INTRODUCTION

Various factors, such as economic changes, environmental crises, and globalization, force many people to leave their country and willingly or forcefully migrate or seek asylum to other countries. These circumstances have created multicultural population structures comprising individuals, families, and groups from different cultures and subcultures worldwide.¹

Since Turkey is located on routes of migration, it has experienced mass migration because of conflicts occurring in surrounding countries.² Civilians in Syria, which borders Turkey, have left their country and taken refuge in neighbouring countries because of the state of the Syrian regime and internal conflicts in the country since 2011. Turkey is the first of many countries where Syrians took refuge.³ As of 2020, 3,585,209 Syrians live in Turkey under temporary protection.⁴

Health is a relative concept that varies according to countries and their cultures. The increasingly multicultural structure of societies and the need to provide culture-specific care significantly influence the practice of nursing.⁵ In a world with increasing cultural diversity, the importance of intercultural nursing is increasing. Cultural competence in healthcare corresponds to the cultural needs of patients.⁶ Cultural competence for nurses is the adoption of the necessary knowledge, skills, approaches, and personal attitudes to ensure to provide services and care in accordance with the cultural characteristics of their patients.⁵ For providing effective and adequate healthcare, nurses must be aware of and understand the cultures of their patients.⁷ Nurses  cultural competence are familiar with cultural experiences and their own personalities, apply sociocultural knowledge to nursing care and provide individualised patient care. The provision of culturally appropriate care has become a necessity for reasons such as increased cultural diversity, increasing openly exhibited identities, growing trend of home care, and inequalities in the provision of healthcare.⁸ The relevant literature has emphasized the lack of cultural competence in the care of patients from different cultures as a problem. Cultural conflict is considered the result of an ethnocentric focus leading to lack of cultural competence, misunderstanding, lack of trust and obstacles against effective communication and positive relationship formation.⁷ Nurses must have cultural enthusiasm, cultural awareness, cultural knowledge, and experience to provide culturally appropriate care.⁵

One study found that nurses had a moderate level of cultural awareness, but exhibited low levels of cultural knowledge and skills in patient encounters.⁹ In a study conducted among nursing students, the students were found to have a low level of cultural competence.¹⁰ A review of the literature revealed that limited studies have examined intercultural nursing care in Turkey, although some studies have examined the perspectives of nursing and midwifery students on patient care.^11,12 This study is crucial because it helps nurses in providing appropriate holistic care to patients from different cultures, gaining an understanding of the intercultural approach, and learning how to manage such situations.¹³ Therefore, this study was conducted to examine the cultural competence of nurses working in hospitals on the Syrian border.

MATERIALS AND METHODS

This descriptive study was conducted in Suruc, Akcakale, Harran and Ceylanpınar State Hospitals on the Syrian border between July and August 2020. No sampling method was used for sampling. The study population comprised 302 nurses working in hospitals, and the sample involved 245 of the nurses (81%) who agreed to participate in the study. The sociodemographic information form and cultural competence scale for nurses were used for data collection. The data collection forms were completed by the nurses in approximately 10 min. The forms were filled by the nurses in a face-to-face setting. The personal information form comprised 14 questions acquiring information on age, gender, education, marital status, employment status, department, duration, area of residence, knowledge of a foreign language, and any previous experience of intercultural education.

Cultural Competence Scale for Nurses

The cultural competence scale for nurses, which were validated by Gözüm et al.¹⁴, comprised 20 items and three subdimensions (i.e., cultural skills, cultural knowledge, and cultural sensitivity). These subdimensions determine the nurses’ cultural knowledge, skills, and sensitivity levels. It is a five-item Likert-type scale with answers ranging from “strongly disagree” indicated by 1 to “strongly agree” indicated by 5. The lowest and highest possible scores on the scale are 20 and 100, respectively. The Cronbach’s alpha coefficient of the scale was 0.96. A high score on the scale indicates that nurses have high cultural qualifications.¹⁴ The Cronbach’s alpha coefficient of the study was 0.95.

Statistical Analysis

SPSS 22.0 package was used for evaluating the data. The descriptive statistics (i.e. numbers, percentages, and mean) were used in data analysis. The t-test was used for normally distributed data; the analysis of variance was used in independent groups; and Kruskal-Wallis analysis was used for nonconforming values. In statistical comparisons, the alpha level of the error was considered significant at p<0.05.

The ethical approval was obtained from the Ethics Committee of Clinical Research at Harran University’s Faculty of Medicine (date and no: 30.03.2020/7) and the Provincial Directorate of Health. Consent was obtained from the participants of the study.

RESULTS

The study included 52.2% male nurses; 85.7% of the nurses had an Associate or Bachelor’s degree; and 44.1% had been working as nurses for less than a year. The average age of the nurses was 26.51±4.24 years (Table 1).

According to the results, 57.1% of the nurses agreed that patient care should be culture specific; 56.9% stated that they offered culture-specific care to their patients; 69.8% had heard the concept of cultural competence; 74%.³ expressed that cultural competence was a necessity for patient care; 87.3% stated that they had provided care to patients from different cultures; and 73.1% stated that they had used a different language when caring for patients (Table 2).

The overall mean score of the cultural competence scale for nurses was 74.95±13.50, with mean scores for the cultural skill, cultural knowledge, and cultural sensitivity subdimensions being 45.18±8.43, 22.32±4.23, and 7.44±1.68, respectively.

A significant difference was noted between the scores of nurses working in managerial positions and the service levels for the cultural skill subdimension of the scale (p<0.05). Moreover, no significant difference was noted between the mean scores of the cultural competence scale and its subdimensions based on the age, gender, education status, and duration of employment of the nurses (Table 3).

The mean scores of the cultural competence scale and all its subdimensions were significantly higher for the nurses who stated that nursing care should be culture specific, provided culture-specific care, had heard of cultural competence before and considered cultural competence necessary for patient care (p<0.05) (Table 4).

The mean scores of the cultural competence scale and its subdimensions of cultural skills and knowledge were significantly higher for nurses who had provided care to patients from different cultures and had used languages other than Turkish while providing care (p<0.05) (Table 4).

DISCUSSION

Most nurses participating in the study stated that cultural competence is a necessity for patient care. Moreover, the nurses’ levels of cultural competence were found to be satisfactory. Other studies in the literature emphasize that raising the level of cultural competence is crucial for patient care and eliminating of inequalities in healthcare.^15,16 Similar to the findings of the present study, Beer and Chipp¹⁷ reported nurses’ cultural qualification levels were high (70.2±7.2). The same study reported that the levels of cultural sensitivity, skills, and knowledge were high, which was similar to the findings of this study.¹⁷ However, another study demonstrated that cultural competence in nursing was unsatisfactory, which contradicts the findings of this study.⁷ Nurses must have cultural skills, knowledge, and sensitivity to provide culturally appropriate care to their patients. Therefore, nurses must strive to understand their patients’ beliefs regarding health and their worldviews.⁵ The results of this study revealed that  nurses’ levels of cultural competence, knowledge, skills, and sensitivity are high. More than 50% of the nurses who participated in the study stated that they had provided culture-specific care, that nursing care should be culture specific, that cultural competence is necessary for patient care, and that they had heard of cultural competence before. These results support the conclusion of this study.

In this study, as the level of education of nurses increased, the mean cultural competence scores increased as well. However, the difference between them was not found to be statistically significant. A study reported a correlation between nurses’ levels of education and their cultural understanding and competence.¹⁸ In a study with nurses in hemodialysis services, Mahabeer¹⁵ identified a meaningful correlation between the level of education and cultural competence. Another study demonstrated that as the level of education increases, healthcare decisions are increasingly influenced by culture.¹³ The results of this study are important because they demonstrate the necessity of including cultural competence in both nursing students’ educational curriculum and in-service training of nurses.

Nurses with a longer duration of employment have a higher level of cultural competence. However, no significant difference was noted between the duration of employment and the level of cultural competence. In a study by Hart and Mareno¹⁹, no relationship was noted between nursing experience and cultural knowledge in their study. A study by Noble et al.²⁰ identified a correlation between professional experience and cultural competence.

This study found that the levels of cultural competence, cultural knowledge, skills, and sensitivity of nurses who had cared for individuals from different cultures were higher. Similarly, Meydanlıoğlu et al.²¹ conducted a study with university students from health departments and reported a significant difference in the intercultural sensitivity of individuals who did and did not co-exist with individuals from different cultures. Furthermore, a study by Bulduk et al.²² found the cultural sensitivity levels of those who interact with individuals from other cultures to be significantly different.

Other studies in the literature indicate that the levels of cultural competence among nurses and nursing students are high.^21-24 In this study, the results were anticipated to indicate a high level of cultural competence in nurses. The high level of cultural competence among nurses improves the health outcomes of patients they care for and their families, institution where they work, and the society as a whole. It further enhances the professional appreciation for their institution.

The level of cultural sensitivity in nurses was considerably high in this study. However, a study by Suk et al.²⁵ indicates that school nurses had a low mean score for cultural sensitivity. The nurses in this study had a high level of cultural sensitivity, which may indicate a high awareness of cultural competence.

CONCLUSION

In conclusion, we found that the nurses’ cultural competence levels were above average. The inclusion of training on cultural evaluation in undergraduate and postgraduate programs for nursing is recommended to improve the levels of cultural competence and cultural evaluation skills of nurses.

MAIN POINTS

• Cultural competence should be a priority in the provision of healthcare.

• Planning is essential to develop this competence among health professionals.

• Cultural competence education should be included in the training programs for nurses.

ETHICS

Ethics Committee Approval: Ethics committee approval was obtained from the Noninvasive Clinic Ethics Committee of the Medical Faculty at Harran University (date: dated 30.03.2020, no: 7).

Informed Consent: Consent was obtained from the participants.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: S.H., F.E., Design: S.H., F.E., Data Collection and/or Processing: S.H., F.E., Analysis and/or Interpretation: S.H., F.E., Literature Search: S.H., F.E., Writing: S.H., F.E., Critical Review: S.H., F.E.

DISCLOSURES

Conflict of Interest: The authors declare no conflict of interest.

Financial Disclosure: The authors declare that this study received no financial support.