Transcultural Nursing Care in Turkey.

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.

INTRODUCTION

Presently, the demographic structure of society changes, and societies are composed of different ethnic and multicultural individuals. Technological developments and social media, including transportation, migration, communication resources, and economic, environmental, and social factors, affect health systems (Ray, 2016). Nurses who cannot adapt to this changing health system cannot offer quality nursing care expected from them.

Care is one of the basic building blocks of nursing. Every individual’s culture is unique, and care needs to be tailored to the individual, so care is a complex situation. Individuals with different cultures may have different perspectives on health, disease, disability, birth, and death (Ray, 2016). A nurse who does not know the value and importance of culturally appropriate care cannot provide effective care (Giger, 2017). To be able to provide better nursing care, nurses should consider race, ethnicity, culture, and cultural heritage (Giger, 2017). This demonstrates the importance of transcultural nursing for effective nursing care. Culturally sensitive care in the provision of health service is not considered a privilege but a human right (Prosen, 2015). Leininger reveals that the transcultural nursing approach prevents cultural problems or errors and increases the quality of care (Seviğ & Gülbu, 2012).

Transcultural nursing care, professionally, began with Leininger’s anthropology work in the 1950s (Andrews & Boyle, 2008; Prosen, 2015). In 1970, she developed the concept of transcultural nursing (Molloy, Walker, Lakeman & Skinner, 2015). In 1969, the International Council of Nursing started using the culture content in nursing. In 1974, the “Transcultural Nursing Society” was established to educate nurses in this field (Hotun-Şahin, Bayram & Avcı, 2009), and in 1989, the “Journal of Transcultural Nursing” began publication, which aims to develop nurses’ training and practice in transcultural care (http://tcn.sagepub.com/). Associated with the adoption of the concept of transcultural care in vocational practice in nursing in international communities, studies in this area also started in Turkey. Initially, an article that assessed the nursing profession from a cultural point of view was published in 1978 (Seviğ & Gülbu, 2012). The Transcultural Nursing Association was established in 2013 (http://kulturlerarasihemsirelikdernegi.com/?page_id=133). There are regular congresses in transcultural nursing in various regions worldwide (Giger, 2017). One of these countries is Turkey. The first “Culture and Nursing” symposium was organized in 2005. Following this, the “Transcultural Competency and Distance Education” workshop in 2006 and “Nursing and Midwifery Cultural Approach” symposium in 2009 were conducted. The first congress in this field was organized in İçel in 2011 under the title “1st International Transcultural Nursing and Midwifery Congress,” which was participated by international delegates. Then, in June 2013, The National Transcultural Nursing Congress was held. In 2015, The International Participatory Transcultural Nursing Congress was organized in Çanakkale (http://www.kahd.org/kongre-4-1.htm) Then, the first international 4th National Transcultural Nursing Congress was organized in Sanliurfa between October 21 and 24 2017 (http://www.kahd.org/kongre-5-2.htm)

In Turkey, nurses contribute to professional development through various studies in the field of transcultural nursing care, and these studies are published in national and international academic journals (Ceylantekin & Öcalan, 2016; Cinar et al., 2015). The “Transcultural Nursing” course is available in nursing undergraduate programs, and thesis studies are conducted in postgraduate education. However, it is shown that still the concept of transcultural nursing is not addressed in all dimensions and studies are concentrated only in certain areas. Determining the present situation by examining the studies conducted to address this issue is important for the development of transcultural nursing in Turkey.

The study aims were as follows:

To examine the studies in the area of transcultural nursing in Turkey

To introduce studies that focused on transcultural nursing practice

To provide readers an idea of transcultural nursing practice in Turkey

METHOD

Study Design

This study is a systematic review design.

Search process and study identification

This review was conducted according to the criteria established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher, Liberati, Tetzlaff, & Altman, 2009). The ScienceDirect, Web of Science, Academic Search Complete, Medline, PubMed, Scopus, and Google Academic electronic databases were searched for related studies conducted between 2000 and 2018 using various combinations of keywords, including care, culture, nursing, transcultural, transcultural nursing, and Turkey, in Turkish and English. Studies published in national and international journals were included in the review. A total of 150 articles were obtained. Initially, studies with Turkey and culture, Turkey and culture and nursing, and Turkey and nursing and care keywords in the 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 determined by Leininger were evaluated. Gray literature search was not performed. The latest search was performed in December 2018. A flowchart of the process of study identification is shown in Figure 1.

Figure 1

Flowchart of the process of study identification

Eligibility

A total of 150 articles were obtained in the first stage, 119 of them were included in the review because studies that did not meet the evaluation criteria were excluded (Table 1). Studies that were excluded in the review were review articles (22), had no full texts (32), and did not have the subject content compatible with the keyword (65).

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

Data Analysis

Thirty one studies that met the inclusion criteria were grouped according to the eight main areas that Leininger identified as the building block of transcultural nursing (Andrews & Boyle, 2008) (the health of migrants within and among countries; knowledge of faith, life, and values that individuals have and respect; increasing technological developments that may conflict with the cultural values of people; cultural controversy worldwide and impact of violence on healthcare; cultural strife, neglect, and blindness caused by regional laws and practices; ease and diversity of people’s travel to various parts of the world; women and child health needs of feminism and other genders; community and cultural influences of healthcare services on environmental conditions).

Bias

The evaluation synthesis of the results was used depending on the differences in study design, sample population, type of measuring instruments, and significance in the results.

RESULTS

The results of the studies were examined under two headings: characteristics of the study methods and characteristics of the transcultural nursing field determined by Leininger. The results of the review were evaluated in two separate sections.

Characteristics of the study methods

The general properties of studies are shown in Table 2.

Table 2

Features of included studies (n=31)

Name of research and authors	Journal, date	Purpose	Type of study sample size	Data collection methods	Findings and results
Belief that individuals have and knowledge of their life and values and respect
Experiences of patients with newly diagnosed breast cancer in Turkey İnan et al.	TCN, 2016	To describe the experiences of women in Turkey in the breast cancer diagnosis stage	Phenomenological approach to qualitative research 9 women	Semistructured in-depth interviews	Women have an intense ambiguity about illness, treatment, and social relations and, therefore, exhibit avoidance behavior.
Traditional and religious death practices in Western Turkey Bahar et al.	Asian Nursing Research, 2012	To investigate the traditional and religious practices related to death in Narlıdere district of İzmir	Qualitative study 181 women	Semistructured in-depth interviews	Among the religious practices following death is the first place to pray. It has been found that relatives and friends who participated in the tomb ceremony visited the house of the deceased 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 postpartum practices of women and infants and the factors influencing such practices in Southeastern Turkey Geckil et al.	Midwifery, 2009	To understand the traditional postnatal practices of women and infants and determine the factors that affect these practices	Descriptive study 273 women	Questionnaire prepared by researchers	In the postpartum period, women have several traditional practices. Nutritional practices are particularly important for newborn mothers. Again, these women were found to have traditional practices, such as wrapping a tight cloth, putting a heated brick in the snow, and lying in hot land.
Factors influencing women’s decision to deliver at home in rural Turkey Kukulu and Öncel	Midwifery, 2009	To determine women’s thoughts about homebirth and examine the factors that affect homebirth	Cross-sectional descriptive study 392 women	Questionnaire prepared by researchers	The decision of homebirth concerns economic difficulties and the desire to benefit from the help of neighbors. Women who gave birth in the home, planned or unplanned, reported that homebirth was unsafe.
Pregnancy planning and antenatal health behavior: findings from one maternity unit in Turkey Arslan Ozkan and Mete	Midwifery, 2010	To determine the relationship between pregnancy planning and prenatal behavior	Cross-sectional descriptive study 1355 women	Questionnaire prepared by researchers	Mothers with unplanned pregnancies smoke more cigarettes and consume more beverages that contain caffeine than mothers who plan their pregnancies. Moreover, these women had lower vitamin levels and had more nutritional problems and did not have the recommended weight during pregnancy.
Traditional methods applied in caring for ınfants of mothers in Karaman Arısoy et al.	Anatolian Journal of Nursing and Health Sciences, 2014	To determine the traditional methods that the mothers of Karaman province apply to their newborn babies	Cross-sectional and descriptive study 443 women	Questionnaire prepared by researchers	During pregnancy, childbirth, and postpartum and postnatal periods, parents receive information from the health workers initially and from the family elders. Mothers use traditional methods in the care of infants such as 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.
Traditional methods used in ınfants Arabacı et al.	Journal of Child and Civilization, 2016	To identify the traditional practices of child care of mothers with 0–12-month-old infants	Descriptive study 98 women	Questionnaire prepared by researchers	Women try to solve their baby’s health problems by using traditional methods that they know or are recommended by their parents. Mothers use a yellow scarf on the baby to prevent jaundice, swaddle, and 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 nursing concept: a study of nursing students in Turkey Ayaz et al.	INR, 2010	To determine the cultural diversity of students and the patients they live with and provide patient care services. Transcultural nursing’s knowledge was also investigated	Descriptive study 622 students	Questionnaire prepared by researchers	Most students have cultural differences in patient care and sometimes have difficulty in caring due to these differences. The lessons on cultural education in the curriculum of the students will reduce the living problems.
Experiences and attitudes of nurses regarding complementary health approaches used by themselves and their patients Cirik et al.	TCN, 2016	To describe the experience of nurses’ complementary health practices and personal and professional attitudes toward the use of complementary health practices	Descriptive study 220 nurses	Questionnaire prepared by researchers	The most popular preferences that have been identified in nurses who use complementary health practices are physical and mental relaxation techniques. According to nurses, complementary health practices are useful, effective, and cheap. Nurses know the risks and potential benefits of complementary health practices and advise their patients on this issue.
Cultural sensitivity among clinical nurses: A descriptive study Yılmaz et al.	J Nurs Scholarsh, 2017	To investigate the cultural sensitivity of nurses working in rural and urban hospitals in Turkey	Descriptive and correlational study 516 nurses	Sociodemographic Questionnaire Intercultural Sensitivity Scale	Many nurses did not have transcultural nursing courses during university education. Nurses were found to have more problems with language, level of education of the patient (when low), health perception of the disease, and religious beliefs.
Cultural perceptions and clinical experiences of nursing students in Eastern Turkey Karatay et al.	Int Nurs Rev, 2016	To explore Turkish nursing students’ perceptions of providing care to patients culturally different from themselves	Qualitative study 21 students	Focus group interview	While some students focus on language and ethnic differences, some focus on gender and secrecy, while others focus on traditional practices of the cultural subgroup. While most students can describe cultural elements, only 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.
Nursing students’ attitudes to suicide and suicidal persons: A cross-national and cultural comparison between Turkey and the United Kingdom Flood et al.	J Psychiatr Ment Health Nurs, 2018	To undertake a comparative investigation of nursing students’ attitudes toward suicide and suicidal persons in Turkey and the UK	Descriptive study 240 Turkish nurse students, 82 UK nurse students	Eskin’s Attitudes toward Suicide Scale Eskin’s Social Reactions to Suicidal Persons Scale (E-SRSPS)	There are differences in the attitudes of Turkish and UK student nurses. Turkish students have some difficulty in understanding suicide in a nonjudgmental way. Societal influences such as religious belief, culture, and tradition may have a deterrent effect on attitudes to suicide.
Cultural conflicts worldwide and studies on the effect of violence on healthcare
Views of women’s sexuality and violence against women in Turkey: a cross-sectional investigation among university students Gursoy et al.	TCN, 2016	To investigate the opinions of Turkish university students on gender roles, sexuality, and violence against women on issues related to women	Descriptive cross-sectional study 605 students (337 women; 268 male)	Attitude Scale for University Students	Male students have more traditional and unfair attitudes toward women’s problems than female students. Education levels and areas of study do not significantly affect students’ views of women, and a small percentage of students have endorsed violence against women. The traditional, patriarchal qualities of the Turkish society have been found to be extremely effective even in highly educated individuals.
Influence of workplace bullying on Turkish nurses’ psychological distress and nurses’ reactions to bullying Bardakçı and Gunusen	TCN, 2016	To investigate the effect of bullying on psychological problems of nurses	Descriptive study 284 nurses Workplace Bullying Behavior Scale	General Health Questionnaire Nurse Information Form	Nurses are at serious risk of exposure to bullying behavior. Nurses with graduate degrees are more likely to be bullied and nurses who are exposed to bullying have higher levels of psychological distress and prefer to remain silent in this regard. Nurses often stay silent in the face of bullying, sharing with family and friends, or persecuting the tyrant.
Studies on the influence of environmental conditions on healthcare services in terms of society and culture
Comparison of attitudes of Turkish and Danish nursing students toward the care of persons with HIV/AIDS	DEUHYO ED, 2013	To compare the attitudes of nursing students in Turkey and Denmark toward individuals with HIV/AIDS and examine the relationship between attitudes and care willingness	Descriptive study 99 students, (52 students from Turkey; 47 students from Denmark)	AIDS attitude scale (AAS) Demographic Data Collection Form	Danish students’ attitudes toward individuals with HIV/AIDS are more positive than those of Turkish students. There is about a twofold difference between the rates of HIV/AIDS care and dating in the students of the two countries. Danish nursing students have less fear of transmission and negative feelings toward individuals with HIV/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.
Transcultural sensitivity of nursing students according to their empathy level Egelioğlu Çetişli et al.	İKÇÜSBD, 2016	To determine the relationship between the levels of transcultural sensitivity and empathy of nurse candidates and compare students from first and fourth grade in this respect	Descriptive and comparative study 195 students	Individual Definition Form Transcultural Sensitivity Scale Basic Empathy Scale	In the fourth grade, the ability of female students to empathize is higher than the ability of male students to empathize. Nursing students from the first year of the course is subject to cultural sensitivity, and cultural awareness and cultural issues should be added with an emphatic approach to individuals with different nursing management planning and should be taught.
Defining cultural diversities experienced in patient care by nursing students in eastern Turkey Tortumluoglu et al.	Nurse Educ Today, 2006	To identify the cultural diversity that nursing students have with their patients and offer disease care and determine the effects of the students’ demographic variables on these variations	Cross-sectional study 263 students	Questionnaire prepared by researchers	Nursing students experience cultural differences when they provide nursing care services. Generally, it has been observed that nursing students from Erzurum and other regions outside of Eastern Anatolia and at the beginning of their studies have experienced more cultural diversity while providing disease care. Students who have cultural diversity in patient care experience these diversities while communicating with patients regarding religious beliefs and lifestyle.
An analysis of the cultural problems encountered during caregiving by the nurses working in two different regions of Turkey Kılıc et al.	Int J Nurs Pract, 2014	To identify the cultural issues faced by nurses working in two university hospitals in the western and eastern regions during their care	Descriptive, comparative study 338 nurses	Questionnaire prepared by researchers	Extremely few nurses obtained transcultural nursing education. In nurses in western hospital, significant differences in beliefs and values between the health staff and the patients should be considered. Most nurses provide care to patients with different cultures (language, traditions, habits, traditions, 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 menopause: the Turkish and German women’s comparıson Irmak-Vural et al. Balcı-Yangın	GÜSBD, 2016	To reveal the opinions of Turkish and German women who live in Alanya province and entered menopause regarding menopausal perceptions	Comparative and descriptive study 320 women (160 German Women; 160 Turkish Women)	Questionnaire on the Descriptive Characteristics of Women Opinions on Perception of Menopause form	Turkish and German women had a difference between menopause age and duration, and there were cultural differences in social development, worship, and sexuality during menopausal period. The problems experienced by women in the menopausal period and transcultural differences and the initiatives aimed at the 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 students toward people with disabilities Uysal et al.	Nursing EducToday, 2014	To investigate the demographic variables affecting the attitudes of nursing students toward the disabled and the factors affecting this attitude	Descriptive study 587 students	Questionnaire prepared by researchers	Age group, type of school, previous education for disabled individuals and conditions for care for disabled individuals, and factors affecting attitudes of nursing students toward individuals with disabilities. There are still significant gaps in the current knowledge of the attitudes of nursing students in Turkey and factors influencing these attitudes.
Attitudes of Turkish nursing and medical students toward elderly people Ayoğlu et al.	TCN, 2014	To evaluate the attitudes of medical faculty and nursing students in Turkey toward elderly individuals	Cross-sectional and comparative descriptive study 618 students	Kogan attitude scale against older	Medical students’ attitudes toward old age were more positive than those of nursing students. Concurrently, it was determined that the students had more positive behaviors as their age increased. According to sex, there were differences in attitudes toward elderly individuals, and it was determined that students had negative behaviors.
Comparison of nurses in two different cultures: who experiences more burnout Karaman-Özlü et al.	J Perianesth Nurs, 2016	To determine the burnout levels of nurses working in surgical clinics in two countries	Descriptive study 179 nurses (Turkey, 87; Iran, 92)	Maslach Burnout Inventory Questionnaire prepared by researchers by literature survey	Nurses working in Turkey have more emotional exhaustion and less personal success compared to their counterparts in Iran. Nurses working in surgical units with higher occupational risk and workload 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 of traditional practices used in pregnancy, labor, and postpartum period among women in Turkey and Iran Ozsoy and Katabi	Midwifery, 2008	To examine pregnancy, childbirth, and traditional practices of women regarding postpartum period and to compare	Descriptive and comparative field study 300 women (Turkey, 150; Iran, 150)	A questionnaire form prepared by researchers by literature survey and semistructured interview	Cultures in pregnancy, labor, birth, and postpartum period in comparison to the beliefs and practices of the period between Turkey and Iran revealed a large difference. However, despite the cultural differences, some of the practices and beliefs are common. Consuming high-calorie foods; 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 Gypsies’ living in Çanakkale according to “Purnell” Cultural Competence Model” Tanriverdi et al.	Anatolian Journal of Nursing and Health Sciences, 2012	To evaluate the cultural characteristics of Roma with Purnell’s cultural competence model	Qualitative study (focus group interviews, voice recording and written recordings) 30 novels between the ages of 15 and 70 years	Semistructured interview form based on Purnell’s cultural competence model	Negativities such as early marriages (approximately 15 years), adolescent pregnancies, domestic violence against women, alcohol consumption and cigarette smoking among men, drug use at a minimum, prevalence of traditional practices, environmental hygiene insufficiency, and inadequate health behaviors have been identified among Gypsies. It has been found that Gypsies are prone to use primary healthcare services in all health problems.
The relationship between cultural sensitivity and assertiveness in nursing students from Turkey Kılıc and Sevinc	TCN, 2017	To determine the relationship between cultural sensitivity and assertiveness in university nursing students	Descriptive study 444 students	Chen and Starosta’s Intercultural Sensitivity Scale (ISS) and Rathus Assertiveness Scale (RAS).	There is relationship between cultural sensitivity and gender and desire to work overseas; assertiveness and year of nursing education and desire to work overseas. Nursing students at both schools had a moderate level of 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 of relatives of Syrian patients in intensive care units in a state hospital in Turkey Sevinc et al.	J Clin Nurs, 2016	To describe the personal experiences of relatives of Syrian patients in an intensive care unit in a hospital in Turkey	Descriptive qualitative study 30 Syrian families treated in Turkey	Semistructured interview	Relatives of Syrian patient who were treated in the intensive care unit in Turkey were found to have problems on their patients, and problems on social support, expectations were not met adequately, and communication difficulties were experienced.
A comparison of the prenatal health behaviors of women from four cultural groups in Turkey: an ethnonursing study Tasci-Duran and Sevil	Nurs Sci Q, 2013	To determine the health behaviors of women in the prenatal period with a transcultural approach	Qualitative ethnonursing model 18 women	In-depth semistructured interviews	Pregnant women from different cultures have different health behaviors in the prenatal period. Women differ in terms of culture influence and culture, perceptions, and transformations of cultural themes, cultural structure, attitudes, health, and life.
Motherhood in the shade of migration: a qualitative study of the experience of Syrian refugee mothers living in Turkey Korukcu et al.	Nurs Health Sci, 2018	To determine the childbirth experience of Syrian refugee mothers and their transition to motherhood in Turkey	17 Syrian mothers who gave birth at Akdeniz University Hospital	Individual in-depth interviews (semistructured form)	Syrian refugee mothers giving birth in Turkey had difficulties during their pregnancies. The difficulties are related to the subthemes of fear and struggle. The women are unable to prepare for childbirth due to financial problems and other factors related to poverty. Moreover, they have heavy 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 reliability of the Turkish version of the Nurse Cultural Competence Scale Gözüm et al.	TCN, 2015	To adapt the Cultural Competence Scale for Turkish nurses and determine its validity and reliability	Methodological study 235 nurses	Cultural Competence Scale for Turkish Nurses	The psychometric properties of the Turkish form of Cultural Competence Scale for nurses were found to be highly reliable and valid. The scale can be used in transcultural studies to compare the cultural competences of nurses.
Cultural awareness scale: psychometric properties of the Turkish version Başalan İz and Bayık Temel	Collegian, 2017	To analyze the psychometric properties of the Turkish language version of the Cultural Awareness Scale and determine any possible similarities between the compositions of the Turkish version and the original scale	Methodological study 197 students	Cultural Awareness Scale	The adapted Turkish version of CAS is a valid and reliable tool for nursing students. CAS can serve as a reliable measurement tool to assess the initial outcomes of a course to enhance the cultural competence of nursing students.
Measurement properties of the Turkish Intercultural Sensitivity Scale among nursing students Bulduk et al.	Turkey Klinikleri J Med Ethics, 2011	To determine the intercultural sensitivities of Turkish nursing students and evaluate the psychometric validity of the Turkish Crysanturism Sensitivity Scale	Methodological study 148 students	Intercultural Sensitivity Scale	The Intercultural Sensitivity Scale is a valid and reliable tool that can be used by nurse educators to measure the cross-cultural sensitivities of nursing students. It can be used as a guide in defining the cultural sensitivities of nursing students and evaluating the effectiveness of cultural models and guides in nursing education.

Years of studies

There are two studies in 2018 and 2017. Most studies related to the subject (10) were published in 2016, followed by 2014 (5 studies). The number of studies annually decreases retrospectively. There are two studies each in 2015, 2013, 2012, 2011, 2010, and 2009, and one study each in 2008 and 2006. The oldest study was conducted in 2006.

Types of participants

The sample group consisted of nursing students (12 studies), nurses (6 studies), and women (5 studies) in most studies. Two studies were conducted on patients. The size of the sample varies in the studies. Qualitative studies were conducted with a minimum of 9 and a maximum of 181 participants. Quantitative studies were performed with larger sample groups (n=98–1355).

Geographical regions

The studies were conducted in different regions of Turkey and compared Turkey with different countries. In the western part of Turkey, most studies were conducted in the province of Izmir. Moreover, studies on individuals between countries were conducted in Iran with Erzurum and İzmir and United Kingdom and Turkey. Outside of these studies, some were conducted in the form of joint studies in different regions in Turkey.

Ethnic groups in the studies

Although a large part of the studies is conducted on the Turk population, some studies were also conducted on the Syrian, English, and Iranian populations.

Data collection methods used in studies

Questionnaires developed by the researchers were used in 12 quantitative studies and one qualitative study, while the scale was used in 14 studies. All questionnaires used are in nonstandard form created by researchers based on relevant literature review. Scales were used to determine cultural competence in studies: Chen and Starosta’s Intercultural Sensitivity Scale, Nurse Cultural Competence Scale developed by the World Health Organization, and Cultural Awareness Scale. In one qualitative study, questions developed by Campinha-Bacote using the Cultural Qualification Process in the Distribution of Health Services in 2002 were used. Five qualitative studies were conducted through semistructured interviews.

Result of the studies

Nurse’s studies

These studies frequently examined the state of knowing cultural care and problem of cultural differences in education and care during this period. Based on the results of these studies, the rate of transcultural nursing education is extremely low. Nurses often provide care to individuals from different cultures. The main point that nurses experience cultural differences is the language problem.

Nursing student’s studies

It was determined that, as in the nursing group, similar issues were also analyzed in the student group. It is observed that students have cultural differences in the care of patients, so they have difficulties in the caregiving process, and there is a relationship between empathy levels and cultural sensitivities. Cultural problems are caused by language disabilities, religious beliefs, and lifestyle. Almost all these studies emphasized that courses related to cultural sensitivity should be included in undergraduate nursing education and that awareness should be developed through trainings for nurses working in the field.

Different groups’ studies

These studies were frequently focused on cultural differences and effects of these differences on the use of health services. Although there is a close relationship in geographical location between Turkish and Iranian women and there is a belief based on Islamic heritage in both cultures, both groups have different cultural beliefs and practices. Gypsies who live in Turkey have worked to resolve all health problems of primary healthcare services. A study on Syrian migrants also investigated the difficulties they experienced during treatment with relatives of Syrian patients in intensive care units in a state hospital in Turkey. The most important obstacle for quality nursing care in studies conducted on foreign nationals is language.

Characteristics of the transcultural nursing field determined by Leininger

Studies in the field of transcultural nursing care are quite different. It has been determined that these studies are generally in the areas of health of immigrants who emigrate internationally or internally (Korukcu et al., 2018; Sevinc et al., 2016; Tasci-Duran & Sevil, 2013); knowledge of faith, life, and values the individuals have and respect (Arabacı, Yıldırım, Dündar, & Kadam, 2016; Arısoy et al., 2014; Arslan-Ozkan & Mete, 2010; Ayaz et al., 2010; Bahar et al., 2012; Cirik et al., 2016; Geckil et al., 2009; Karatay et al. 2016; Kukulu & Öncel, 2009); cultural conflict and impact of violence on healthcare (Bardakçi & Gunusen, 2016; Gursoy et al., 2016); and social and cultural healthcare services influenced by environmental conditions (Ayoğlu et al., 2014; Çimen et al., 2013; Egelioğlu Çetişli et al., 2016; Karaman-Özlü et al., 2016; Kilic et al., 2014; Kilic & Sevinc, 2017; Ozsoy & Katabi, 2008; Tanriverdi et al., 2012; Tortumluoglu et al., 2006; Uysal et al., 2014; Vural & Yangin, 2016). Additionally, a study was conducted to assess the suitability of a measuring instrument for cultural care in the Turkish population (Gözüm, Tuzcu, & Kirca, 2015).

In a state hospital in Turkey, Syrian patients in intensive care units were evaluated regarding the difficulties they experienced during treatment with their relatives (Sevinc et al., 2016) in studies conducted among countries and health of immigrants within the country itself. In another study conducted on Syrian migrants, it was determined that immigrants had difficulty during their pregnancy due to language barrier, some racist behaviors and discrimination, poverty, culture, and family structures (Korukcu et al., 2018).

In studies on faith, life, and value the individuals have and respect, Inan et al. (2016) found that nurses were aware of psychological difficulties experienced by patients with breast cancer and supported them (Inan et al., 2016). In a study conducted on Turkish and English nursing students, it was determined that Turkish nurses were more judgmental regarding suicide (Flood et al., 2018). Bahar et al. (2012) conducted a study to examine the practices of traditional and religious deaths in the western part of Turkey. At the end of the study, nurses and physicians came to the conclusion that they should recognize the practices of traditional and religious death closely in the community they serve (Bahar et al., 2012). They determined the traditional postpartum practices of women and infants in the southeast region and factors affecting these practices (Geckil et al., 2009). Kukulu and Öncel (2009) determined that factors affecting the decision to give birth at home in rural areas. Arslan-Ozkan and Mete (2010) explored pregnancy planning and antenatal health behavior. Arısoy et al. (2014) determined the traditional methods used by mothers in Karaman province in the care of their babies (Arısoy et al., 2014), and Arabaci et al. (2016) examined the traditional practices of child care of mothers with 0–12-month-old infants. In their study, Ayaz et al. (2010) found that nursing students of the three universities had cultural differences related to language and communication, leading to difficulty in providing care. Cirik et al. (2016) investigated that the point of view of nurses toward cultural situations and their experiences on complementary medical practices about themselves and their families.

In the area of cultural conflict and violence in healthcare, Bardakçı and Gunusen (2016) examined the situations of stressfulness due to workplace bullying of Turkish nurses. Gursoy et al. (2016) analyzed violence and sexuality toward women in university students and determined that the characteristics of patriarchal society in the viewpoint of gender and violence are preliminary.

In areas where community and cultural healthcare services are affected by environmental conditions, researchers have attempted to determine both cultural differences in the Turkish community within healthcare services and the differences in healthcare services compared to those in other societies. Kilic et al. (2014) identified that nurses who work in the western part of Turkey had language as the biggest obstacle while caring for individuals with different cultures. Çimen et al. (2013) compared Turkish and Danish nursing students’ attitudes toward care for individuals with HIV/AIDS and found that Danish students’ attitudes toward individuals with HIV/AIDS were more positive than those of Turkish students. Egelioğlu-Cetişli et al. (2016) found increasing empathy level of nursing students and their transcultural sensitivity in their study. Tortumluoglu et al. (2006) found that nursing students from Erzurum and other regions outside Eastern Anatolia were experiencing cultural diversity in their religious faith, lifestyle, and communication when performing nursing care. Tanriverdi et al. (2012) evaluated the lives of individuals living in Çanakkale based on Purnell’s cultural competence model. It was found that, among those in Roma, early marriages and adolescent pregnancies are common, with domestic violence against women, alcohol consumption and cigarette smoking in men, and drug use at a minimum. However, it was revealed that traditional practices, environmental hygiene deficiency, and inadequacy of healthy lifestyle behavior are widespread. Moreover, they found that those in Roma tend to use primary healthcare services in all health problems. Uysal et al. (2014), who evaluated the attitudes of nursing students toward disabled individuals, found that age group, type of school, previous education for disabled individuals, and conditions of care for disabled individuals were factors that affected the attitudes of nursing students toward individuals with disabilities. Ayoğlu et al. (2014) examined the attitudes of nursing and medical students toward elderly individuals and found that medical students had more positive attitudes toward elderly individuals than nursing students. Vural and Balcı-Yangın (2016) examined the opinions of Turkish and German women who live in Alanya province and entered menopause regarding perceptions on menopause and found differences in social development, worship, and sexuality in the menopausal period. Karaman-Özlü et al. (2016) investigated burnout in nurses working in Turkey and Iran. Ozsoy and Katabi (2008) examined traditional practices among women in Turkey and Iran during pregnancy, childbirth, and postpartum period.

Scales adapted to Turkish society

It was determined that three scales were adapted in the Turkish society. Gözüm et al. (2015) conducted a validity-reliability study of the Nurse Cultural Competence Scale and found that the psychometric properties of the Turkish form were extremely reliable and valid. Başalan İz and Bayık (2017) conducted the validity-reliability study of the Basic Cultural Awareness Scale and reached the conclusion that nursing students can be used to increase their cultural competence. Bulduk et al. (2011) conducted the validity study of the Intercultural Sensitivity Scale and determined that nurse trainers could use the scale to measure the intercultural sensitivity of nursing students. They also emphasized that the scale can be used as a guide in defining students’ cultural sensitivities and evaluating the effectiveness of cultural models and guides in nursing education.

DISCUSSION

In this review, it was observed that the number of studies on the field of transcultural nursing in Turkey has increased and the articles have been published in national and international academic journals. This progress is associated with the establishment of the transcultural nursing foundation and organization of congresses. Studies attempted to determine the factors that cover the different dimensions of transcultural nursing, including nursing education and training process, clinical and hospital applications, and some scales and guides were adapted in the Turkish language and became useful in the Turkish population.

The Turkish society is a heterogeneous and multicultural society due to its geographical and geopolitical location (Yılmaz, Toksoy, Direk, Bezirgan, & Boylu, 2017). Turkey has experienced immigration recently due to civil war and confusion in Syria and neighboring countries. Thus, local, national, and global migration can lead to inequality in obtaining and using healthcare services (Yılmaz et al., 2017). However, it was observed that the number of studies on immigrants’ health in Turkey is small.

Leininger’s transcultural nursing theory requires nursing practices to understand and analyze both cultural and universal applications of human life. This process guides nurses in designing and presenting nursing care that fit the individual’s specific lifestyle for a culturally compatible care (Rommelspacher, 2006). However, there were insufficient studies on the contradiction of cultural values of individuals with increasing technological developments; cultural conflicts, negligence, and blindness caused by regional laws and practices; ease and diversity of people’s travel to various parts of the world; and woman and child health needs of feminism and other gender phenomena. This can be explained by the fact that the concept of culturally sensitive care has not yet been widely established in nursing care.

It is not possible to achieve the goal of quality care in nursing with an approach that cultural differences are not considered. To provide quality nursing care, nurses should respect the cultural values of individuals and plan nursing care in this direction (Tortumluoglu, 2004). Turkey is a culturally diverse country, where individuals with different cultures live together. It is a requirement of contemporary nursing care to plan and perform care by recognizing this richness and evaluating each individual in their own cultural characteristics, and it does not adopt, exclude and ignore the importance of culture to the individuals of that community.

This review revealed the forefront in areas on the contradiction of cultural values of individuals with increasing technological developments; cultural controversy, neglect, and blindness caused by regional laws and practices; ease and diversity of people traveling to various parts of the world; women with feminism and other gender events, and child health needs. This can be explained by the fact that the concept of culturally sensitive care has not yet been widely established nursing care in Turkey.

Study limitations

Because of the factors that make culture varied, the number of factors influencing transcultural nursing care is also quite large. Therefore, studies on transcultural nursing care are also quite diverse. In this review, studies on this area have been evaluated. However, this review may be inadequate to assess the whole of the studies in transcultural nursing care.

CONCLUSION

The concept of “transcultural nursing” has been used in nursing care since 2004 and included in the nursing curriculum of many universities in Turkey. However, there are deficiencies in providing adequate knowledge to provide culturally sensitive nursing care in studies. Most studies in this review used quantitative methods. Qualitative studies can be beneficial in determining cultural factors and enable acquisition of in-depth knowledge in determining nurse’s views on this issue. In future studies, studies should be conducted using different methods; examine different cultural characteristics; determine the effect of technological development and regional practices on culture, which are the subjects that are hardly studied; and analyze areas such as travel and violence.