/relatives (14). The multiethnic issues in health care have also been studied from the perspective of healthcare staff belonging to the majority population. Danish nurses experienced difficulties in communication when they met minority ethnic patients in the Danish healthcare system (18). Communication difficulties were also highlighted in a Norwegian study about nurses’ experiences of professional and cultural conflicts related to the practical situation of meeting families with different ethnic backgrounds (19). In Sweden, primary child health nurses expressed a lack of cultural competence and difficulties in communication when dealing with children and parents with immigrant backgrounds (20). These difficulties also occur in the care relationship with minority ethnic nurses (14). Studies about the aspect of ethnicity in health care have become more and more focused on the concept of culture, transcultural nursing and cultural competence (20–25). This also holds true in Swedish paediatric research (12, 20).
other than their own (21, 25, 27). The goal for transcultural nursing is ‘to provide culturally congruent, sensitive, and competent nursing care to people of diverse cultures’ (28, p. 4). The concept of cultural competence has been studied by many theorists from Sweden, United States, England and New Zealand (21, 26, 29, 30). Swedish researchers have highlighted awareness of diversity among human beings and a nonjudgemental openness towards all individuals as important aspects of cultural competence (31). According to a Swedish study, cultural competence includes nurses’ cultural understanding, cultural sensitivity and cultural encounters (32). In Sweden, cultural care encounters in hospitals occur in several constellations: for example, a majority ethnic nurse (ethnic Swedish nurse) caring for a minority ethnic patient; a minority ethnic nurse caring for a majority ethnic patient; and, finally, a minority ethnic nurse caring for a patient from a minority ethnic group (21). Multiethnic issues from the perspective of the patients/ relatives and the majority group have not been studied sufficiently either in Sweden or internationally. The increasing number of minorities in the health profession is a fact. It is important to know patients’/relatives’ opinion about minorities working in the health profession. This study can be used as an important aspect of quality of care in a multiethnic society. This is important for all nurses practicing within a multiethnic society such as Sweden.
Aim This study aims to explore how parents with ethnic Swedish backgrounds experience minority ethnic nurses’ cultural competence and the care the nurses provided in a Swedish paediatric care context.
Methods Design The study was conducted using an exploratory qualitative design (33). The focus in the study was on parents’ experience of nurses’ cultural competence and the care provided by them.
Cultural competence in nursing The concept of culture is multidimensional and complex with several definitions. In relation to nursing, culture is defined as ‘the shared way of life of a group of people that includes beliefs, values, ideas, language, communication, norms and visibly expressed forms such as customs, art, music and clothing’ (26, p.10). The present study draws upon the theories of cultural competence in nursing which refer to the knowledge and skills nurses need in order for them to be able to provide culturally competent care for patients from an ethnic and cultural background
Participants The sample consisted of 14 parents (Table 1) (seven mothers and seven fathers, not couples) with ethnic Swedish backgrounds who had their child in a ward at a children’s hospital in the Stockholm County Council between October and December 2011. The length of the child’s hospital stay varied from a few days to a few months. Parents were between 31 and 49 years old. On the child’s discharge, a member of the research team (AGT) or the study’s contact nurse at the ward provided © 2013 Nordic College of Caring Science
Minority ethnic nurses’ cultural competence
Table 1 Demographic background of the participants
Interview
Relationship with child patient
Age
Length of child’s hospitalisation
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Mother Father Father Mother Mother Mother Mother Father Father Mother Mother Father Mother Father
41 Unknown 49 31 41 Unknown 37 39 42 49 35 Unknown 37 46
6 days 6 days 2 days* 5 days 7 days 4 days 3 days 2 days 3 weeks, 4 times Every third month 3 days * 6 months 5 days* Once a week
*The child has been hospitalised several times before.
parents verbal and written information regarding the aim of the study. All ethnic Swedish parents in the ward were approached when the contact nurse or AGT was present in the ward (2 days a week). One of the members (AGT) of the research team contacted all parents who expressed an interest in participating in the study. The parents were contacted 2 weeks after their child was discharged. If the parent agreed to participate in the study, an appointment was made for the interview that was conducted in a setting chosen by the parent, for example, their home, the researcher’s office, at the hospital or over the phone. In this study, the term minority ethnic nurses is based on the definition by Culley and Mayor (34). The term implies not only those who have migrated to a country but also those who have been born in the country and describe their ethnic origin as other than the majority population (34).
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Data analysis The data were analysed using content analysis. Content analysis is a systematic, objective, qualitative analysis and a relevant research method for establishing reliable and valid conclusions from data to their text in order to give knowledge (37). The interviews were tape-recorded, transcribed verbatim and analysed by qualitative content analysis in an inductive way according to Elo and Kyng€as’s (38) description of this method. According to them, the analysis process includes three phases: preparation, organising and reporting the data (38). The first step is that the preparation was to read through the text several times to make a sense of the whole and to select the units of analysis. The units of analysis were identified, which were constellations of words or sentences related to the aim of the study. The data were then organised, a process that included open coding, creating categories and abstraction. The written texts were read through again, and open coding was created. The codes were compared with each other in relation to differences and similarities and thereafter sorted into groups and subcategories. In the next step, the subcategories were created. We have involved an interpretation of the underlying meaning of the text in this step, which is called the latent content (39). The next step was abstraction, where we formulated a general description of the research topic by creating main categories. The second author (ZNK) independently analysed five randomly selected interview transcripts, and the analyses AGT and ZNK undertook were compared and discussed until agreement was reached. Finally, after the first author had completed the analysis of all interview transcripts, the second (ZNK) and the third author (MJ) read all the interview transcripts and confirmed the analysis in order to increase credibility of the content and the results (40).The quotes were translated after the analysis had been carried out.
Data collection Data were collected using semi-structured interviews (35,36). The focus in the study was on parents’ perception and experience of nurses’ cultural competence. An interview guide was developed based on the previous research regarding cultural competence and its related categories: cultural sensitivity, cultural understanding and cultural encounters as defined by Swedish researchers (32). The main themes in the interview guide were interaction and care relationship between the nurse and the parents as well as nurses’ cultural competence. The first author (AGT) conducted and transcribed all the interviews. The interviews lasted 19–35 minutes and were digitally recorded. The interviews and transcripts were in Swedish. Only the excerpts quoted in the results section were translated into English. © 2013 Nordic College of Caring Science
Ethical considerations The study was approved by the Regional Ethical Review Committee, Stockholm. The parents were informed that they could withdraw from the study at any time, and they were even informed that their interviews were recorded. All parents provided written consent to participate in the study. The data provided by the participants have been handled confidentially.
Results Analyses of the interviews led to four main categories: (I) influence of nurses’ ethnicity, (II) significance of crosscultural communication, (III) cross-cultural skills and (IV) the importance of nursing education; and the six
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subcategories were (i) nurses’ ethnicity does not matter, (ii) experiences of minority ethnic nurses, (iii) the importance of language skills, (iv) the importance of adaptation and awareness of the Swedish culture, (v) cultural encounters and personal attributes and (vi) cultural sensitivity as shown in Figure 1. Quotes from the interviews have been used to illustrate main categories and subcategories.
Influence of nurses’ ethnicity All interviewed parents emphasised that nurses’ cultural background and affiliation had no impact on their experience of care. But they had mixed feelings and different experiences and opinions of the minority ethnic nurses’ professional knowledge. Nurses’ ethnicity does not matter. Parents emphasised that nurses’ cultural background in terms of ethnic differences had no bearing on the nursing care and how nurses supported the parents. There was no difference in parents’ experience whether their child received care from an ethnic Swedish nurse or an ethnic minority nurse. It was nurses’ professional knowledge, that is, their nursing skills, medical knowledge and competence, as well as
The importance of language skills
personal attributes that mattered. Some of the parents thought that ethnic minority nurses are a good resource to health care. I have not experienced cultural differences as a barrier or something uncomfortable or anything like that at all, not at all (Father, 49 years). Experiences of minority ethnic nurses. The parents mentioned different experiences and opinions about the care they had received from minority ethnic nurses. Most of the parents felt that minority ethnic nurses were nice, talented and competent. The parents felt respected and well treated by the nurses. I personally think that foreign nurses are talented and much warmer and personal. This was my experience, and I felt very positive (Mother, 37 years). Some parents believed that the minority ethnic nurses had good knowledge of the medical technical tasks and nursing care. Some of the nurses had even had previous experience in their home countries, which was an advantage. I think they have an extra skill that makes them even better at what they do. The fact that they certainly have practiced where they come from and that they have adjusted to another culture, I would
The importance of adaptation and awareness of the Swedish culture
Nurses ethnicity dosen’t matter
Expreiences of minority ethnic nurses
Influences of nurses’ ethnicity
Significance of crosscultural communication
Cultural competence
The importance of nursing education
Cross-cultural skills
Cultural encounters
Personal attributes and cultural sensitivity
Figure 1 Swedish parents´ experiences of minority ethnic nurses’ cultural competence. © 2013 Nordic College of Caring Science
Minority ethnic nurses’ cultural competence think would give them an advantage, absolutely (Father, 46 years). Nurses’ lack of knowledge in medical and nursing care reduces parents’ confidence in the nurse and creates frustration. The parents expected that the nurse should be able to inform them correctly about their child’s condition, that he or she should be well informed about the child’s medical records and that he or she should be prepared with information when entering the child’s room. The parents should not have to explain and repeat the information time after time. Parents expressed the same expectations of a Swedish nurse, however. It was a nurse who was incredibly incompetent that I actually sent out from the room. She made mistakes with the medication and she could not speak Swedish well. I would react exactly the same way if it were a Swedish nurse. It had nothing to do with her background. It had everything to do with her competence (Mother, 41 years). In addition, some of the parents expressed their view that minority ethnic nurses tended to be authority driven in the sense that they listened more to the doctors than to the parents. The parents thought that some of the minority ethnic nurses did not have good listening skills. The doctor or nurse should be able to listen and have a capacity for empathy, but those from other cultures do not have this listening ability. They have more of an authoritative approach, an authoritative upbringing, and you get very frustrated (Mother, 49 years).
Significance of cross-cultural communication Communication was one of the most important aspects for all interviewed parents and was regarded as the basis for good quality nursing care. The parents thought that language skills, adaptation to Swedish culture and awareness of the Swedish culture are the foundations for a well-functioning communication between minority ethnic nurses and Swedish patients/relatives. The importance of language skills. All the parents expressed the importance of Swedish language skills of minority ethnic nurses. Parents emphasised the importance of communication and felt the communication must work well. The nurses’ lack of linguistic skills was one of the factors that could reduce the parents’ satisfaction with the care minority ethnic nurses provided. Parents felt that most of the minority ethnic nurses could speak good Swedish, but they had also met some minority ethnic nurses whom they could not understand. If the parents were unsure whether the nurse could understand them, they felt insecure. The language is very important. I do not want to experience flawed language; then I do not know if they understand me (Mother, 37 years). © 2013 Nordic College of Caring Science
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The importance of adaptation and awareness of the Swedish culture. Parents expected that minority ethnic nurses who worked in a Swedish hospital should know about and respect Swedish norms and values. The parents pointed out the importance of adaptation. They expected that minority ethnic nurses should modify and adapt their values to Swedish values. The parents stated that because all nurses have a Swedish education and licence to practise in the country, they should know about Swedish culture. Swedish culture is very socially controlled and has many hidden codes. It is very important that the nurses know these codes; otherwise, there will not be a successful interaction between the nurse and the patient/relative. I am Swedish, my daughter is Swedish, and we are admitted to a Swedish hospital and [we have] a nurse with a foreign background; she knows, she sees us, and she should adjust her values [to] Swedish norms (Father, 49 years). Nurses should also be aware that there are individual differences between people from the same cultural background and that people from other cultures have different needs than one’s own. The nurses should have the confidence to ask questions.
Cross-cultural skills Nurses’ cultural competence/skills were described by parents as the nurses’ ability to have a successful encounter with patients/relatives from a different culture; nurses should have the ability to be sensitive to patients’ needs. Nurses’ personal attributes were also mentioned as an important factor by parents. Cultural encounters. According to the interviewed parents, health care is a great place to meet one another and share the culture and be aware of differences and similarities between the cultures. Health care is a place where you touch each other and meet each other in a very peaceful yet critical manner. It is a very good place to start to reduce prejudices (Father, 46 years). Parents mentioned that a cultural encounter in health care is an encounter between different cultures, whether it is a doctor, a patient or a nurse who comes from a different culture. One should avoid conflict in order to have a successful cultural encounter. Parents describe conflict as something that one individual may be comfortable with but another may feel uncomfortable with. It is very difficult to know how conflict works in different cultures. It is important to be aware of and have knowledge about the patients’ culture and treat patients in the way they want to be treated as well as to meet them at their level. For example, a Swedish family may need to be by themselves during the patient’s recovery. Swedish families like
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structure and routines. Gender equality – the concept that men and women are equal – is very important to a Swede; it permeates Swedish society. Minority ethnic nurses need to know about these values. This knowledge is even more importance when the child is hospitalised for a long period. This parent had a good experience of cultural encounters in the ward. There have been many nurses as well as many parents from other cultures in the ward. There has been an understanding for the other cultures and from other cultures to us Swedish-born (Father, 42 years). The parents had confidence in the nurses and they felt that they had a good relationship with minority ethnic nurses. One parent, however, felt that it was much easier for her to relate to an ethnic Swedish nurse. Of course, it is easier to relate to a Swedish nurse. I cannot put my finger on why it is really so. It is a common behavior (Mother, 41 years). Some parents felt that they had poor knowledge of minority ethnic nurses’ cultural values and norms. This lack of knowledge hindered a good relationship with the nurse. Parents did not know, for example, whether they could joke with a Muslim nurse wearing a headscarf, if she would feel offended by jokes. Parents thought that they needed more knowledge about the minority ethnic groups in Sweden. Something that was a little harder to be yourself [if you] do not really know how to respond to them and their culture [the nurse’s culture]. They wear a headscarf, and when they enter a room, there I am, half dressed. The respect towards her? I do not know how to handle it (Father, age unknown). Personal attributes and cultural sensitivity. The parents thought it was important that the nurse have a human outlook and have a feel for and sensitivity towards the patients’ cultural needs. The nurse should be open to cultural differences and have the confidence to ask questions. For almost all parents, cultural competence and cultural encounters are not about knowledge. It is more a question of openness, feeling, respect and understanding of diversity. It is all about the nurses’ characteristics. It is about respect for individual differences, even though some of the differences are cultural and religious. The parents believe that one can show respect with a humble attitude. It was not the nurses’ ethnicity and/or cultural background that played a role in the parents’ experience of care; it was the nurses’ personal attributes and professional qualities that played a major role in how satisfied parents felt about their needs being met while their child was hospitalised. All parents thought that the nurse must be able to listen to them, be attentive, sensitive, humble, open and empathise with and respect others. Nurses, parents felt, must show an interest in the individual; then,
they can see the culture as a part of the individual and show that they care about the patients and their culture. It is a question of mutual respect and understanding. In a nursing job, the individual is so important: the individual and the individual’s attitude towards the people one meets, and the cultural part comes into it (Mother, 41 years). In all human encounters, a person should respect differences, and that respect can be shown with a humble attitude. Almost all parents felt respected. They felt that the nurse was humble and listened to them. The nurses were nice and had a nice attitude. In all human encounters one should respect others’ differences, and it can be done with a humble attitude (Mother, 37 years). Regarding ‘cultural needs’, some parents mentioned that they did not have any particular cultural or religious needs, or they did not know whether their needs were cultural needs. Some of the parents thought they had cultural needs, and the nurse should know very early on about their needs as a Swedish parent and should satisfy these needs. Cultural needs are very important. Many have cultural needs, and so long as resources allow for it, [they] should be satisfied (Father, 46 years). In addition, the nurse should always ask the patient whether he or she has any specific needs. It does not need to be a cultural need but may be any other need, such as a dietary need. Asking should be a routine for all nurses. According to the parents, there was no one who asked them whether they had any specific or cultural needs. We need to be asked this question. One comes to the hospital with a child, and there is a lot to think about. One misses a lot in communication. The more the nurse asks, the less she misses (Father, 39 years).
The importance of nursing education Parents highlighted the importance of nursing education. They expect that the training should include information about the Swedish norms and values. Parents knew that everyone working in health care has a Swedish education and a licence to practise in Sweden. The parents take it for granted that the non-Swedish nurses have knowledge of Swedish culture from their education. Cultural knowledge should be recognised and be included in the programme. At every place, I have met nurses and doctors who did not have a Swedish background. Many of them have a Swedish education, even if they have a different background. I think [cultural awareness] should be in the nursing education. I do not know how nursing education is, but it is something that must be discussed in nursing (Mother, 41 years). © 2013 Nordic College of Caring Science
Minority ethnic nurses’ cultural competence
Discussion This study explored the Swedish parents’ experiences of the care minority ethnic nurses provided in Swedish paediatric care. This study is among the few studies that describe the majority’s experiences with minority ethnic staff in health care in a multicultural society. This study confirms the previous theories of cultural competence, which emphasise nurses’ need to be culturally competent and knowledgeable about patients’ culture (29, 41). The current study also adds new aspects to the conceptualisation of cultural competence, such as the importance of minority ethnic nurses’ adaptation to the majority’s culture and the importance of nurses’ linguistic skills. The importance of nursing education in training minority ethnic nurses on cultural competence was highlighted. A new finding in this study was that nurses’ ethnicity did not have much impact on parents’ experience of their child’s care. None of the participants expressed a judegmental attitude when they talked about their experiences with minority ethnic nurses. The parents were respectful and understanding of the minority ethnic nurses and respected their professional knowledge. These findings are in contrast to minority ethnic nurses’ own experiences of the influence of their ethnicity in their professional workplace. Minority ethnic nurses described racism, prejudice and discrimination as shared experiences (14, 16, 17). Parents’ experiences of minority ethnic nurses were mixed. They thought that the minority ethnic nurses had good medical knowledge and had respect and a humble attitude. At the same time, the parents felt frustrated with the minority ethnic nurses’ authoritative approach, lack of language skills and poor knowledge of Swedish culture. Minority nurses’ leaning towards an authoritative approach was not reported in other studies and should be followed up in future research. The parents mentioned the importance of a good communication in paediatric care. Parents expressed that difficulties in communication between the nurse and the patient create anxiety and uncertainty and also reduce parents’ satisfaction with health care. These findings confirm the results of other research about minorities in health care. Previous studies mention difficulties in communication and the need for culturally and linguistically competent staff in health care (12,16,18,20,42). Parents expected that minority ethnic nurses should be able to speak Swedish clearly; nurses’ language skills were very important for all interviewed parents in this study. This finding is in contrast to a similar study from Israel on the relationship between elderly care recipients and minority ethnic nurses working in home care. This study reported that a similar cultural background as well as nonverbal and good understanding between the healthcare provider and the patient was more effective than speaking a © 2013 Nordic College of Caring Science
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common language (43). In regard to communication that functioned well, parents highlighted the importance of nurses’ adaptation to the Swedish culture. Minority ethnic nurses needed to adapt the parents’ culture and integrate themselves with the new culture in their professional work. The results of this study confirm the previous models of cultural competence in nursing, which involve the integration of cultural awareness, cultural knowledge (26, 29), cultural encounters and cultural sensitivity (26,32). The participants in this study emphasised that cultural competence is more about nurses’ cultural awareness and cultural sensitivity and their ability to have a successful cultural encounter, rather than just cultural knowledge in itself. These findings also confirm the previous studies on cultural competence (44,45). Some parents thought that not only healthcare staff but also patients/relatives should be culturally aware in a multicultural society. This attitude is about mutual respect and understanding. This finding adds a new dimension to the concept of cultural competence. The participants in this study expressed that nursing education should include cultural competence with regard to knowledge about Swedish culture and norms. The importance of including transcultural nursing in nursing education is also highlighted in previous research (12, 46–48). Some researcher pointed out that training in cultural competence improves the skills and attitude of healthcare professionals and positively impacts patient satisfaction (11). According to Maier-Lorentz (47), nurses need to be open-minded and to show a positive interest in learning about other cultures. This attitude is the most effective way to increase nurses’ awareness of cultural differences. Finally, the positive relationship between this study and theories of cultural competence is important and also influences the development of nursing knowledge. In summary, this study has explored Swedish parents’ experiences with minority ethnic nurses in Swedish paediatric care. Nurses’ ethnicity did not have much impact on parents’ satisfaction related to their child’s care. Parents attached great importance to nurses’ language skills, to their adaptation to and awareness of the Swedish culture and to their professional knowledge and personal attributes. A transcultural encounter is about mutual respect. Nursing education plays a role in increasing nurses’ cultural awareness. It is important to discuss some limitation of the study. The study was performed in a large hospital in Stockholm. People in big cities are generally exposed to more people from minority ethnic groups. This could affect the results of the study. The interviewer’s own foreign background could have played a role during data collection and even in the interpretation of the data. The research team was aware of this and tried to avoid imposing their own values in the interpretation of data. The length of each child’s hospitalisation was different. This difference
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could also affect parents’ experiences of the care minority ethnic nurses provided. The small study sample based on a single hospital means one has to be careful drawing general conclusions from the findings. This study is an exploratory qualitative study and not a large study with the aim to generalise the results. Instead, the context is described so that the reader can conclude whether the results are possible to transfer into his/her context. However, the wider international literature examining cultural competence and the care the nurses provide support many of the findings in this study.
manuscript preparation. Zarina Nahar Kabir (ZNK) and Maria Jirwe (MJ) were involved in the study design, data analysis, manuscript preparation and also in critical revision of manuscript and linguistic revision.
Ethical approval The study was approved by the Regional Ethical Review Committee, Stockholm, Dnr: 2011/927-31/5, dated 22 June 2011.
Funding Acknowledgements We acknowledge Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden, for their financial supports.
Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden, have supported the research, Dnr: 2919/2010, dated 24 September 2010.
Author contribution
Conflict of interest
Azar Gashasb Tavallali (AGT) was involved in the study design, data collection, data analysis and also in
The authors declare no conflict of interests.
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