Transcultural Nursing Care in Turkey

FNJN

Florence Nightingale Journal of Nursing DOI: 10.5152/FNJN.2020.18008

Systematic Review

Songül Çağlar1 , Naile Bilgili2

1Department of Public Health Nursing, Bolu Abant İzzet Baysal University, Bolu, Turkey 2Department of Public Health Nursing, Gazi University, Ankara, Turkey

ORCID IDs of the authors: S.Ç. 0000-0002-5412-0708; N.B. 0000-0002-7639-0303.

Cite this article as: Çağlar, S., Bilgili, N. (2020). Transcultural nursing care in Turkey. Florence Nightingale Journal of Nursing, 28(1), 110-123.

ABSTRACT Aim: For quality and adequate nursing care, nurses should evaluate the cultural factors that patients have, respect these factors, and consider their impact on the patient’s health. This review aimed to examine studies conducted in the field of transcultural nursing in Turkey. Method: Studies published between 2000 and 2018 were searched from the electronic databases of ScienceDirect, Web of Science, Academic Search Complete, PubMed, Scopus, and Google Academic using the keywords care, culture, nursing, transcultural, transcultural nursing, and Turkey. Results: As a result of the search, 150 studies were obtained, and 31 studies that fit the inclusion criteria were evaluated. These studies attempted to determine the factors that cover different dimensions of transcultural nursing, nursing education and training process, clinical and hospital applications, and several scales and guides and have been adapted and used in the Turkish population. Conclusion: Studies conducted in the field of transcultural nursing in Turkey have gained momentum recently and have a more basic descriptive level. Keywords: Care, culture, nursing, systematic review, transcultural, Turkey

INTRODUCTION nursing care. Culturally sensitive care in the provision Presently, the demographic structure of society of health service is not considered a privilege but a changes, and societies are composed of different human right (Prosen, 2015). Leininger reveals that ethnic and multicultural individuals. Technological the transcultural nursing approach prevents cultural developments and social media, including trans- problems or errors and increases the quality of care portation, migration, communication resources, and (Seviğ & Gülbu, 2012). economic, environmental, and social factors, affect health systems (Ray, 2016). Nurses who cannot Transcultural nursing care, professionally, began with adapt to this changing health system cannot offer Leininger’s anthropology work in the 1950s (Andrews quality nursing care expected from them. & Boyle, 2008; Prosen, 2015). In 1970, she developed the concept of transcultural nursing (Molloy, Walker, Care is one of the basic building blocks of nursing. Lakeman & Skinner, 2015). In 1969, the International Every individual’s culture is unique, and care needs to Council of Nursing started using the culture content be tailored to the individual, so care is a complex sit- in nursing. In 1974, the “Transcultural Nursing Soci- uation. Individuals with different cultures may have ety” was established to educate nurses in this field different perspectives on health, disease, disability, (Hotun-Şahin, Bayram & Avcı, 2009), and in 1989, birth, and death (Ray, 2016). A nurse who does not the “Journal of Transcultural Nursing” began pub- know the value and importance of culturally ap- lication, which aims to develop nurses’ training and propriate care cannot provide effective care (Giger, practice in transcultural care (http://tcn.sagepub. 2017). To be able to provide better nursing care, com/). Associated with the adoption of the concept nurses should consider race, ethnicity, culture, and of transcultural care in vocational practice in nursing cultural heritage (Giger, 2017). This demonstrates in international communities, studies in this area also the importance of transcultural nursing for effective started in Turkey. Initially, an article that assessed the

Corresponding author: Songül Çağlar Date of receipt: 13.07.2018 E-mail: [email protected] Date of acceptance: 04.04.2019

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License Çağlar and Bilgili. Transcultural Nursing Care in Turkey

nursing profession from a cultural point of view was shown that still the concept of transcultural nurs- published in 1978 (Seviğ & Gülbu, 2012). The Trans- ing is not addressed in all dimensions and studies are cultural Nursing Association was established in 2013 concentrated only in certain areas. Determining the (http://kulturlerarasihemsirelikdernegi.com/?page_ present situation by examining the studies conduct- id=133). There are regular congresses in transcultur- ed to address this issue is important for the develop- al nursing in various regions worldwide (Giger, 2017). ment of transcultural nursing in Turkey. One of these countries is Turkey. The first “Culture and Nursing” symposium was organized in 2005. The study aims were as follows: Following this, the “Transcultural Competency and • To examine the studies in the area of transcul- Distance Education” workshop in 2006 and “Nurs- tural nursing in Turkey ing and Midwifery Cultural Approach” symposium • To introduce studies that focused on transcul- in 2009 were conducted. The first congress in this tural nursing practice field was organized in İçel in 2011 under the title “1st • To provide readers an idea of transcultural nurs- International Transcultural Nursing and Midwifery ing practice in Turkey Congress,” which was participated by international delegates. Then, in June 2013, The National Trans- METHOD cultural Nursing Congress was held. In 2015, The In- ternational Participatory Transcultural Nursing Con- Study Design gress was organized in Çanakkale (http://www.kahd. This study is a systematic review design. org/kongre-4-1.htm) Then, the first international 4th National Transcultural Nursing Congress was Search process and study identification organized in Sanliurfa between October 21 and 24 This review was conducted according to the criteria 2017 (http://www.kahd.org/kongre-5-2.htm) established by the Preferred Reporting Items for Sys- tematic Reviews and Meta-Analyses (Moher, Liberati, In Turkey, nurses contribute to professional devel- Tetzlaff, & Altman, 2009). The ScienceDirect, Web opment through various studies in the field of trans- of Science, Academic Search Complete, Medline, cultural nursing care, and these studies are published PubMed, Scopus, and Google Academic electron- in national and international academic journals ic databases were searched for related studies con- (Ceylantekin & Öcalan, 2016; Cinar et al., 2015). The ducted between 2000 and 2018 using various com- “Transcultural Nursing” course is available in nurs- binations of keywords, including care, culture, nursing, ing undergraduate programs, and thesis studies are transcultural, transcultural nursing, and Turkey, in conducted in postgraduate education. However, it is Turkish and English. Studies published in national and international journals were included in the review. A total of 150 articles were obtained. Initially, studies Care, culture, nursing, transcultural nursing, Turkey with Turkey and culture, Turkey and culture and nurs- keywords were searched in Science Direct, Web of Science, Academic Search Complete, PubMed, Scopus ing, and Turkey and nursing and care keywords in the and Google Academic databases. title were included in the review. Then, the summaries of the studies were read, and the studies conducted according to the eight transcultural nursing areas de- A total of 150 articles were reached as a result of the search. termined by Leininger were evaluated. Gray literature search was not performed. The latest search was performed in December 2018. A flowchart of the process A s a result of screening, 119 studies were excluded due to content and method. of study identification is shown in Figure 1.

Eligibility Studies were grouped according to Leininger’s 8 main areas identified as the building blocks of A total of 150 articles were obtained in the first transcultural nursing stage, 119 of them were included in the review because studies that did not meet the evaluation cri- 31 studies providing all conditions were teria were excluded (Table 1). Studies that were ex- evaluated. cluded in the review were review articles (22), had no full texts (32), and did not have the subject content Figure 1. Flowchart of the process of study identification compatible with the keyword (65).

111 Florence Nightingale Journal of Nursing, 28(1), 110-123

Data Analysis Types of participants: The sample group con- Thirty one studies that met the inclusion criteria sisted of nursing students (12 studies), nurses (6 were grouped according to the eight main areas that studies), and women (5 studies) in most studies. Leininger identified as the building block of trans- Two studies were conducted on patients. The cultural nursing (Andrews & Boyle, 2008) (the health size of the sample varies in the studies. Qualita- of migrants within and among countries; knowledge tive studies were conducted with a minimum of 9 of faith, life, and values that individuals have and re- and a maximum of 181 participants. Quantitative spect; increasing technological developments that studies were performed with larger sample groups may conflict with the cultural values of people; cul- (n=98–1355). tural controversy worldwide and impact of violence on healthcare; cultural strife, neglect, and blindness Geographical regions: The studies were conducted caused by regional laws and practices; ease and di- in different regions of Turkey and compared Turkey versity of people’s travel to various parts of the world; with different countries. In the western part of Tur- women and child health needs of feminism and oth- key, most studies were conducted in the province er genders; community and cultural influences of of Izmir. Moreover, studies on individuals between healthcare services on environmental conditions). countries were conducted in Iran with Erzurum and İzmir and United Kingdom and Turkey. Outside of Bias these studies, some were conducted in the form of The evaluation synthesis of the results was used de- joint studies in different regions in Turkey. pending on the differences in study design, sample population, type of measuring instruments, and sig- Ethnic groups in the studies: Although a large part nificance in the results. of the studies is conducted on the Turk population, some studies were also conducted on the Syrian, RESULTS English, and Iranian populations. The results of the studies were examined under two headings: characteristics of the study methods and Data collection methods used in studies: Ques- characteristics of the transcultural nursing field de- tionnaires developed by the researchers were used termined by Leininger. The results of the review were in 12 quantitative studies and one qualitative study, evaluated in two separate sections. while the scale was used in 14 studies. All ques- tionnaires used are in nonstandard form created Characteristics of the study methods by researchers based on relevant literature review. The general properties of studies are shown in Table Scales were used to determine cultural compe- 2. tence in studies: Chen and Starosta’s Intercultural Sensitivity Scale, Nurse Cultural Competence Scale Years of studies: There are two studies in 2018 and developed by the World Health Organization, and 2017. Most studies related to the subject (10) were Cultural Awareness Scale. In one qualitative study, published in 2016, followed by 2014 (5 studies). The questions developed by Campinha-Bacote using number of studies annually decreases retrospective- the Cultural Qualification Process in the Distribu- ly. There are two studies each in 2015, 2013, 2012, tion of Health Services in 2002 were used. Five 2011, 2010, and 2009, and one study each in 2008 qualitative studies were conducted through semi- and 2006. The oldest study was conducted in 2006. structured interviews.

Table 1. Inclusion and exclusion criteria

Inclusion Exclusion

Type of study Research article Review article

Publication National/international journal Gray literature

Language English and Turkish Others

Participants Nurses, nursing students, patients, or healthy individuals -

Place Turkey and between Turkey and other places Except Turkey

112 Çağlar and Bilgili. Transcultural Nursing Care in Turkey

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

Belief that individuals have and knowledge of their life and values and respect

Experiences of TCN, 2016 To describe the Phenomenological Semistructured in- Women have an intense ambiguity patients with experiences of approach to depth interviews about illness, treatment, and social newly diagnosed women in Turkey in qualitative relations and, therefore, exhibit breast cancer in the breast cancer research 9 women avoidance behavior. Turkey İnan et al. diagnosis stage

Traditional and Asian To investigate the Qualitative study Semistructured in- Among the religious practices following religious death Nursing traditional and 181 women depth interviews death is the first place to pray. It has practices in Research, religious practices been found that relatives and friends Western Turkey 2012 related to death in who participated in the tomb ceremony Bahar et al. Narlıdere district of visited the house of the deceased İzmir person to provide social support to their relatives at home, and 55.2% of them had visited the house to express their belief that the deceased person could not claim any further rights.

Traditional Midwifery, To understand the Descriptive study Questionnaire In the postpartum period, women have postpartum 2009 traditional postnatal 273 women prepared by several traditional practices. Nutritional practices of practices of women researchers practices are particularly important women and and infants and for newborn mothers. Again, these infants and determine the women were found to have traditional the factors factors that affect practices, such as wrapping a tight influencing such these practices cloth, putting a heated brick in the practices in snow, and lying in hot land. Southeastern Turkey Geckil et al.

Factors Midwifery, To determine Cross-sectional Questionnaire The decision of homebirth concerns influencing 2009 women’s thoughts descriptive study prepared by economic difficulties and the desire women’s decision about homebirth 392 women researchers to benefit from the help of neighbors. to deliver at and examine the Women who gave birth in the home, home in rural factors that affect planned or unplanned, reported that Turkey Kukulu homebirth homebirth was unsafe. and Öncel

Pregnancy Midwifery, To determine Cross-sectional Questionnaire Mothers with unplanned pregnancies planning and 2010 the relationship descriptive study prepared by smoke more cigarettes and consume antenatal between pregnancy 1355 women researchers more beverages that contain health behavior: planning and caffeine than mothers who plan their findings from one prenatal behavior pregnancies. Moreover, these women maternity unit had lower vitamin levels and had more in Turkey Arslan nutritional problems and did not have Ozkan and Mete the recommended weight during pregnancy.

Traditional Anatolian To determine the Cross-sectional Questionnaire During pregnancy, childbirth, and methods Journal of traditional methods and descriptive prepared by postpartum and postnatal periods, applied in caring Nursing that the mothers of study 443 women researchers parents receive information from the for ınfants of and Health Karaman province health workers initially and from the mothers in Sciences, apply to their family elders. Mothers use traditional Karaman Arısoy 2014 newborn babies methods in the care of infants such as et al. wrapping their infant with salt, using powder to protect rashes, swaddling the infant, and using antipyretic medications, cold water, and vinegar to lower the infant’s temperature during fever.

113 Florence Nightingale Journal of Nursing, 28(1), 110-123

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

Traditional Journal of To identify the Descriptive study Questionnaire Women try to solve their baby’s health methods used in Child and traditional practices 98 women prepared by problems by using traditional methods that ınfants Arabacı Civilization, of child care of researchers they know or are recommended by their et al. 2016 mothers with parents. Mothers use a yellow scarf on the 0-12-month-old baby to prevent jaundice, swaddle, and infants conduct practices related to the umbilical cord. When the infant is born, they perform Islamic memorial service, apply various practices on the excretion of the shrub, and read a prayer to preserve the religion.

The transcultural INR, 2010 To determine the Descriptive study Questionnaire Most students have cultural differences nursing concept: cultural diversity of 622 students prepared by in patient care and sometimes have a study of nursing students and the researchers difficulty in caring due to these students in patients they live differences. The lessons on cultural Turkey Ayaz et al. with and provide education in the curriculum of the patient care services. students will reduce the living problems. Transcultural nursing’s knowledge was also investigated

Experiences TCN, 2016 To describe the Descriptive study Questionnaire The most popular preferences that and attitudes of experience of nurses’ 220 nurses prepared by have been identified in nurses who nurses regarding complementary researchers use complementary health practices complementary health practices are physical and mental relaxation health and personal and techniques. According to nurses, approaches used professional attitudes complementary health practices are by themselves toward the use of useful, effective, and cheap. Nurses and their patients complementary know the risks and potential benefits Cirik et al. health practices of complementary health practices and advise their patients on this issue.

Cultural J Nurs To investigate the Descriptive and Sociodemographic Many nurses did not have transcultural sensitivity among Scholarsh, cultural sensitivity correlational study Questionnaire nursing courses during university education. clinical nurses: A 2017 of nurses working 516 nurses Intercultural Nurses were found to have more problems descriptive study in rural and urban Sensitivity Scale with language, level of education of the Yılmaz et al. hospitals in Turkey patient (when low), health perception of the disease, and religious beliefs.

Cultural Int Nurs To explore Turkish Qualitative study Focus group While some students focus on language perceptions Rev, 2016 nursing students’ 21 students interview and ethnic differences, some focus and clinical perceptions of on gender and secrecy, while others experiences of providing care to focus on traditional practices of the nursing students patients culturally cultural subgroup. While most students in Eastern Turkey different from can describe cultural elements, only Karatay et al. themselves a few of them explain how cultural differences will affect the way they care. Students who are aware of historical confrontation have organized more empathic approaches to these elderly illnesses, but they do not know exactly how to behave. Some students, even if they do not have language differences, have weak communication because they refuse to question their patients’ beliefs because of fears of misunderstanding. Some students thought that ethnic and religious differences were obstacles to intervention, while others believe that religious or ethnic similarities increased the confidence of the patient.

114 Çağlar and Bilgili. Transcultural Nursing Care in Turkey

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

Nursing students’ J Psychiatr To undertake Descriptive study Eskin’s Attitudes There are differences in the attitudes attitudes to Ment a comparative 240 Turkish nurse toward Suicide of Turkish and UK student nurses. suicide and Health investigation of students, 82 UK Scale Eskin’s Turkish students have some difficulty suicidal persons: Nurs, 2018 nursing students’ nurse students Social Reactions in understanding suicide in a A cross-national attitudes toward to Suicidal Persons nonjudgmental way. Societal influences and cultural suicide and suicidal Scale (E-SRSPS) such as religious belief, culture, and comparison persons in Turkey tradition may have a deterrent effect on between Turkey and the UK attitudes to suicide. and the United Kingdom Flood et al.

Cultural conflicts worldwide and studies on the effect of violence on healthcare

Views of TCN, 2016 To investigate the Descriptive cross- Attitude Scale Male students have more traditional women’s opinions of Turkish sectional study for University and unfair attitudes toward women’s sexuality and university students 605 students Students problems than female students. violence against on gender roles, (337 women; 268 Education levels and areas of study do women in Turkey: sexuality, and male) not significantly affect students’ views a cross-sectional violence against of women, and a small percentage investigation women on issues of students have endorsed violence among university related to women against women. The traditional, students Gursoy patriarchal qualities of the Turkish et al. society have been found to be extremely effective even in highly educated individuals.

Influence of TCN, 2016 To investigate the Descriptive study General Health Nurses are at serious risk of exposure to workplace bullying effect of bullying 284 nurses Questionnaire bullying behavior. Nurses with graduate on Turkish nurses’ on psychological Workplace Nurse Information degrees are more likely to be bullied psychological problems of nurses Bullying Behavior Form and nurses who are exposed to bullying distress and Scale have higher levels of psychological nurses’ reactions distress and prefer to remain silent in to bullying this regard. Nurses often stay silent in Bardakçı and the face of bullying, sharing with family Gunusen and friends, or persecuting the tyrant.

Studies on the influence of environmental conditions on healthcare services in terms of society and culture

Comparison DEUHYO To compare the Descriptive study AIDS attitude Danish students’ attitudes toward of attitudes ED, 2013 attitudes of nursing 99 students, scale (AAS) individuals with HIV/AIDS are more of Turkish and students in Turkey (52 students Demographic Data positive than those of Turkish students. Danish nursing and Denmark from Turkey; 47 Collection Form There is about a twofold difference students toward toward individuals students from between the rates of HIV/AIDS care the care of with HIV/AIDS Denmark) and dating in the students of the two persons with HIV/ and examine countries. Danish nursing students have AIDS the relationship less fear of transmission and negative between attitudes feelings toward individuals with HIV/ and care willingness AIDS than Turkish students. Danish students are more willing to provide care. To improve the positive attitude toward individuals with HIV/AIDS and increase the willingness to care, it is especially important for nursing students to have a much more diverse cultural background in the future due to the increased cultural mobility and be equipped with the skills to care for cultural competence, and cultural attitudes toward HIV/AIDS must be addressed.

115 Florence Nightingale Journal of Nursing, 28(1), 110-123

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

Transcultural İKÇÜSBD, To determine Descriptive and Individual In the fourth grade, the ability of female sensitivity of 2016 the relationship comparative study Definition Form students to empathize is higher than the nursing students between the levels 195 students Transcultural ability of male students to empathize. according to their of transcultural Sensitivity Scale Nursing students from the first year empathy level sensitivity and Basic Empathy of the course is subject to cultural Egelioğlu Çetişli empathy of nurse Scale sensitivity, and cultural awareness and et al. candidates and cultural issues should be added with an compare students emphatic approach to individuals with from first and fourth different nursing management planning grade in this respect and should be taught.

Defining cultural Nurse Educ To identify the Cross-sectional Questionnaire Nursing students experience cultural diversities Today, cultural diversity study 263 prepared by differences when they provide nursing experienced in 2006 that nursing students researchers care services. Generally, it has been patient care by students have with observed that nursing students from nursing students their patients and Erzurum and other regions outside of in eastern Turkey offer disease care Eastern Anatolia and at the beginning Tortumluoglu and determine of their studies have experienced more et al. the effects of cultural diversity while providing disease the students’ care. Students who have cultural diversity demographic in patient care experience these diversities variables on these while communicating with patients variations regarding religious beliefs and lifestyle.

An analysis of the Int J Nurs To identify the Descriptive, Questionnaire Extremely few nurses obtained cultural problems Pract, 2014 cultural issues comparative study prepared by transcultural nursing education. In encountered faced by nurses 338 nurses researchers nurses in western hospital, significant during caregiving working in two differences in beliefs and values between by the nurses university hospitals the health staff and the patients should working in two in the western and be considered. Most nurses provide different regions eastern regions care to patients with different cultures of Turkey Kılıc during their care (language, traditions, habits, traditions, et al. beliefs, etc.). Most nurses were found to have problems in maintaining care for individuals due to language differences. The most common group are the nurses working in the west.

Perceptıon of GÜSBD, To reveal the Comparative and Questionnaire on Turkish and German women had a menopause: 2016 opinions of Turkish descriptive study the Descriptive difference between menopause age the Turkish and and German 320 women (160 Characteristics of and duration, and there were cultural German women’s women who live in German Women; Women Opinions differences in social development, worship, comparıson Alanya province and 160 Turkish on Perception of and sexuality during menopausal period. Irmak-Vural et al. entered menopause Women) Menopause form The problems experienced by women in Balcı-Yangın regarding the menopausal period and transcultural menopausal differences and the initiatives aimed at the perceptions problems were explained to the nurses through the in-service training programs, and preconceptions were grasped. Nurses should be more sensitive to recognize the cultures and reflect this effectively in their services.

Attitudes of Nursing To investigate Descriptive study Questionnaire Age group, type of school, previous nursing students EducToday, the demographic 587 students prepared by education for disabled individuals and toward people 2014 variables affecting researchers conditions for care for disabled individuals, with disabilities the attitudes of and factors affecting attitudes of nursing Uysal et al. nursing students students toward individuals with disabilities. toward the disabled There are still significant gaps in the current and the factors knowledge of the attitudes of nursing affecting this students in Turkey and factors influencing attitude these attitudes.

116 Çağlar and Bilgili. Transcultural Nursing Care in Turkey

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

Attitudes of TCN, 2014 To evaluate the Cross-sectional Kogan attitude Medical students’ attitudes toward Turkish nursing attitudes of medical and comparative scale against older old age were more positive than those and medical faculty and nursing descriptive study of nursing students. Concurrently, it students toward students in Turkey 618 students was determined that the students elderly people toward elderly had more positive behaviors as their Ayoğlu et al. individuals age increased. According to sex, there were differences in attitudes toward elderly individuals, and it was determined that students had negative behaviors.

Comparison of J To determine the Descriptive Maslach Burnout Nurses working in Turkey have nurses in two Perianesth burnout levels of study 179 nurses Inventory more emotional exhaustion and different cultures: Nurs, 2016 nurses working in (Turkey, 87; Iran, Questionnaire less personal success compared to who experiences surgical clinics in 92) prepared by their counterparts in Iran. Nurses more burnout two countries researchers by working in surgical units with higher Karaman-Özlü literature survey occupational risk and workload et al. and heavier working conditions are expected to improve the working environment and conditions, provide organizational support to increase job satisfaction, decide to prevent burnout, reduce burnout, and strengthen communication skills to cope. Providing psychological counseling services and efficient use of humor has been proposed.

A comparison Midwifery, To examine Descriptive and A questionnaire Cultures in pregnancy, labor, birth, and of traditional 2008 pregnancy, comparative field form prepared postpartum period in comparison to practices used in childbirth, and study 300 women by researchers the beliefs and practices of the period pregnancy, labor, traditional practices (Turkey, 150; Iran, by literature between Turkey and Iran revealed a and postpartum of women regarding 150) survey and large difference. However, despite period among postpartum period semistructured the cultural differences, some of the women in Turkey and to compare interview practices and beliefs are common. and Iran Ozsoy Consuming high-calorie foods; and Katabi drinking hot herbal teas; applying religious and holy motifs (pray, go to sacred places); mystical practices (bad eye); limitations to specific areas such as traditional practices, physical activity, and sexual intercourse are similar in both countries. Turkish and Iranian cultures depend heavily on Islamic heritage and fertility and are extremely valuable. Pregnancy and birth are important life events that need to be encouraged and preferred.

Evaluate Anatolian To evaluate Qualitative Semistructured Negativities such as early marriages Gypsies’ living Journal of the cultural study (focus interview (approximately 15 years), adolescent in Çanakkale Nursing characteristics group interviews, form based on pregnancies, domestic violence against according to and Health of Roma with voice recording Purnell’s cultural women, alcohol consumption and “Purnell” Cultural Sciences, Purnell’s cultural and written competence model cigarette smoking among men, drug use Competence 2012 competence model recordings) 30 at a minimum, prevalence of traditional Model” Tanriverdi novels between practices, environmental hygiene et al. the ages of 15 and insufficiency, and inadequate health 70 years behaviors have been identified among Gypsies. It has been found that Gypsies are prone to use primary healthcare services in all health problems.

117 Florence Nightingale Journal of Nursing, 28(1), 110-123

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

The relationship TCN, 2017 To determine Descriptive study Chen and There is relationship between cultural between cultural the relationship 444 students Starosta’s sensitivity and gender and desire to sensitivity and between cultural Intercultural work overseas; assertiveness and year assertiveness in sensitivity and Sensitivity Scale of nursing education and desire to nursing students assertiveness in (ISS) and Rathus work overseas. Nursing students at from Turkey Kılıc university nursing Assertiveness both schools had a moderate level of and Sevinc students Scale (RAS). cultural sensitivity and assertiveness. As assertiveness level of the students increased, their intercultural sensitivity also increased.

Studies on the health of immigrants within and between countries

Expectations J Clin Nurs, To describe Descriptive Semistructured Relatives of Syrian patient who were of relatives of 2016 the personal qualitative study interview treated in the intensive care unit in Syrian patients experiences of 30 Syrian families Turkey were found to have problems in intensive care relatives of Syrian treated in Turkey on their patients, and problems on units in a state patients in an social support, expectations were not hospital in Turkey intensive care unit met adequately, and communication Sevinc et al. in a hospital in difficulties were experienced. Turkey

A comparison Nurs Sci Q, To determine the Qualitative In-depth Pregnant women from different of the prenatal 2013 health behaviors ethnonursing semistructured cultures have different health behaviors health behaviors of women in the model 18 women interviews in the prenatal period. Women differ in of women prenatal period terms of culture influence and culture, from four with a transcultural perceptions, and transformations of cultural groups approach cultural themes, cultural structure, in Turkey: an attitudes, health, and life. ethnonursing study Tasci- Duran and Sevil

Motherhood Nurs To determine 17 Syrian mothers Individual in- Syrian refugee mothers giving birth in the shade Health Sci, the childbirth who gave birth at depth interviews in Turkey had difficulties during their of migration: a 2018 experience of Syrian Akdeniz University (semistructured pregnancies. The difficulties are qualitative study refugee mothers Hospital form) related to the subthemes of fear and of the experience and their transition struggle. The women are unable to of Syrian refugee to motherhood in prepare for childbirth due to financial mothers living in Turkey problems and other factors related to Turkey Korukcu poverty. Moreover, they have heavy et al. domestic duties, and this affects their ability to access healthcare services during pregnancy and the postnatal period and their general health and well-being. Refugee mothers want to perform their cultural practices and raise their children according to their own beliefs.

Scales related to cultural care adapted in the Turkish society

Validity and TCN, 2015 To adapt Methodological Cultural The psychometric properties of the reliability of the Cultural study 235 nurses Competence Scale Turkish form of Cultural Competence the Turkish Competence Scale for Turkish Nurses Scale for nurses were found to be highly version of the for Turkish nurses reliable and valid. The scale can be used Nurse Cultural and determine in transcultural studies to compare the Competence its validity and cultural competences of nurses. Scale Gözüm reliability et al.

118 Çağlar and Bilgili. Transcultural Nursing Care in Turkey

Table 2. Features of included studies (n=31) (Continued)

Name of research and Journal, Type of study Data collection authors date Purpose sample size methods Findings and results

Cultural Collegian, To analyze the Methodological Cultural Awareness The adapted Turkish version of CAS awareness scale: 2017 psychometric study 197 Scale is a valid and reliable tool for nursing psychometric properties of students students. CAS can serve as a reliable properties of the the Turkish measurement tool to assess the initial Turkish version language version outcomes of a course to enhance Başalan İz and of the Cultural the cultural competence of nursing Bayık Temel Awareness Scale students. and determine any possible similarities between the compositions of the Turkish version and the original scale

Measurement Turkey To determine Methodological Intercultural The Intercultural Sensitivity Scale is a properties of Klinikleri the intercultural study 148 Sensitivity Scale valid and reliable tool that can be used the Turkish J Med sensitivities of students by nurse educators to measure the Intercultural Ethics, Turkish nursing cross-cultural sensitivities of nursing Sensitivity Scale 2011 students and students. It can be used as a guide in among nursing evaluate the defining the cultural sensitivities of students Bulduk psychometric nursing students and evaluating the et al. validity of effectiveness of cultural models and the Turkish guides in nursing education. Crysanturism Sensitivity Scale

Result of the studies Although there is a close relationship in geographi- Nurse’s studies: These studies frequently exam- cal location between Turkish and Iranian women and ined the state of knowing cultural care and problem there is a belief based on Islamic heritage in both of cultural differences in education and care during cultures, both groups have different cultural be- this period. Based on the results of these studies, the liefs and practices. Gypsies who live in Turkey have rate of transcultural nursing education is extreme- worked to resolve all health problems of primary ly low. Nurses often provide care to individuals from healthcare services. A study on Syrian migrants also different cultures. The main point that nurses expe- investigated the difficulties they experienced during rience cultural differences is the language problem. treatment with relatives of Syrian patients in intensive care units in a state hospital in Turkey. The most Nursing student’s studies: It was determined that, important obstacle for quality nursing care in studies as in the nursing group, similar issues were also conducted on foreign nationals is language. analyzed in the student group. It is observed that students have cultural differences in the care of Characteristics of the transcultural nursing field patients, so they have difficulties in the caregiving determined by Leininger process, and there is a relationship between empa- Studies in the field of transcultural nursing care are thy levels and cultural sensitivities. Cultural problems quite different. It has been determined that these are caused by language disabilities, religious beliefs, studies are generally in the areas of health of im- and lifestyle. Almost all these studies emphasized migrants who emigrate internationally or internally that courses related to cultural sensitivity should be (Korukcu et al., 2018; Sevinc et al., 2016; Tasci-Duran included in undergraduate nursing education and & Sevil, 2013); knowledge of faith, life, and values the that awareness should be developed through train- individuals have and respect (Arabacı, Yıldırım, Dün- ings for nurses working in the field. dar, & Kadam, 2016; Arısoy et al., 2014; Arslan-Oz- kan & Mete, 2010; Ayaz et al., 2010; Bahar et al., Different groups’ studies: These studies were fre- 2012; Cirik et al., 2016; Geckil et al., 2009; Karatay quently focused on cultural differences and effects et al. 2016; Kukulu & Öncel, 2009); cultural conflict of these differences on the use of health services. and impact of violence on healthcare (Bardakçi &

119 Florence Nightingale Journal of Nursing, 28(1), 110-123

Gunusen, 2016; Gursoy et al., 2016); and social and ences related to language and communication, lead- cultural healthcare services influenced by environ- ing to difficulty in providing care. Cirik et al. (2016) mental conditions (Ayoğlu et al., 2014; Çimen et al., investigated that the point of view of nurses toward 2013; Egelioğlu Çetişli et al., 2016; Karaman-Özlü et cultural situations and their experiences on comple- al., 2016; Kilic et al., 2014; Kilic & Sevinc, 2017; Ozsoy mentary medical practices about themselves and & Katabi, 2008; Tanriverdi et al., 2012; Tortumlu- their families. oglu et al., 2006; Uysal et al., 2014; Vural & Yangin, 2016). Additionally, a study was conducted to assess In the area of cultural conflict and violence in health- the suitability of a measuring instrument for cultur- care, Bardakçı and Gunusen (2016) examined the al care in the Turkish population (Gözüm, Tuzcu, & situations of stressfulness due to workplace bully- Kirca, 2015). ing of Turkish nurses. Gursoy et al. (2016) analyzed violence and sexuality toward women in university In a state hospital in Turkey, Syrian patients in inten- students and determined that the characteristics of sive care units were evaluated regarding the difficul- patriarchal society in the viewpoint of gender and vi- ties they experienced during treatment with their olence are preliminary. relatives (Sevinc et al., 2016) in studies conducted among countries and health of immigrants within In areas where community and cultural healthcare the country itself. In another study conducted on services are affected by environmental conditions, Syrian migrants, it was determined that immigrants researchers have attempted to determine both cul- had difficulty during their pregnancy due to language tural differences in the Turkish community within barrier, some racist behaviors and discrimination, healthcare services and the differences in health- poverty, culture, and family structures (Korukcu et care services compared to those in other societies. al., 2018). Kilic et al. (2014) identified that nurses who work in the western part of Turkey had language as the big- In studies on faith, life, and value the individuals have gest obstacle while caring for individuals with differ- and respect, Inan et al. (2016) found that nurses ent cultures. Çimen et al. (2013) compared Turkish were aware of psychological difficulties experienced and Danish nursing students’ attitudes toward care by patients with breast cancer and supported them for individuals with HIV/AIDS and found that Dan- (Inan et al., 2016). In a study conducted on Turkish ish students’ attitudes toward individuals with HIV/ and English nursing students, it was determined that AIDS were more positive than those of Turkish stu- Turkish nurses were more judgmental regarding sui- dents. Egelioğlu-Cetişli et al. (2016) found increasing cide (Flood et al., 2018). Bahar et al. (2012) conduct- empathy level of nursing students and their trans- ed a study to examine the practices of traditional cultural sensitivity in their study. Tortumluoglu et al. and religious deaths in the western part of Turkey. (2006) found that nursing students from Erzurum At the end of the study, nurses and physicians came and other regions outside Eastern Anatolia were ex- to the conclusion that they should recognize the periencing cultural diversity in their religious faith, practices of traditional and religious death closely in lifestyle, and communication when performing nurs- the community they serve (Bahar et al., 2012). They ing care. Tanriverdi et al. (2012) evaluated the lives of determined the traditional postpartum practices of individuals living in Çanakkale based on Purnell’s cul- women and infants in the southeast region and fac- tural competence model. It was found that, among tors affecting these practices (Geckil et al., 2009). those in Roma, early marriages and adolescent preg- Kukulu and Öncel (2009) determined that factors nancies are common, with domestic violence against affecting the decision to give birth at home in ru- women, alcohol consumption and cigarette smoking ral areas. Arslan-Ozkan and Mete (2010) explored in men, and drug use at a minimum. However, it was pregnancy planning and antenatal health behavior. revealed that traditional practices, environmental Arısoy et al. (2014) determined the traditional meth- hygiene deficiency, and inadequacy of healthy life- ods used by mothers in Karaman province in the style behavior are widespread. Moreover, they found care of their babies (Arısoy et al., 2014), and Araba- that those in Roma tend to use primary healthcare ci et al. (2016) examined the traditional practices of services in all health problems. Uysal et al. (2014), child care of mothers with 0–12-month-old infants. who evaluated the attitudes of nursing students to- In their study, Ayaz et al. (2010) found that nursing ward disabled individuals, found that age group, type students of the three universities had cultural differ- of school, previous education for disabled individ-

120 Çağlar and Bilgili. Transcultural Nursing Care in Turkey

uals, and conditions of care for disabled individuals The Turkish society is a heterogeneous and multicul- were factors that affected the attitudes of nursing tural society due to its geographical and geopolitical students toward individuals with disabilities. Ayoğ- location (Yılmaz, Toksoy, Direk, Bezirgan, & Boylu, lu et al. (2014) examined the attitudes of nursing 2017). Turkey has experienced immigration recently and medical students toward elderly individuals and due to civil war and confusion in Syria and neighbor- found that medical students had more positive at- ing countries. Thus, local, national, and global mi- titudes toward elderly individuals than nursing stu- gration can lead to inequality in obtaining and using dents. Vural and Balcı-Yangın (2016) examined the healthcare services (Yılmaz et al., 2017). However, it opinions of Turkish and German women who live in was observed that the number of studies on immi- Alanya province and entered menopause regarding grants’ health in Turkey is small. perceptions on menopause and found differences in social development, worship, and sexuality in the Leininger’s transcultural nursing theory requires menopausal period. Karaman-Özlü et al. (2016) in- nursing practices to understand and analyze both vestigated burnout in nurses working in Turkey and cultural and universal applications of human life. This Iran. Ozsoy and Katabi (2008) examined traditional process guides nurses in designing and presenting practices among women in Turkey and Iran during nursing care that fit the individual’s specific lifestyle pregnancy, childbirth, and postpartum period. for a culturally compatible care (Rommelspacher, 2006). However, there were insufficient studies on Scales adapted to Turkish society the contradiction of cultural values of individuals It was determined that three scales were adapted in with increasing technological developments; cultur- the Turkish society. Gözüm et al. (2015) conduct- al conflicts, negligence, and blindness caused by re- ed a validity-reliability study of the Nurse Cultural gional laws and practices; ease and diversity of peo- Competence Scale and found that the psychomet- ple’s travel to various parts of the world; and woman ric properties of the Turkish form were extremely and child health needs of feminism and other gender reliable and valid. Başalan İz and Bayık (2017) con- phenomena. This can be explained by the fact that ducted the validity-reliability study of the Basic Cul- the concept of culturally sensitive care has not yet tural Awareness Scale and reached the conclusion been widely established in nursing care. that nursing students can be used to increase their cultural competence. Bulduk et al. (2011) conduct- It is not possible to achieve the goal of quality care ed the validity study of the Intercultural Sensitivity in nursing with an approach that cultural differences Scale and determined that nurse trainers could use are not considered. To provide quality nursing care, the scale to measure the intercultural sensitivity of nurses should respect the cultural values of individ- nursing students. They also emphasized that the uals and plan nursing care in this direction (Tortum- scale can be used as a guide in defining students’ luoglu, 2004). Turkey is a culturally diverse country, cultural sensitivities and evaluating the effective- where individuals with different cultures live togeth- ness of cultural models and guides in nursing edu- er. It is a requirement of contemporary nursing care cation. to plan and perform care by recognizing this richness and evaluating each individual in their own cultural DISCUSSION characteristics, and it does not adopt, exclude and In this review, it was observed that the number of ignore the importance of culture to the individuals studies on the field of transcultural nursing in Turkey of that community. has increased and the articles have been published in national and international academic journals. This This review revealed the forefront in areas on the progress is associated with the establishment of the contradiction of cultural values of individuals with transcultural nursing foundation and organization increasing technological developments; cultural of congresses. Studies attempted to determine the controversy, neglect, and blindness caused by re- factors that cover the different dimensions of trans- gional laws and practices; ease and diversity of peo- cultural nursing, including nursing education and ple traveling to various parts of the world; women training process, clinical and hospital applications, with feminism and other gender events, and child and some scales and guides were adapted in the health needs. This can be explained by the fact that Turkish language and became useful in the Turkish the concept of culturally sensitive care has not yet population. been widely established nursing care in Turkey.

121 Florence Nightingale Journal of Nursing, 28(1), 110-123

Study limitations Arslan-Ozkan, I., & Mete, S. (2010). Pregnancy planning and Because of the factors that make culture varied, the antenatal health behaviour: findings from one maternity unit number of factors influencing transcultural nursing in Turkey. Midwifery, 26(3), 338-347. [CrossRef] Ayaz, S., Bilgili, N., & Akın, B. (2010). The transcultural nurs- care is also quite large. Therefore, studies on trans- ing concept: a study of nursing students in Turkey. Interna- cultural nursing care are also quite diverse. In this re- tional Nursing Review, 57(4), 449-453. [CrossRef] view, studies on this area have been evaluated. How- Ayoğlu, F. N., Kulakçı, H., Ayyıldız, T. K., Aslan, G. K., & Veren, ever, this review may be inadequate to assess the F. (2014). Attitudes of Turkish nursing and medical students whole of the studies in transcultural nursing care. toward elderly people. Journal of Transcultural Nursing, 25(3), 241-248. [CrossRef] CONCLUSION Bahar, Z., Beser, A., Ersin, F., Kissal, A., & Aydogdu, N. G. The concept of “transcultural nursing” has been used (2012). Traditional and religious death practices in Western Turkey. Asian Nurs Res, 6(3), 107-114. [CrossRef] in nursing care since 2004 and included in the nurs- Bardakci, E., & Gunusen, N. P. (2016). Influence of work ing curriculum of many universities in Turkey. How- place bullying on Turkish Nurses’ psychological distress and ever, there are deficiencies in providing adequate nurses’ reactions to bullying. J Transcult Nurs, 27(2), 166-171. knowledge to provide culturally sensitive nursing care [CrossRef] in studies. Most studies in this review used quantita- Başalan İz, F., & Bayık Temel, A. (2017). Cultural awareness tive methods. Qualitative studies can be beneficial in scale: psychometric properties of the Turkish andrsion. Colle- determining cultural factors and enable acquisition gian 24, 499-504. [CrossRef] of in-depth knowledge in determining nurse’s views Bulduk, S., Tosun, H., & Ardıç, E. (2011). Measurement prop erties of Turkish intercultural sensitivity scale among nursing on this issue. In future studies, studies should be students. Turkiye Klinikleri J Med Ethics 19(1): 25-31. conducted using different methods; examine differ- Ceylantekin, Y., & Öcalan, D. (2016). The cultural awareness ent cultural characteristics; determine the effect of of the nursing students and their ideas about transcultural technological development and regional practices on nursing. GÜSBD, 5(4), 45-53. culture, which are the subjects that are hardly stud- Cinar, F. I., Cinar, M., Yilmaz, S., Acikel, C., Erdem, H., Pay, S., ied; and analyze areas such as travel and violence. et al. (2016). Cross-cultural adaptation, reliability, and validity of the Turkish version of the compliance questionnaire on rheumatology in patients with Behcet’s disease. J Transcult Peer-review: Externally peer-reviewed. Nurs, 27(5), 480-486. [CrossRef] Cirik, V., Efe, E., Oncel, S., & Gozum, S. (2017). Experiences Author Contributions: Concept – S.Ç., N.B.; Design – S.Ç., and attitudes of nurses regarding complementary health ap- N.B.; Supervision – S.Ç., N.B.; Resources – S.Ç., N.B.; Materials proaches used by themselands and their patients. J Transcult – S.Ç.; Data Collection and/or Processing – S.Ç., N.B.; Analysis Nurs, 28(4), 381-390. [CrossRef] and/or Interpretation – S.Ç., N.B.; Literature Search – S.Ç., N.B.; Çimen, S., Bahar, Z., Öztürk, C., & Bektaş, M. (2013). To Writing Manuscript – S.Ç., N.B.; Critical Review – S.Ç., N.B.; comparison of attitudes of Turkish and Danish nursing stu- Other – S.Ç., N.B. dents toward the care of persons with HIV/AIDS. DEUHYO ED, 6(3), 139-143. Conflict of Interest: The authors has no conflicts of interest Egelioğlu-Çetişli, N., Işık, G., Özgüandn-Öztornaci, B., Ar- to declare. dahan, E., Özgürsoy-Uran, B. 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