Journal of Professional Nursing 37 (2021) 1119–1131
Contents lists available at ScienceDirect
Journal of Professional Nursing
journal homepage: www.elsevier.com/locate/jpnu
Challenges and approaches to transcultural care: An integrative review of
nurses' and nursing students' experiences
Sharoon Shahzad a, Nizar Ali b, c, Ahtisham Younas d, e, *, Jude L. Tayaben f
a
Islamabad Nursing College, Islamabad, Pakistan
Prime Institute of Health Sciences, Islamabad, Pakistan
c
PAEC General Hospital Islamabad, Pakistan
d
Swat College of Nursing, Mingora Swat, Pakistan
e
Faculty of Nursing, Memorial University of Newfoundland, Canada
f
College of Nursing, Benguet State University @ La Trinidad, Philippines
b
A R T I C L E I N F O
A B S T R A C T
Keywords:
Transcultural care
Cross-cultural care
Cultural diversity
Culturally diverse patients
Culturally sensitive care
Integrative review
Background: Provision of transcultural care is an essential nursing competency. It is important to comprehen­
sively understand the challenges nurses and nursing students face while striving to provide transcultural care in
clinical settings.
Purpose: The purpose of this review was to develop a comprehensive understanding of nurses' and nursing stu­
dents' challenges and approaches to the provision of transcultural care to people with diverse ethnicities.
Methods: An integrative review was conducted. Literature was searched within five databases, and 30 studies
published from January 2010 to January 2021 were reviewed and appraised using mixed methods critical
appraisal tool. Literature summary tables and inductive approaches were used for data extraction and synthesis.
Results: The challenges to the provision of transcultural care were intrapersonal struggle, cultural conflicts, varied
expressions of pain and suffering, and navigation of personal and organizational constraints. Addressing these
challenges required nurses and students to practice self-criticism and tolerate differences, develop interpersonal
and psychological skills, and collaborate with peers and patients' families.
Conclusions: Provision of transcultural care is a complex task for nurses and students because of different
interpretation of personal and organizational factors. Health care institutions should proactively provide re­
sources to nurses and students to strengthen their interpersonal and psychological skills to provide effective
transcultural care.
Introduction
The contemporary health care settings are becoming increasingly
culturally diverse due to globalization and immigration as people with
diverse ethnicities enter healthcare (Institute for Healthcare Improve­
ment, 2021). Contemporary research notes that social and cultural de­
terminants of health play a significant role in the access and delivery of
health care services, thereby affecting the physical and mental wellbeing of underserved populations (Bos et al., 2019; Cena et al., 2020;
Galea et al., 2011; Han & Lee, 2015; Markwick et al., 2015; Nandi et al.,
2014; Reibling et al., 2017). Global humanitarian organizations such as
the United Nations and World Health Organization emphasize that all
human beings must receive needed healthcare services without gender,
race, color, or cultural discrimination to achieve the highest level of
general well-being.
With increased diversity in healthcare, nurses being the front-line
care providers, are also expected to provide sensitive and culturally
appropriate care to patients and families with distinct cultural and social
backgrounds (Douglas et al., 2011; Jeffreys, 2015). People from
different cultures have their own ethical, social, and moral values and
beliefs which must be respected and valued. Therefore, providing
effective and culturally sensitive care may become daunting, requiring
nurses to be aware of personal and patients' cultural and social beliefs
and preferences and acting accordingly (Douglas et al., 2011; MaierLorentz, 2008). Culturally sensitive and competent care falls under the
umbrella of transcultural nursing. Leininger defined transcultural
nursing as “a substantive area of study and practice focused on
comparative cultural care (caring) values, beliefs, and practices of
* Corresponding author at: 174 Patrick Street A1C, 5C4, St. John's, Newfoundland and Labrador, Canada.
E-mail address: ay6133@mun.ca (A. Younas).
https://doi.org/10.1016/j.profnurs.2021.10.001
Received 7 June 2021;
Available online 9 October 2021
8755-7223/© 2021 Elsevier Inc. All rights reserved.
S. Shahzad et al.
Journal of Professional Nursing 37 (2021) 1119–1131
individuals or groups of similar or different cultures. Transcultural
nursing's goal is to provide culture specific and universal nursing care
practices for the health and well-being of people or to help them face
unfavorable human conditions, illness, or death in culturally meaningful
ways” (Leininger, 1995, p.58).
Providing transcultural care is a professional responsibility and
moral obligation of nurses (Bjarnason et al., 2009). Health care and
nursing organizations worldwide emphasize the need for the provision
of transcultural and sensitive care (American Nurses Association, 2021;
College of Nurses of Ontario, 2018; Institute for Healthcare Improve­
ment, 2021; Transcultural Nursing Society, 2020). Receiving culturally
sensitive or transcultural care improves patients' general well-being and
makes them feel valued and respected in health care settings (Giger &
Haddad, 2020; Leininger, 1997). It also improves patient satisfaction
with health care and care providers' behaviors and promotes positive
health outcomes (Maier-Lorentz, 2008). Nevertheless, the provision of
transcultural or culturally sensitive care is a complex endeavor as nurses
need to learn about various cultures, become aware of the potential
influence and effect of personal cultural values and beliefs on patients'
cultural values and beliefs, and discern the most appropriate and
respectful interventions to meet the culturally specific needs of patients
(College of Nurses of Ontario, 2018; Younas, 2020). The complexity of
transcultural care could be further attributed to interpersonal, contex­
tual, organizational, political, and system-level factors (Ahmed et al.,
2017; Felix, 2017; Nápoles-Springer et al., 2005). Such factors affect the
dynamics of health care organizations and the alliances among organi­
zations, community support groups, and the health care system.
Therefore, nurses and nursing students may find it daunting to provide
transcultural care while navigating the demands of organizations and
health systems.
To date, no reviews have synthesized nurses' challenges and ap­
proaches to provide transcultural care to people with diverse ethnicities
and cultures. Previous reviews focused on different aspects of trans­
cultural care such as state of literature concerning transcultural nursing
in the UK (Narayanasamy & White, 2005) and across the world (Mur­
phy, 2006), strategies for guiding teaching and learning about crosscultural care and anti-racism in nursing education (Allen, 2010),
providing culturally appropriate care in health care settings (Williamson
& Harrison, 2010), interventions to improve culturally competent in
health care (Truong et al., 2014), using simulation to improve culturally
competent nursing care (San, 2015), and theoretical works about
transcultural nursing care (Im & Lee, 2018). One systematic qualitative
review of eight studies determined nurses' barriers when caring for
ethnic minorities (Joo & Liu, 2020). The authors identified that the key
barriers were: communication, missing or unclear care information and
resources, inadequate cultural training and education, the challenges in
developing a therapeutic relationship, and issues surrounding quality of
care. This review has limitations such as the inclusion of only qualitative
studies, the inclusion of studies only published in the western countries
(the US, Norway, England, Ireland, and Finland), and no synthesis of
information about approaches used to improve the quality of trans­
cultural care. Given this gap, it is essential that a comprehensive un­
derstanding is developed about challenges faced by nurses and nursing
students and the approaches to provide transcultural care. Gaining this
understanding may enable health and community organizations to
develop strategies and necessary policies to support nurses in providing
effective transcultural care. Educational institutions could consider the
challenges and tailor their teaching and learning approaches to prepare
a culturally sensitive workforce. Therefore, this review seeks to address
this gap.
Methods
An integrative review was conducted because this type of review
allows for the synthesis of various literature sources with various
research designs. The steps included: problem identification, literature
search, data evaluation, and data analysis (Whittemore & Knafl, 2005).
Problem identification
The emerging literature about social and cultural determinants of
health and the need and effect of transcultural care for individuals' wellbeing served as the baseline to understand the challenges and ap­
proaches of nurses to provide such care. There is an expectation that
health care professionals be equipped with skillsets and knowledge to
provide culturally sensitive care to people with diverse cultural back­
grounds (Douglas et al., 2011; Jeffreys, 2015). It was deemed essential
to develop a comprehensive understanding of nurses' and students'
challenges so that health care organizations and educational institutions
can prepare nurses who can better care for diverse patient groups.
Inclusion and exclusion criteria
The inclusion criteria of the studies were: a) original research
(qualitative, quantitative, and mixed methods) published in the English
language in peer-reviewed journals from January 2010 until January
2021, b) research articles that included nursing students and/or nurses
as a sample and were focused on their experiences, perceptions, views,
and opinions concerning transcultural care for patients from diverse
cultures, c) articles about students and nurses' views and experiences of
interactions and communication with patients with diverse cultures,
refugees, and immigrants, and d) articles exploring nurses' and students
views about transcultural care in any hospital or community care
setting. The exclusion criteria were: discussion papers, reviews, reports,
letters, commentaries, and dissertations.
Literature search
The literature was searched in Cumulative Index of Nursing and
Allied Health Literature (CINAHL), PubMed, Scopus, Science Direct, and
Google Scholar databases using indexed keywords and MESH terms:
“transcultural care”, “cross-cultural care”, “culturally sensitive care”,
“students, nursing”, “cultural”, “immigrant patients”, “culturally diverse
patients”, “experiences”, “challenges”, “culturally competent care”,
“clinical practice”, and “nurses”. Initial search retrieved 14,351 searches
in all of the databases. Of these, 1375 articles were entered into the
screening phase after removing the duplicates, dissertations, and book
results. Of these articles, 1022 commentaries, discussions, literature
reviews, and other records about interventions, educational strategies,
and organizational approaches to promote transcultural care and arti­
cles including health care providers along with nurses as sample were
excluded because they were irrelevant. Finally, 353 articles were
entered into the screening phase and evaluated after reading the ab­
stracts. After removing additional irrelevant articles about nurses' and
students' perspectives and views about intercultural communication,
levels of cultural competence, scale development and testing on cultural
competence, intercultural competence, and curriculum content on
transcultural and culturally competent and sensitive care, 31 articles
were entered into the full-text screening. Of these 31 full-texts, we
excluded one article about the lived experiences of transcultural nurses
about participation in Hajj (i.e., Islamic pilgrimage to Mecca in Saudi
Arabia). In total, 30 articles were included in this review. The PRISMA
diagram outlining a detailed search strategy is presented in Figure 1.
Purpose
The purpose of this review was to develop a comprehensive under­
standing of nurses' and nursing students' challenges and approaches to
the provision of transcultural care to people with diverse ethnicities.
Data evaluation
We used the Mixed Methods Appraisal Tool (MMAT) (Hong et al.,
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Journal of Professional Nursing 37 (2021) 1119–1131
Fig. 1. Search strategy.
2018) for appraisal and quality assessment. Following the recommen­
dations, the overall quality scores were not assigned. However, the
studies were rated as strong, moderate, and weak in quality. The MMAT
includes quality assessment regarding overall research questions and the
data quality to answer the questions and different items to appraise
qualitative, quantitative, and mixed methods studies. The reviewers are
encouraged to respond “yes” and “no” to the critical appraisal items and
offer comments regarding the study quality.
After rating the studies as low, moderate, and high quality, more
emphasis was placed on the high and moderate studies during data
analysis and synthesis. Due to the diversity of empirical research studies,
weakly rated studies were not excluded from the synthesis. Instead, their
findings were only used to support the synthesized findings from strong
and moderately rated studies. Two reviewers independently performed
the critical appraisal resulting in two sets of critical appraisals. These
sets of appraisals were discussed and merged into one after resolving
discrepancies. The remaining team members assessed the quality of
rating based on: a) their reading of the included studies and b) their
reading of the strengths and limitations of the studies outlined by the
two reviewers who performed the critical appraisal.
strengths and limitations, and conclusions (Younas & Ali, 2021). The
results and discussion sections were thoroughly read and coded for data
synthesis, and narrative and thematic summaries were developed
(Younas et al., 2021). One reviewer also wrote one page summary of all
the reviewed articles. These summaries were analyzed following the
overall review purpose and the summary tables. Then sub-themes were
developed and collated into themes. Two reviewers independently
synthesized the data. The discrepancies were discussed between the
reviewers, and then the developed themes and sub-themes were shared
with the team. During this stage, the reviewers conducted several online
meetings to evaluate the consistency and validity of generated themes.
The review team appraised the themes and sub-themes; evaluated their
fit with the study findings; and offered alternative themes and subthemes if missed by the two reviewers. This process was continued
until a consensus was reached. After the themes were finalized, the
write-up of the review findings was completed.
Findings
Overview of the studies
Of 30 studies, five studies each originated from Sweden and Turkey,
followed by three each from the US, Norway, and Ireland, and two each
from Finland and China. The remaining studies were from the UK,
Netherlands, Canada, India, Taiwan, Jordan, and Iran. In total, 23
studies used qualitative approaches, five studies used a quantitative
Data analysis
Literature summary tables were developed for data extraction. The
tables included information about the authors, purpose, methods, sam­
ple and characteristics, data collection methods, main findings,
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approach, and two studies utilized mixed methods designs (Suurmond
et al., 2010; Alpers & Hanssen, 2014). The commonly used qualitative
designs were descriptive qualitative, exploratory qualitative, interpre­
tative description, interpretive phenomenology, descriptive phenome­
nology, grounded theory, and ethnography. The sample size for the
qualitative studies ranged from five to 374. All quantitative studies used
cross-sectional designs with a sample size of participants ranging from
30- to 1190. Most of the studies included nurses (i.e., intensive care,
emergency, community and home care, general medical and surgical,
and mental health nurses) and nurse practitioners as the sample while
six studies included nursing students (Jirwe et al., 2010; Dotevall et al.,
2018; Markey et al., 2018, 2019; Evgin & Muz, 2021; Tosun & Sinan,
2020) (Table 1).
appropriate care. Often patients and their families refused the care
offered by nurses and nursing students and relied on traditional and
cultural modalities of care (Evgin & Muz, 2020). Lin et al. (2019) noted
that many elderly patients were stringent about taboos and folk beliefs
that affected nurses' ability to care for them. They described that some
patients wanted to go home because they believed that staying in hos­
pital for a specific time may result in death. Sometimes, cultural conflicts
arose due to patients' preference for not accepting care from a nurse of
the opposite gender. For example, Sevinc (2017) noted that female pa­
tients did not want to be cared for by male nurses. Similarly, Kalengayi
et al. (2015) noted that male patients refused care from female nurses.
Amiri and Heydari (2017) discussed cultural conflicts arising due to
differing religious orientations of nurses and patients (e.g., Afghani-Iraqi
and Shia-Sunni).
Debesay et al. (2014) discussed that cultural conflicts also resulted
from patients' and nurses' distinct health beliefs. For example, based on
the research evidence, some nurses encouraged patients and their fam­
ilies to mobilize their relatives with stroke as early as possible and
tolerated. However, patients and their families believed that more rest is
better and placed little confidence and effort in early mobility. The
cultural conflicts greatly affected nurses' ability to engage in effective
transcultural care (LicSc, 2018; Kalengayi et al., 2015).
Critical appraisal
Most of the studies were rated as moderate (n = 12), followed by
strong (n = 10) and weak (n = 8). The strongly and moderately rated
studies had several strengths such as large and representative samples,
robust data analysis, researcher and methods triangulation, member
checking, detailed description of study findings, valid and reliable tools,
pilot testing of interviews guides, audit trail, detailed description about
researcher reflexivity and data saturation, and use of multiple recruit­
ment strategies. Two or more of the above-listed elements were absent in
weakly rated studies in accordance with the study methodology
(Table 1). The key themes are described as follows and also illustrated in
Table 2.
Understanding varied expressions of suffering and combating uncertainties
Nurses and students noted varied ways in which people from diverse
ethnicities expressed their suffering and pain. Therefore, nurses required
more effort to understand the various expressions and emotions
depicting pain and suffering (McCarthy et al., 2013). Listerfelt et al.
(2019) noted that nurses shared that the patients and their families
expressed feelings of grief and sorrow dramatically with loud noises.
Such expressions were unusual for nurses and led to uncertainty and
anxiety as to how to provide effective and relevant care. Alpers et al.
(2014) also noted that pain and mental health assessment was quite
challenging for nurses because of the differences in expressions of pain
and suffering of patients and their families. Many patients learned not to
express their pain because it was viewed negatively in their culture.
Inability to effectively assess patients' pain and suffering led to more
significant uncertainties, fears, and feelings of hopelessness among
nurses and students (Kalengayi et al., 2015; Larsen et al., 2021). They
feared that if they misinterpreted the suffering and misread the cues and
behaviors, it might upset the patients and their families (Debesay et al.,
2014; Markey et al., 2019; Tosun & Sinan, 2020). Jirwe et al. (2010)
noted that nurses were fearful of committing mistakes, making them
doubtful. Despite the desire to care for these patients, nurses felt anxious
as they did not want to put patients and their families in distress.
Overarching theme 1: Challenges to the provision of transcultural care
Intrapersonal struggle: I want to provide effective care, but maybe I cannot?
One of the key challenges to the provision of transcultural care was
an intrapersonal struggle for nurses and nursing students. Intrapersonal
struggle was conceptualized as the desire and need to provide effective
care to people with diverse ethnicities, but a continuous tussle to
recognize personal biases and preconceived notions about people's cul­
tural and social beliefs and the inability to change engrained biased
practices and care modalities. Coleman and Angosta (2017) noted that
nurses demonstrated the desire to communicate, connect, provide care,
and develop cultural respect and understanding. However, they also
experienced communication issues, frustrations due to the inability to
meet patient and family needs. Often nurses' and students' intrapersonal
struggle was affected by language and cultural differences, organiza­
tional and cultural barriers, intra and intercultural differences, fears,
and uncertainties associated with the care of diverse ethnic groups. The
nurses and nursing students grappled with the complexities of their
inherent and learned beliefs and values and their interactions with
people with diverse ethnicities. For example, Hart and Mareno (2014)
reported that many nurses were insensitive to the cultural needs of their
patients and bluntly shared that people from other countries must adapt
to their norms and traditions. Other nurses also noted that health care
providers need to recognize their biased views to provide transcultural
care.
Markey et al. (2019) remarked that nurses and nursing students
demonstrated an awareness of ethnocentric values and beliefs, and
biases that they may have been developed at an early age. Despite an
awareness of ethnocentric values, likely developed early in life, nurses
did not recognize the diversity among their patients nor did they chal­
lenge their stereotyped beliefs. Nursing students and nurses indicated
uncertainties and a lack of confidence in overcoming cultural differences
and personal biases while striving to provide effective transcultural care
(Lin et al., 2019; Evgin & Muz, 2020).
Navigating personal and organizational constraints
Nurses and students had to battle various personal and organiza­
tional constraints that prevented them from providing transcultural
care. Personal constraints included lack of training about transcultural
care, language barriers, lack of knowledge about diverse cultures and
societies, limited knowledge about patient needs, and personalized fears
and uncertainties related to patient care (Ali & Watson, 2018; Dotevall
et al., 2018; Bai et al., 2020; Larsen et al., 2021; Leclerc et al., 2020;
Vicente et al., 2020). Tosun and Sinan (2020) noted that of 371 students,
98.1% of students noted language barriers, and 81.5% noted cultural
barriers as the common barriers to the provision of transcultural care.
Ali and Watson (2017) discussed that communication barriers among
nurses, patients, and their family members greatly affected nurses'
ability to understand patient needs and provide transcultural care. Li
et al. (2020) determined that of 1190 nurses, 91.6% nurses had mod­
erate levels of cognitive (i.e. cultural knowledge confidence to provide
transcultural care), 90.8% practical (confidence in interviewing people
with diverse cultural backgrounds), and 88.7% affective (confidence in
identifying values, attitudes, and beliefs concerning cultural awareness,
appreciation, and advocacy) transcultural efficacy levels. Üzar-Özçetin
Cultural conflicts: Divergence in patients-providers views and expectations
Nurses and students experienced cultural conflicts regarding diver­
gent views and expectations of patients and their own beliefs about
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Table 1
Literature summary tables.
Authors/
country
Purpose
Methods
Key findings
Critical appraisal
Høye &
Severinsson
(2010)
Norway
To explore nurses' experiences
of conflicts during their encounters
with culturally diverse
families of critically ill patients
Design: Exploratory qualitative
Setting: Intensive care
Sample size: 16 Intensive care
nurses practitioners
Sampling: Purposive
Data collection: Focus groups
Data analysis: Content analysis
Strengths: Robust qualitative
analysis, detailed information about
the study context, and audit trail
Limitations: No member checking
and no discussion about reflexivity
and data saturation
Quality rating: Moderate
Jirwe et al.
(2010)
Sweden
To explore nursing students
experiences of communication in
cross-cultural care encounters
Design: Exploratory qualitative
Setting: University
Sample size: 10 students
Sampling: Purposive
Data collection: Semi-structured
interviews
Data analysis: Framework analysis
Suurmond
et al. (2010)
Netherlands
To explore nurse practitioners views
about important cultural competencies
for caring for asylum seekers
Design: Triangulation
Setting: Asylum seekers centers
Sample size: 89 nurse practitioners
Sampling: Convenience
Data collection: Questionnaires &
semi-structured group interviews
Data analysis: Framework analysis
Karakuş et al.
(2013)
Turkey
To determine nurses' views about
transcultural nursing care
McCarthy et al.
(2013)
Ireland
To explore nurses' experiences
of communicating with people from
diverse cultures
Design: Quantitative
Setting: Hospital
Sample size: 80 nurses
Sampling: Convenience
Data collection: Anonymous
questionnaire
Data analysis: Descriptive analysis
Design: Descriptive qualitative
Setting: General nurses
Sample size: 07 nurses
Sampling: Purposive
Data collection: Semi-structured
interviews
Data analysis: Thematic analysis
While striving to provide quality care
and complete information to family
members, nurses tackled
communication barriers and valuebased cultural issues. Nurses
negotiated with family members to
address cultural issues and ensure the
provision of culturally sensitive care.
Students experienced difficulties
communicating due to language
barrier. Nurses were fearful of
committing mistakes in uncertain
situations and lacked confidence. They
sought relatives' help to interpret,
nonverbal communication, gestures,
and artifacts.
Nurse practitioners discussed the
importance of knowledge and training
about political situation and judicial
context of asylum seekers' country of
origin, and common diseases and their
potential effects on refugees health.
They also noted that the ability to deal
with asylum seekers' traumatic
experiences is critical for transcultural
care.
Nurses noted that communication and
language and limited training and
competency in transcultural care are
common barriers. They recommended
more training of professionals.
Alpers &
Hanssen
(2014)
Norway
To investigate how nurses' selfassessment of their competency to care
for patients with minority
backgrounds
Debesay et al.
(2014)
Norway
To explore the challenges of
community nurses while caring for
ethnic minority patients.
Eklof et al.
(2014),
Finland
To describe nurses' perceptions of the
factors to consider when using
interpreters in primary health care
with immigrant patients
Hart & Mareno
(2014), USA
To describe nurses' challenges of
providing culturally competent care to
diverse patient populations.
Design: Sequential exploratory
mixed methods
Setting: Medical and psychiatric
nursing
Sample size: 245 Medical and
psychiatric nurses
Sampling: Convenience
Data collection: Focus groups &
survey
Data analysis: Descrptive statistics
Design: Hermeneutics inspired
descriptive qualitative
Setting: Community and home care
Sample size: 19 nurses
Sampling: Purposive
Data collection: Semi-structured
interviews
Data analysis: Content analysis
Design: Descriptive qualitative
Setting: Community
Sample size: Eight nurses
Sampling: Purposive
Data collection: Semi-structured
interviews
Data analysis: Inductive content
analysis
Design: Descriptive qualitative
Setting: Hospital
Sample size: 374 nurses
Sampling: Purposive
Inability to communicate affected
nurses' ability to perform
comprehensive patient assessment and
recognize patient suffering. Family and
professional interpreters were used,
but nurses noted that using
professional interpreters is an
important skill to learn.
Nurses noted inadequate knowledge
about illness and treatment values of
eastern cultures. The nurses also
experienced challenges during
symptom assessment of patients.
Fear of committing mistakes and
crossing cultural boundaries during
intimate care was stressful. The
differences among nurses and patients
and their families values and
preferences for care influenced the
quality of care.
Strengths: Researcher triangulation,
robust qualitative analysis, detailed
information about the study context,
experienced interviewers, data
saturation discussed, and audit trail
Limitations: No member checking
Quality rating: Strong
Strengths: Data triangulation &
robust qualitative analysis
Limitations: No information about
the validity and reliability of
questionnaires, small convenience
sample,
Quality rating: Moderate
Strengths: Appropriate data analysis
Limitations: No information about
the validity and reliability of
questionnaires, small convenience
sample, and single setting
Quality rating: Weak
Strengths: Multiple recruitment
strategies
Limitations: Small sample, limited
information about study rigor,
researcher reflexivity, audit trail,
data saturation, and study context
Quality rating: Weak
Strengths: Reasonable sample,
multiple settings, and integration at
interpretation and reporting.
Limitations: No description of
integration at the analysis level,
psychometric properties of the
developed questionnaire, and
qualitative data analysis.
Quality rating: Moderate
Professional knowledge, role, and
personal characteristics of the
interpreters, nurses education,
communication skills and challenges,
patient preferences, and privacy were
important factors to collaboration of
nurses, interpreters, and patients.
Strengths: Researcher triangulation,
robust data analysis, reflexivity
discussed, thick description of
findings, and reasonable sample size
Limitations: Limited information
about context, strategies to ensure
rigor, audit trail, and member
checking.
Quality rating:
Moderate
Strengths: Robust data analysis and
thick description of findings
Limitations: Limited information
about study context, strategies to
ensure rigor, researcher reflexivity,
audit trail, and member checking.
Quality rating: Weak
Nurses noted barriers such as time,
money, and resources to develop
cultural competence. Greater diversity
of cultures required greater work on
Strengths: Large sample, reflexivity
discussed, audit trail, and researcher
triangulation
Limitations: Secondary data for
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Table 1 (continued )
Authors/
country
Purpose
Methods
Key findings
Critical appraisal
Data collection: Two open ended
questions of Clinical Cultural
Competency Questionnaire
Data analysis: Thematic analysis
Design: Interpretive description
Setting: Community
Sample size: 15 nurses
Sampling: Purposive
Data collection method: Semistructured interviews
Data analysis: Thematic analysis
nurses' end to provide culturally
sensitive care.
qualitative research and limited
information about the context
Quality rating: Moderate
Nurses noted inconsistences between
their and the migrants' views about
medical screening and care practices.
The sociocultural differences among
nurses and immigrants influenced the
screening and care.
Strengths: Researcher triangulation,
detailed information about study
context, reflexivity discussed, rich
description of results, audit trail,
adequate sample, and robust data
analysis.
Limitations: No member checking
Quality rating: Strong
Strengths: Researcher triangulation,
detailed information about study
context, rich description of results,
and robust data analysis
Limitations: Small sample, no
member checking, audit trail, and
discussion about reflexivity and data
saturation.
Quality rating: Moderate
Strengths: Data triangulation,
detailed information about study
context, member checking, peer
debriefing, rich description of
results, audit trail, adequate sample,
and robust data analysis.
Limitations: Limited information
about audit trail
Quality rating: Strong
Strengths: Researcher triangulation,
reflexivity and data saturation
discussed, rich description of
results, audit trail, adequate sample,
and robust data analysis.
Limitations: Limited information
about the study context
Quality rating: Strong
Kalengayi et al.
(2015)
Sweden
To explore caregivers' experiences in
screening newly arrived migrants.
Johansson
et al. (2016)
Sweden
To explore child health care nurses'
experiences of conducting health
dialogues with non-native speaking
parents.
Design: Descriptive qualitative
Setting: Community
Sample size: 11 nurses
Sampling: Purposive
Data collection: Focus groups
Data analysis: Content analysis
Nurses noted the need to develop
better awareness of diverse cultures.
They experienced uncertainties during
the care process and had to adapt the
process of heath dialogue. Mutual
learning was considered essential to
overcome the uncertainties and
challenges.
Ali & Watson
(2017) UK
To explore nurses' perspectives of
language barriers and their impact on
the provision of care to patients with
limited English proficiency from
diverse backgrounds
Design: Descriptive qualitative
Setting: Hospital
Sample size: 59 nurses
Sampling: Purposive/Snowball
Data collection method: Semistructured interviews and focus
groups
Data analysis: Thematic analysis
Amiri et al.
(2017) Iran
To explore the nurses' experience of
caring for patients with different
cultures.
Coleman &
Angosta
(2017) USA
To explore the lived experiences of
acute-care bedside
nurses caring for patients and their
families with limited English
proficiency
Design: Hermeneutic
phenomenology
Setting: Community
Target population: Nurses
Sample size:12
Sampling: Purposive
Data collection method: In-depth
interviews
Data analysis: Interpretation
method
Design: A qualitative exploratory
with phenomenological lens
Setting Hospital
Sample: 40 nurses
Sampling: Purposive
Data Collection: Digitally recorded
interviews
Data Analysis: Van Manen's six-step
phenomenological method
Communication and language barrier
prevented nurses from providing
effective and timely care. Interpreters
were used, but the nurses noted
challenges such as difficulties,
availability, accessibility of services,
convenience, confidentiality and
privacy-related issues and impact on
the patient's comfort.
Nurses strived to provide better care
through collaboration and greater
attentiveness to patients' needs.
However, many nurses neglected the
care of patients with ethnic minorities
due to religious and cultural biases,
communication issues, cultural
conflicts, and judgements about
patients' lifestyle.
Ogbolu (2017)
USA
To explore perspectives of chief nurse
executives regarding the provision of
culturally and linguistically
appropriate services in hospitals
Design: Qualitative study Settings:
Hospitals
Sample: Eight chief nurses executive
Sampling: Convenience
Data Collection: Interview Data
Analysis: Content analysis
Markey et al.
(2017)
Ireland
To explore the experiences of student
and qualified nurses of caring for
patients from diverse cultural, ethnic
and linguistic backgrounds.
Sevinç (2018)
Turkey
To describe the experiences of nurses
who provide care for Syrian refugees
in internal medicine clinics in a
hospital located in Turkey.
Design: Grounded theory
Setting: Hospital
Sample size: 30 nurses and students
Sampling: Purposive
Data Collection: Semi-structured
interviews and focus groups
Data analysis: Coding, constant
comparison
and theoretical sampling.
Design: Qualitative descriptive
Setting: Hospital
Sample size: 10
Sampling: Purposive
Nurses indicated a desire to
communicate, connect, provide care,
and developed cultural respect and
understanding. However, they also
experienced communication issues,
frustrations due to inability to meet
patient and family needs, and
challenges associated with patient
teaching and safety.
Chief nurses noted frontline nurses'
lack of awareness of resources (e.g.,
cost and time), challenges with cultural
competency training as the key
barriers. However, they noted that
developing mutual understanding with
patient and their families, increasing
workplace diversity, developing
community outreach programs, and
the improving understanding of patient
expectation were important facilitators
to culturally diverse care.
Nurses and students experienced
uncertainty, anxiety, and helplessness
in asking culturally specific questions
and learning about patient
expectations. Nurses and students also
had narrow view of race, culture, and
gender.
Nurses experienced difficulties
establishing communication and
providing nursing care to Syrian
patients and their relatives due to
Strengths: Researcher triangulation,
reflexivity and data saturation
discussed, rich description of
results, audit trail, adequate sample,
and robust data analysis, participant
checking, and prolong engagement
with the participants.
Limitations: Limited information
about study context
Quality rating: Strong
Strengths: Researcher triangulation
and rich description of results
Limitations: No member checking,
no discussion about reflexivity,
limited information about study
context, no discussion about
strategies to ensure rigor.
Quality rating: Weak
Strengths: Researcher and method
triangulation, rich description of
results, adequate sample, and robust
data analysis.
Limitations: No member checking,
limited information about context,
reflexivity, and strategies to ensure
rigor.
Quality rating: Moderate
Strengths: Researcher triangulation,
rich description of results, member
checking, and robust data analysis.
Limitations: Limited information
(continued on next page)
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Journal of Professional Nursing 37 (2021) 1119–1131
Table 1 (continued )
Authors/
country
Purpose
Methods
Key findings
Critical appraisal
Data Collection: semi-structured
interview
Data analysis: Content Analysis
language as well as cultural
differences. Patient fears and
uncertainties also made nurses
uncertain about care approaches.
about study context, no discussion
of reflexivity and missing
information how data saturation
was achieved, and no discussion
about audit trail.
Quality rating: Moderate
Strengths: Robust data analysis and
rich description of results
Limitations: Limited information
about study context, no discussion
of reflexivity and limited
information how data saturation
was achieved, and no discussion
about audit trail and member
checking
Quality rating: Weak
Strengths: Researcher reflexivity,
detailed information about the
context, and rich description of
results
Limitations: Small sample, missing
information how data saturation
was achieved, and no discussion
about audit trail and member
checking, and no information about
strategies to ensure rigor
Quality rating: Weak
Strengths: Adequate sample,
member checking, researcher
triangulation, robust data analysis,
detailed information about study
context, and rich description of
results
Limitations: Limited information
about researcher reflexivity and
audit trail.
Quality rating: Strong
Strengths: Adequate sample,
researcher triangulation, robust
data analysis, detailed information
about study context, and rich
description of results
Limitations: Limited information
about researcher reflexivity and
audit trail no member checking, and
no information about strategies to
ensure rigor
Quality rating: Moderate
Strengths: Researcher and method
triangulation, rich description of
results, adequate sample, and robust
data analysis.
Limitations: No member checking,
limited information about context,
reflexivity, and strategies to ensure
rigor.
Quality rating: Moderate
Strengths: Researcher triangulation,
information about data saturation,
rich description of results, adequate
sample, participant checking, audit
trail, detailed information about the
study context, and robust data
analysis.
Limitations: No information about
researcher
Quality rating: Strong
Strengths: Valid and reliable data
collection instruments, large sample
and representative sample, multiple
settings, relevant data analysis, and
detailed information about study
setting
Limitations: Convenience sample &
limited information about
Dotevall et al.
(2018)
Jordan
To explore Jordanian nursing students'
experience of caring for refugees with
mental health problems
Design: Qualitative design
Setting: Hospital
Sample size: Eight nursing students
Sampling: Convenience
Data Collection: Interview
Data analysis: Content Analysis
Language barrier is one of the major
issue faced by students while caring for
refuges which can be minimize by the
help of interpreters. Students also
experienced fears and uncertainties
about caring for patients.
Kallakorpi
et al. (2018)
Finland
To explore nurses' experience of caring
for culturally diverse patients in
psychiatric units
Design: Ethnographic study
Setting: Psychiatry Unit Hospital
Sample size: Five nurses
Sampling: Purposive
Data Collection: In-depth interviews
& observations
Data analysis: Content analysis
Cultural conflicts were caused by
different views of illnesses between
nurses and patients' relatives, the lack
of knowledge of relatives regarding
visiting hours, the lack of verbal
communication, patients' cultural
habits and disagreements between
patients themselves. With interpreter
nurses find difficult to understand the
patients' needs and views.
Lin, Wu, et al.
(2019)
Taiwan
To generate a descriptive theory
framework regarding the experiences
of the cultural competencies among
clinical nurses
Design: Grounded theory
Setting: Hospital
Sample size: 30 Nurses
Sampling: Purposive
Data Collection: In-depth interviews
Data analysis: open, axial, and
selective coding
When providing direct care to patients
from different cultures nurses feel less
confident due to lack of knowledge
about different culture.
Listerfelt et al.
(2019)
Sweden
To explore the experiences of critical
care nurses and enrolled nurses
(nurses who do not have legislative
nursing responsibilities but have
considerable caring expertise and
assist critical care nurses with nursing
activities) in caring for culturally
diverse patients in intensive care units
Design: Descriptive Qualitative
Setting: Hospital
Sample size: 15 critical care nurses
Sampling: Purposive
Data Collection: Focus groups
Data analysis: Content analysis
Nurses reported that language barriers
increase workload, and dealing with
language barriers demands manpower
and is time consuming.
Markey et al.
(2019)
Ireland
To develop a theory that explains
students and registered nurses'
behaviors
when caring for culturally and
linguistically diverse patients
Students and nurses become
complacent and indifferent to the
needs of culturally and linguistically
diverse patients, despite articulating
their desire to provide quality care.
Evgin & Muz
(2020)
Turkey
To determine problems faced by
nursing students who care for refugee
patients.
Design: Grounded theory
Setting: Hospital
Sample size: 30 students and nurses
Sampling: Purposive
Data Collection: Semi-structured
interview
Data analysis: Coding, constant
comparison and theoretical
sampling
Design: Descriptive phenomenology
Setting: Hospital
Sample size: 25 students
Sampling: Random focused group
discussion
Data Collection: Interviews
Data analysis: Colaizzi's method of
data analysis
Bai et al.
(2020) China
To describe the challenge of crosscultural care encounters from
perspective of imported nurses and to
investigate the relationship of crosscultural care encounters and its
influencing factors
Design: Cross sectional survey
Setting: Hospital
Sample size: 300 Nurses
Data Collection: Cultural
Competence Health Practitioner
Assessment, Cross-Cultural Care
Need Questionnaire, & CrossCultural Care Encounter
Language barrier is one of main
obstacles to implement culturally
competent care for nurses. Culturally
competent care increased with
education and experiences among
nurses. Nurses noted that more cultural
knowledge is required.
Language barrier was a common
barrier. Students noted that patients
refused nursing care and relied on
traditional and spiritual approaches to
care. Students also felt helplessness and
incompetence in providing care.
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Table 1 (continued )
Authors/
country
Purpose
Larsen et al.
(2020), India
To explore interpersonal
communication as experienced by
nurses working in culturally diverse
hospitals.
Li et al. (2020),
China
To evaluate the transcultural selfefficacy of nurses working in the
tertiary general hospital
Leclerc et al.
(2020)
Canada
To explore the transcultural health
practices of Canadian emergency
nurses working with indigenous
peoples.
Tosun & Sinan
(2020)
Turkey
To determine the knowledge,
attitudes, and prejudices of nursing
students regarding the provision of
transcultural nursing care to refugees
Üzar-Özçetin
et al. (2020),
Turkey
To explore how cancer survivors and
nurses define and experience cultural
care and to make recommendations
towards improvements in nursing
practice
Vicente et al.
(2020)
Sweden
To explore prehospital emergency
nurse specialists' experiences with
ethnic minority patients
Methods
Key findings
Questionnaire
Data analysis: Descriptive and
inferential statistics
Design: Descriptive qualitative
Setting: Hospital
Sample size: 12 nurses
Sampling: Purposive
Data Collection: Semi- structured
interviews and participant
observations
Data analysis: Thematic content
analysis
Design: Cross-sectional survey
Setting: Hospital
Sample size: 1190 Nurses Sampling:
Volunteer
Data Collection: Transcultural SelfEfficacy Tool
Data analysis: Descriptive and
inferential analyses
recruitment strategies
Quality rating: Strong
Language problems and
misinterpretations were the main
barriers. Limited knowledge and
respect for personal and cultural
differences make nurses jobs
challenging.
Strengths: Researcher and method
triangulation, reflexivity ensured,
pilot testing of interview guide,
audit trail, and detailed information
about the study context
Limitations: No information how
data saturation was achieved
Quality rating: Strong
The levels of transcultural efficacy
were moderate. Nurses had insufficient
self-confidence to address patients with
different cultural backgrounds.
Strengths: Valid and reliable data
collection instruments, large sample
and representative sample, multiple
settings, relevant data analysis, and
trained data collectors
Limitations: Convenience sample &
limited information about
recruitment strategies Quality
rating: Strong
Strengths: Valid and reliable data
collection instruments, and relevant
data analysis Limitations: Small and
convenience sample, limited
information about recruitment
strategies
Quality rating: Weak
Design: Descriptive Quantitative
Setting: Hospital
Sample size: 30 nurses Sampling:
Volunteer
Data Collection: Cultural
competence clinical evaluation tool
& Transcultural self-efficacy tool
Data analysis: Descriptive analyses
Design: Comparative cross sectional
Setting: University
Sample size: 317 students Sampling:
Purposive
Data Collection: Structured
questionnaire
Data analysis: Descriptive and
inferential stats
Design: Descriptive qualitative
Setting: Hospital
Sample size: 52 nurses and patients
Sampling: Purposive
Data Collection: Semi structured
interview
Data analysis: Framework analysis
About 90% of nurses lacked knowledge
and understanding of indigenous
issues, cultures, and medicinal
practices.
Design: Descriptive qualitative
Setting: Community
Sample size: 12
Sampling: Purposive
Data Collection: Semi structured
interview
Data analysis: Content analysis
Language barriers create insecurities
among nurses. Nurses and patients'
conflicts in thoughts and expectations
affect the provision of culturally
competent care.
et al. (2020) discussed that nurses would often focus more on their pa­
tients' physical care, but ignore various aspects of cultural care.
Under organizational constraints, nurses and students had to tackle
the issues of time, workload, organizational resources to provide
transcultural care, negative role models, and issues concerning in­
terpreters (Ali & Watson, 2018; Bai et al., 2020; Larsen et al., 2021;
Vicente et al., 2020). Markey et al. (2018) and Vicente et al. (2020)
noted that negative culture fostering inadequacy of transcultural care
was a critical organizational issue for nurses. Nurses had to overcome
the negative peer pressure and to enhance their ability to focus on their
patients' and families' cultural, religious, and social needs. Hart and
Mareno (2014) and Ogbolu (2017) discussed that nurses and nurse
managers recognized the need to provide transcultural care, but they
were constrained by limited resources such as cost, time, and lack of
trainings. Almutairi et al. (2017) noted that nurses required interpreters
Critical appraisal
Language and cultural barriers were
commonly reported. Nursing students
experienced challenges in performing
culturally specific care activities.
Language differences between nurses
and patients and the lack of cultural
recognition and open discussion may
lead nurses to dismiss patient needs,
thereby affecting the provision of care.
Strengths: Large sample and
representative sample, multiple
settings, and relevant data analysis
Limitations: Limited validity and
reliability testing of data collection
tool, convenience sample & limited
information about recruitment
strategies Quality rating: Moderate
Strengths: Adequate sample, robust
data analysis, researcher
triangulation, pilot testing of
interview guide, detailed
information about context
Limitations: Limited information
about researcher reflexivity, audit
trail, and strategies to increase rigor
Quality rating: Moderate
Strengths: Robust data analysis,
researcher triangulation, and rich
description of results Limitations:
Limited information about
researcher reflexivity, data
saturation, audit trail, and strategies
to increase rigor. No member
checking, limited information about
study context.
Quality rating: Weak
to communicate with the patients and their families. However, the or­
ganizations were unable to provide such resources, resulting in care
neglect. Jirwe et al. (2010) also discussed the discrepancies in the
written information about patient needs and patients' accounts of their
treatment and care preferences.
Overarching theme 2: Approaches to provide effective transcultural care
Practicing self-criticism and tolerating differences
Nurses and students noted that effective provision of transcultural
care requires a deeper understanding of various cultural and social
values and beliefs and an open attitude towards recognizing and toler­
ating cultural differences among themselves, patients, and their families
(Debesay et al., 2014; Markey et al., 2018, 2019; Kallakorpi et al., 2018;
Larsen 2020; Üzar-Özçetin et al., 2020). Larsen (2020) discussed that
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Journal of Professional Nursing 37 (2021) 1119–1131
Table 2
Themes extraction and reviewed studies.
Authors
Themes
Intrapersonal
struggle: I want to
provide effective care,
but maybe I cannot?
Høye &
Severinsson
(2010)
Jirwe et al.
(2010)
Suurmond
et al. (2010)
Karakuş et al.
(2013)
McCarthy
et al. (2013)
Alpers &
Hanssen
(2014)
Debesay et al.
(2014)
Eklof et al.
(2014)
Hart &
Mareno
(2014)
Kalengayi
et al. (2015)
Johansson
et al. (2016)
Ali & Watson
(2017)
Amiri et al.
(2017)
Coleman &
Angosta
(2017)
Ogbolu
(2017)
Markey et al.
(2017)
Sevinç (2018)
Dotevall et al.
(2018)
Kallakorpi
et al. (2018)
Lin et al.
(2019)
Listerfelt et al.
(2019)
Markey et al.
(2019)
Evgin & Muz
(2020)
Bai et al.
(2020)
Larsen et al.
(2020)
Li et al. (2020)
Leclerc et al.
(2020)
Tosun & Sinan
(2020)
Üzar-Özçetin
et al. (2020)
Vicente et al.
(2020)
Cultural conflicts:
Divergence in
patients-providers
views and
expectations
Understanding varied
expressions of suffering
and combating
uncertainties
Navigating
personal &
organizational
constraints
✓
✓
✓
Practicing selfcriticism &
tolerating
differences
Enhancing
interpersonal &
psychological
skills
Collaborating
with peers &
family caregivers
✓
✓
✓
✓
✓
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nurses should better understand their own culture and practice criticism
towards personal biases and assumptions because it enables under­
standing patients' cultural beliefs. Üzar-Özçetin et al. (2020) and Vicente
et al. (2020) discussed the need to learn to respect personal views and
develop an ability to practice the same respect towards patients and
their families. Nurses and students should also avoid stereotyping of
peoples from a particular area or culture because there is often much
diversity among groups (Markey et al., 2018, 2019).
Üzar-Özçetin et al. (2020) elaborated that challenging personal as­
sumptions about patients and their families is critical to develop an
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Journal of Professional Nursing 37 (2021) 1119–1131
ability to tolerate differences and conflicts in patient and nurses'
thoughts and beliefs about relevant care. It also allows nurses and stu­
dents to become more attentive towards patients' needs and preferences
and develop sensitivity towards their internalized cultural values
(Debesay et al., 2014; Üzar-Özçetin et al., 2020). Kallakorpi et al. (2018)
further elaborated that in addition to tolerating differences; nurses
should also be proactive in communicating those differences among
each other and to the families and developing approaches to address
them.
relatives' views. Instead, they may state what they think nurses want to
hear.
Discussion
This integrative review elucidated the challenges and approaches to
transcultural care based on the experiences of nurses and students across
various settings. The key challenges entailed social and cultural conflicts
among nurses and patients, nurses' personal struggle to provide trans­
cultural care while navigating the complexities of care environments,
and consistent efforts to understand the varied expressions of pain and
suffering. The challenges were mainly attributed to the engrained ste­
reotypes and ignorance about various cultures, nurses' personal complex
environment-induced inability to appreciate the cultural and social
differences, and expectations of patients and their families. The ap­
proaches to tackle these challenges included individual-level ap­
proaches as well as collaborative work with peers and families. At an
individual level, nurses need to practice self-criticism, tolerate differ­
ences, and develop cultural awareness through training. At a collabo­
rative level, nurses desire to work with peers and families to foster
transcultural care. These findings bring into attention the intricacy and
difficulty of providing effective transcultural care and the need for or­
ganizations and institutions to collaborate with, support, and provide
resources for nurses and students to enhance the quality of transcultural
care. A recent scoping review (Handtke et al., 2019) reported somewhat
consistent individual and organizational level strategies, as identified in
this review, to develop culturally competent health care. Individuallevel strategies included language and cultural training, incorporation
of culturally specific concepts into individual contacts, collaborative
family care, and use of culturally and linguistically adapted visual and
written aids to enhance communication. Organizational level strategies
included resources for cultural training of professionals, adaption of the
facility's social and physical environment, and greater networking and
coalitions with community organizations (Handtke et al., 2019). Further
research should focus on the joint and tailored use of individual and
organizational approaches and their evaluation to promote effective
transcultural care. It would be useful to develop and test multifaceted
interventions focused on skills development, communicating with fam­
ilies, and practicing self-awareness in groups involving multiple stake­
holders (e.g., nurses, nurse leaders, nursing students, and patients and
their families). A scoping review noted that theory based strategies,
personal, and educational strategies for self-awareness, reflection, and
empathy have the potential to improve transcultural care (Rasheed
et al., 2019). Further research could evaluate the usefulness of, selfawareness and reflective exercises, empathy training, and language
interpretation and trainings on nurses and nursing students' ability to
provide transcultural care.
Provision of transcultural care is essential to reduce health care
disparities arising due to discrepant social and cultural values, and be­
liefs of patients, healthcare, and nursing professionals (Claeys et al.,
2020; Sundus et al., 2021; Younas & Shahzad, 2021). Previous studies
noted that health care professionals recognized that increased cultural
sensitivity, ability to effectively communicate cross-culturally with pa­
tients, and greater knowledge of diverse cultures are critical for
improving the care of patients with diverse cultures and ethnicities,
thereby reducing the potential of disparities in care provision (Almutairi
et al., 2017; Claeys et al., 2020; Shepherd et al., 2019). Cultural
awareness and sensitivity also enable in reflecting on implicit biases and
recognizing their potential negative effects on providing quality care
(Claeys et al., 2020). Despite the significance of cultural knowledge and
skills required for transcultural care, our review noted that nurses and
students lack training and skillset and consistently circumnavigate
personal and organizational challenges. Therefore, nursing institutions
and educators should play an active role in the practical teaching and
learning about cultural and indigenous practices, and cultural training
of nurses and nursing students in clinical, community, and academic
Enhancing interpersonal and psychological skills
The development of interpersonal and psychological skills provides
nurses with an opportunity to develop a therapeutic relationship and
recognize the needs of patients with diverse cultural backgrounds.
Interpersonal skills included cultural and empathy training, language
courses, and effective use of interpreters to communicate and interact
with patients and their families (Ali & Watson 2017; Debesay et al.,
2014; Dotevall et al., 2018; Evgin & Muz, 2020; Johansson et al., 2016;
Karakuş et al., 2013). Alpers and Hanssen (2014) highlighted that nurses
require training in transcultural care to enhance their abilities to un­
derstand the illness perceptions of patients and their families. Bai et al.
(2020) discussed the need to develop knowledge of patients' culture and
learn their language. Consistently, Jirwe et al. (2010) described that
nurses willingly learned a few words and phrases of their patients' lan­
guage to make them feel comfortable to share their needs. In addition,
Johansson et al. (2016) introduced the idea of health dialogue that
entailed a mutual learning process between nurses and patients to better
understand diverse cultures, potential uncertainties arising during the
care process, and appropriate care approaches to address uncertainties.
Psychological skills included building confidence, developing open­
ness, practicing out of box thinking, and positive attitudes and behaviors
to build relationships with patients. Hart and Mareno (2014) discussed
the need for developing openness to appreciate diversity in cultural and
social values and health beliefs. Suurmond et al. (2010) discussed that
nurses should adopt a positive approach and develop the capability to
deal with traumatic experiences in diverse patient groups. Larsen et al.
(2021) noted that nurses should develop the confidence to discuss their
fears to the patients and families and practice compassion during their
interactions. Nurses should enhance their confidence to engage in
deeper inquiries to explore patients' situations (Larsen et al., 2021; Lin
et al., 2019). Kalengayi et al. (2015) noted that nurses also need to build
the confidence and courage to challenge the nature of offered training to
be tailored to meet the diversity of patients with various cultural
backgrounds. Regarding out of box thinking, Listerfelt et al. (2019)
provided an excellent example that involved nurses' drawing pictures
and asking patients' relatives to draw the most common words for
communicating with the patients. Vicente et al. (2020) noted the use of
mobile translation apps for communication.
Collaborating with peers and family caregivers
Nurses and students desire to develop better collaboration with their
peers and patients' families. One of the most common approaches to
involve families in care was requesting their interpretation services (Ali
& Watson, 2018; Hart & Mareno, 2014; Høye & Severinsson, 2010;
Jirwe et al., 2010; McCarthy et al., 2013; Vicente et al., 2020). Høye &
Severinsson (2010) noted that family members wanted more significant
involvement in care. Therefore, nurses used professional and family
interpreters during the care process. Ali and Watson (2017) advocated
seeking help from multilingual peers for translation if interpretations
from family members are difficult to understand. Lin et al. (2019)
advocated for the use of social workers to develop effective relationships
with patients and their families and improving the care. Nevertheless, it
was also noted that caution should be practiced when using families for
interpreting because of challenges in understanding their views about
their patient needs (Ali & Watson, 2018; Hart & Mareno, 2014). For
example, sometimes family members may not literally translate their
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Journal of Professional Nursing 37 (2021) 1119–1131
settings. Further research should focus on developing, implementing,
and evaluating clinical and academic strategies that involve the
collaboration of educators, health care institutions, professional nurses,
and nurse leaders in promoting a culture of transcultural care. Clinical
and academic strategies focusing on language training, simulated care,
and critical thinking, and groupwork to improve transcultural care can
be tested in future research. Greater efforts should be devoted towards
increasing the interpersonal and psychological skills of nurses and stu­
dents to provide transcultural care, which in turn could reduce the
health care disparities. For strengthening nurse leaders and educational
institutions efforts for enhancing nurses and students' skillset, qualita­
tive and mixed methods studies can be designed to explore nurse leaders'
challenges in improving interpersonal and psychological and then
develop strategies that are contextually relevant.
knowledge base on transcultural care. We did not include the studies
explicitly focused on cultural competence and culturally competent care
to narrow and specify the focus. However, it is possible that studies
focused on culturally competent care may have addressed useful stra­
tegies to foster that provision of transcultural care. Most of the reviewed
studies originated from the European region, and there is a dearth of
studies from other regions particularly the Asian countries which are
rich in culture and indigenous patient populations. Therefore, the
transferability of this review's findings may be limited to other regions.
Further research is needed to generate more knowledge on transcultural
care in other regions of the world.
Conclusions
The provision of transcultural care is a complex and daunting task for
nurses and nursing students because of the negative interplay of per­
sonal and organizational factors. Nurses and students are often not
equipped with the interpersonal and psychological skills to communi­
cate and develop therapeutic relationships with linguistically and
culturally diverse patient populations. Therefore, they encounter con­
flicts in personal biases, values, and care approaches, as well as patients'
expectations and care needs from diverse ethnicities. Self-criticism and
awareness and the ability to tolerate differences through overcoming
personal biases is a key personal strategy to provide transcultural care.
Collaboration with patients' families and interdisciplinary teams can
also play an instrumental role in enhancing the quality of transcultural
care. Health care and educational institutions should take proactive
actions to provide the necessary resources to nurses and students to
strengthen their interpersonal and psychological skills to provide
effective transcultural care.
Implications for nursing education and practice
Transcultural care is an integral part of nursing care. It enables
nurses to value the social and cultural needs and preferences of patients
and their families. Professional nurses and nurse leaders should play a
collaborative role in overcoming the challenges to effective transcultural
education and care. For example, nurse leaders in different hospitals and
educational institutions could conduct meetings to explore challenges to
the provision of transcultural care from nurses and students' perspective
and develop approaches that are relevant to their context. Nurse leaders
could also identify and prepare frontline nursing champions who dedi­
cate themselves to supporting and driving through implementing
transcultural care.
Nursing students are often trained and mentored by professional
nurses and managers in clinical settings. Therefore, if nurses are better
able to provide transcultural care, they can also prepare students to
effectively handle the complexities associated with patient-centered
transcultural care. This could be done by facilitating nursing students
to shadow those nurses who are identified experts in providing trans­
cultural care. Nurse educators, professional nurses, and nurse leaders
should take collective action to create clinical and educational ap­
proaches to create a culture of transcultural care. Some of the collective
actions may include conducting educational meetings about approaches
to transcultural are, developing and distributing educational materials
and toolkits about key aspects of transcultural care, and developing
academic partnerships for revisiting curricula and organizing shared
trainings on transcultural care. The provision of transcultural care
should be emphasized in clinical education so that nursing students are
more cognizant of the need to focus on their care's social and cultural
aspects. The review noted that practicing self-criticism and learning to
tolerate differences can enhance nurses' and students' ability to provide
transcultural care. Therefore, clinical and academic training should offer
nurses and students with the opportunity and resources to engage in
reflective practice and self-awareness exercises focused on recognizing
personal and patients' cultural and social values and beliefs about
health, illness, and approaches to care. Nurses and nursing students
should be encouraged to engage in interdisciplinary practice to develop
workable approaches to address social and cultural conflicts arising
while caring for patients with diverse ethnicities. Nursing institutions
should also promote collaborative family care for adequate provision of
transcultural care. Nursing institutions and educators can develop
collaborative programs and trainings and conduct meetings and
educational sessions across disciplines to deal with patients' social and
cultural issues with diverse ethnicities.
CRediT authorship contribution statement
All authors have agreed on the final version and meet at least one of
the following criteria (recommended by the ICMJE*):
1) Substantial contributions to conception and design, acquisition of
data, or analysis and interpretation of data.
2) Drafting the article or revising it critically for important intel­
lectual content. *http://www.icmje.org/recommendations/.
Authorship contributions
Made substantial contributions to conception and design, or
acquisition of data, or analysis and interpretation of data;
Involved in drafting the manuscript or revising it critically for
important intellectual content;
Given final approval of the version to be published. Each author
should have participated sufficiently in the work to take public
responsibility for appropriate portions of the content;
Agreed to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved.
Author
initials
SS, NA, AY
SS, NA, AY,
JLT
SS, NA, AY,
JLT
SS, N, AY,
JLT
Funding
None declared.
Declaration of competing interest
None declared
Limitations
References
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