Cultural Capability in the Professional Care of Nurses for Medical Tourists in Iran: A Qualitative Study

1. Background

Health tourism is one of the emerging sectors of tourism in the world, which is described as travel from one country of origin to another to maintain and promote health, including medical services and disease rehabilitation (1). The existence of quality care services with international safety standards is the goal of tourists who want the best health care (2). On the other hand, medical tourism has a different behavioral pattern from healthcare providers, which is influenced by values, preferences, and culture (3).

In fact, cultural capability has a unique position as a fundamental part of professionalism due to the cultural diversity of clients (4). Cultural capability is a set of appropriate knowledge, attitudes, and behaviors that enable a person to work effectively in different cultural conditions (5). The cultural capability of nurses is to understand clients' values, beliefs, and health practices, which causes patient satisfaction and positive results in health care and promotion (6).

Studies show that cultural care is the basis for understanding cultural values, beliefs, and practices. The care that meets the needs of each patient is meaningful for him and supports his lifestyle (7, 8). It can be said that nurses are expected to be able to provide appropriate care for different groups and ensure that the human rights of patients are respected regardless of their racial, ethnic, gender, socioeconomic, and religious background. However, there is limited knowledge and understanding of this process in health services (7).

Acknowledging that medical tourism is a unique service and is strongly affected by cultural factors and "culture" plays an important role in designing behavior in the field of health care (9), it seems that the study of related aspects of cultural care of medical tourism will be effective in raising the quality of care (10). This improves the quality of services by reducing the tension of medical tourists who are vulnerable due to their health conditions and have to face additional pressure to endure cultural differences (11).

Therefore, considering that so far, no study has been done to explain the cultural capability of nurses' professional care in health tourism, it is reasonable to know: "How is the cultural capability of nurses' professional care?" and "How do nurses provide professional care?". This study was designed with a qualitative approach to address the existing information gap in the field. Qualitative studies provide more comprehensive and insightful information by delving deeply into the participants' experiences, offering a broader perspective on the investigated topic. This study aims to explore nurses' cultural competence in delivering professional care to medical tourists in Iran.

2. Objectives

This study was conducted to assess cultural capability in the professional care of nurses for medical tourists in Iran.

3. Methods

3.1. Design/Participants

This qualitative study was conducted to investigate cultural capability in nurses' professional care of medical tourists as a qualitative content analysis study. One of the qualitative research methods is content analysis, which is used to analyze data. It is a technique for systematic classification and coding (12, 13). The statistical population of this research included 18 nurses, one supervisor of the international patient ward, one doctor, two patients, and one patient companion from the hospitals of Tehran University of Medical Sciences and Urmia, who were selected by purposive sampling. The participants were selected from a wide range of people for sampling with maximum diversity (nurse, patient, doctor, patient companion, and supervisor) with different characteristics (age, service history, gender, and type of hospital). After obtaining consent and coordination with the participant, the interview was conducted.

3.2. Data Collection

Semi-structured individual interviews were conducted in 2021 - 2022. Before collecting data through the interview, the participants were given sufficient information about the purpose of the study, the methods of data collection, the reasons for recording the interviews, and the role of the interviewer and interviewees. They were assured they could withdraw from the study anytime, and their information remains confidential. After the necessary arrangements due to the COVID-19 epidemic, most of the interviews were conducted through WhatsApp and video calls, and the rest of the interviews were conducted in the international patient ward and the nurses' restroom by the first author. Each interview lasted about 20 to 60 minutes and was recorded by an audio recorder. According to the main purpose of the study, the interview was followed. The interviewer asked about cultural capability in the professional care of nurses plus some probing questions such as "Can you explain more about it?", "What do you mean?" and "Can you give an example?". In order to increase the clarity of the data, these questions were used. Sampling was purposeful, and by conducting 23 interviews, theoretical saturation was achieved, and the main themes and sub-categories were formed. In qualitative research, theoretical saturation is considered at the end of sampling (14). After 19 interviews, the data saturation was reached. Data collection was continued for four more interviews to ensure no further categories emerged.

3.3. Data Analysis

Data analysis was performed simultaneously with data collection immediately after each interview. Data analysis was done using traditional qualitative content analysis by Graneheim and Lundman (13). In the first step, the research team transcribed the interviews after listening to them several times. In the second step, the text of the interviews was read several times to achieve a general understanding in line with the research objectives. In the third step, after reading word by word all the texts of the interviews, primary codes were extracted. In the fourth step, the codes that were similar in meaning and concept and related to each other were placed in a subgroup, integrated, and categorized. In the fifth step, the conceptually more comprehensive and abstract subgroups were included in the main categories. Finally, the entire data analysis process was shared in a joint meeting, and the opinions of all the article's authors were used in the analysis (13). The collected data were analyzed in MAXQDA version 2020.

In order to check the accuracy and confirmability of the data in the present study, Guba and Lincoln's quadruple criteria were used (15), in which confirmability of qualitative studies is defined with four words, including credibility, transferability, confirmability, and dependability. In the present study, the credibility of the data was achieved with the prolonged engagement of the researchers, appropriate interaction and sufficient cooperation with the participants, data compilation, and member checks. Transferability was also possible through the rich explanation of the data presenting the quotes and examples to the masters, and getting scientific advice. The sampling diversity of the participants and the time triangulation were used for data confirmability. Data dependability was provided by conducting interviews as soon as possible, using peer checks, and re-studying all the data.

All participants gave written informed consent to participate in the study. The present study followed the principles of the Revised Declaration of Helsinki, a statement of ethical principles. The time and place of the interview was chosen in coordination with the participants. This study has been approved by the Ethics Committee of Tehran Islamic Azad University of Medical Sciences under the number IR.IAU.TMU.REC.1399.575.

4. Results

Twenty-three people participated in this study. The participants' demographic information is shown in Table 1. In the sample, 56.52% were males. Also, the coding process was done through continuous comparative analysis. After removing duplicate codes and merging similar codes, a general theme (main theme) emerged under the title "Cultural capability in professional care" in 8 categories: "Culture-oriented language communication", "Culture-oriented communication interactions", "Cultural humility", "Valuing cultural diversity", "Context-based client training", "Respectful communication", "Professionalism", and "Appropriate and culture-friendly appearance".

4.1. Cultural Capability in Professional Care

Professional care in nurses refers to standards and tools whose main purpose is to help nurses perform the care they are required to perform efficiently. Achieving professional care requires the cultural capability of nurses, which is possible through understanding and respecting the beliefs and values of patients with different cultural backgrounds. In fact, according to the nurses' statements, cultural capability is a series of characteristics that nurses should have in the field of professional care. In this research, nurses considered cultural capability in professional care to be culture-centered in language communication. They attempted to demonstrate cultural competence in professional care through various measures, including culture-oriented communication interactions. Additionally, as professional nurses, they prioritized cultural professionalism and valued the cultural diversity of international patients. They provided the necessary training to patients in a culturally appropriate context and maintained respectful relationships with them. Furthermore, they presented themselves in a suitable and culturally friendly manner. The participants also stated that professional competence is the gateway to cultural care.

4.2. Culture-oriented Language Communication

Language communication between healthcare providers and patients is essential for collecting important information, making appropriate decisions, sending messages, and providing professional care. Acquiring language communication skills based on the patients' culture is important in accurately diagnosing the disease, adopting effective treatment measures, satisfying the patients, and solving their problems. According to the participants, language communication should be culture-oriented. To do this, the participants mentioned in their experiences that nurses were selected to work in the international patient ward based on their mastery of the language of international patients. So, the nurses selected to work in the international patient ward were fluent in Kurdish and Turkish and could communicate in the patient's language.

"Most of our international patients are from Turkey and Azerbaijan, and for this reason, nurses are hired to work in the ward of international patients who are fluent in the Turkish language of Istanbul and Azerbaijan." (p11)

4.3. Culture-oriented Communication Interactions

In fact, interaction is the communication between two or more people. In the case of international patients, considering that they have a completely different culture, it is very important that these communication interactions be culturally oriented. According to the statements, nurses tried to establish culture-oriented communication interactions by paying attention to the linguistic details of international patients. They achieved this by utilizing bilingualism, creativity, and initiative to communicate effectively. In some cases, communication was facilitated through pantomime and drawing. Additionally, nurses attempted to establish communication interactions through Internet translation services. Also, they determined the relationship according to the culture of the patients. Establishing communication was a criterion for selecting nurses to work in the international patient ward.

"The staff of this ward is different from other wards. People selected as international nurses are very strong in terms of public relations and can communicate very well, have a better appearance, and have no problems in terms of communication". (p12)

4.4. Cultural Humility

Cultural humility is a powerful tool for addressing the differences that people from different backgrounds experience, whether these differences in culture, race, sexual orientation, socioeconomic status, religion, gender, and disability are visible or invisible. According to the participants, many nurses in the international patient ward were humble and respectful toward people of different cultures. They often challenged their cultural prejudices and tried to understand the international patients' culture to provide care based on them. In other words, cultural humility is one of the subclasses that creates cultural capability in professional care. In order to achieve cultural humility, nurses strived to understand the culture of their patients. They may use a translator or research to address cultural gaps and ensure that patient care is culturally sensitive. By knowing the patients' culture and identifying the people's cultural characteristics, the nurses changed how they communicate with the patients and their training to achieve cultural care.

"My relationship with an Iranian patient differs greatly from an international patient. In the beginning, I proceed very cautiously until I get to know them completely and learn more about their culture so that I can treat them based on their culture." (p15)

4.5. Valuing Cultural Diversity

Valuing cultural diversity is necessary to have cultural capability in professional care. In fact, it is necessary to have information about the ethnic and religious background of the patient. Valuing cultural diversity in interaction with medical tourists creates bridges for trust, respect, and understanding of their culture. According to the participants' statements regarding international patients, in addition to mastering language and communication skills, nurses performed care through their ability, skill, knowledge, and speed of action for nursing care, considering the patients' culture. The nurses took into account the cultural differences of the patients; considering the high stress of the international patients, they tried to establish a sense of relaxation for the patients during the procedures, paid more attention to the international patients, and fully performed the care. In other words, they considered cultural diversity in the matter of care.

"The only thing that made me happy was that the patients did not come to the ward very often and they left early, and this made me try my best for these patients, although I did the same for the others, for these patients, I don't know how to say, it was a different feeling that I don't know how to express, but I took care of them and visited them several times." (p10)

4.6. Context-oriented Client Training

All cultures have systems of health beliefs to explain what causes illness, how it can be treated or cured, and who should be involved in the process. The degree of cultural knowledge of medical tourists by nurses and training the clients based on it can profoundly affect their acceptance of the information provided and their willingness to use it. Therefore, context-oriented client training is one of the subclasses of cultural capability in professional care. According to the nurses' statements, most of the selected nurses of the international patient ward had a master's degree in addition to the mentioned characteristics. The education given to international patients differs from that of Iranian patients, and according to the cultural difference, international patients were forced to learn and teach a series of specialized words through a translator or the Internet. Also, nurses provide context-oriented patient training through repetition of materials, training based on age and literacy level, training procedures through the presentation of pamphlets, images, and videos, training of diseases and drug side effects, presentation of pamphlets based on the language of international patients and considering culture in all cases.

"In terms of being teachable, well, I should have explained more to them, and basically, all the brochures, evaluation sheets, and pamphlets are designed in the Kurdish language in the ward." (p9)

4.7. Respectful Communication

Respectful communication is vital because international patients and their families experience many emotions often associated with facing illness and coming to a foreign country. They may be anxious, upset, or scared. Respectful communication helps nurses form mutual respect and achieve cultural capability in professional care. According to the findings of this study, one of the subclasses of cultural capability in professional care is respectful communication. In order to accomplish cultural capability in care, nurses with high public relations, good character, and sociability were selected to work in the international patient ward. In fact, when dealing with international patients, nurses had a calm appearance and demeanor, and they considered the mental and emotional peace of the patients. They could create a sense of peace and satisfaction in the international patients, answered the patients' questions calmly, and thus had respectful communication with patients.

"Firstly, an international patient is a patient who comes from another country. What comes to my mind is to treat them with respect and courtesy". (p12)

4.8. Professionalism

Professionalism in nursing demonstrates an unwavering commitment to the profession and a willingness to consistently provide patients with the highest quality culture-based care. When nurses exhibit professional behaviors, patients receive better care. According to the findings of this study, professionalism is essential to achieve cultural capability in professional care. International nurses pay attention to the basic needs of patients and identify them. They also paid attention to the patients' culture to perform some procedures. Regarding behavioral characteristics, the nurses in the international ward exhibited better behavior. Also, professionalism is highly valued according to the belief that a nurse represents the Iranian people. Keeping one's word to international patients is a key aspect of nurses' professionalism.

"In general, to provide better care to these patients, the most important thing is the skill and speed of care. Skill in providing care is very important because our goal is to treat these patients (p13)".

4.9. Appropriate and Culture-friendly Appearance

Patients' perception of professional care depends on the appropriate appearance of the nurse. The inappropriate appearance of nurses causes a decrease in trust in patients. According to the nurses, appropriate and culture-friendly appearance was one of the sub-classes considered in achieving cultural capability in professional care. For some organizations, a suitable and culture-friendly appearance was very important in providing services to international patients, and, in addition to other subclasses, having an appropriate and culture-friendly appearance was one of the criteria for selecting an international nurse.

"In the international patient ward, nurses whose work was better and worked well were selected, and appearance was also important; because it is an international patient ward, the importance of the appearance and staff uniform is also considered. (p6)

5. Discussion

The present study clarified the cultural capability in the professional care of nurses for medical tourists in Iran. Cultural capability in professional care was classified into 8 categories: "culture-oriented language communication", "culture-oriented communication interactions", "cultural humility", "valuing cultural diversity", "context-oriented client training", "respectful communication", "professionalism," and "appropriate and culture-friendly appearance". The concepts of health and illness are part of a human's view and his place in the world. The treatment staff must coordinate their duties with the patient's needs. Health and care systems should be developed considering cultural contexts (16). Nurses are one of the most basic people in providing care, and to achieve it, cultural capability in professional care is important.

The first class in this regard is culture-oriented language communication. In fact, to communicate with medical tourists, nurses must master patients' language, and knowing patients' language is one of the criteria for choosing nurses to care for medical tourists. Footman et al. conducted a qualitative study on dialysis medical tourists and explained that doctors and nurses are expected to speak more than one language due to the limited availability of translators. In fact, the important item in the care of medical tourists is proper communication through knowing the language of international patients, which should be based on their culture (17). In this regard, other studies also identified the language barrier as the most common barrier to providing care, which has led to miscommunication and anxiety among medical tourists (18, 19). Studies have also shown that in many large medical centers, despite the presence of interpreters, patients still expect healthcare providers to speak their language. In addition, cultural differences are seen as barriers to effective communication between patients and healthcare providers. This finding explains why patients choose a familiar or similar language and culture as their destination (20, 21).

Another class of communication interactions is culture-oriented. Interactions and communications usually happen in a cultural context, which includes a pattern of physical understanding that gives meaning between two members in the context of culture (22). Abisheva et al. stated that knowing the patients' culture affects how nurses understand, combine, present, receive, and interpret their messages. Culture affects everything about communication, including language, nonverbal signals, the meaning of words, issues of time and place, and the rules of human relations (23). Ghosh et al. also conducted a study on medical tourists who came to India and stated that in the new era of medicine in India, it is essential that healthcare providers have sufficient communication skills to properly communicate with patients from very different cultural backgrounds. They acknowledged that interaction with an international patient could be deepened through effective communication adhering to their cultural beliefs. Improving awareness of cultural differences ensures greater patient satisfaction and improves interaction with healthcare providers (22).

Cultural humility is another class of cultural capability of professional care. Cultural humility may be defined as the process of being aware of how people's culture affects their health behaviors and consequently using this awareness to develop sensitive approaches to treating patients (24). Nolan et al. state that promoting cultural humility is every nurse's duty. Every nurse must provide nursing care in a way that communicates with the patient with respect and compassion, understands the cultural diversity of the patients, puts equality at the core of their work, and, in fact, provides clinical care to patients based on the models of cultural nursing (25). Meanwhile, Kibakaya and Oyeku showed that cultural humility is a concept that includes elements of self-inquiry, immersion in the patient's perspective, active listening, and flexibility, all of which serve to confront and address biases or personal and cultural assumptions. Cultural humility frees healthcare professionals from having specialized knowledge about many cultural differences and promotes open communication with patients to achieve common outcomes of health, growth, and professional care (26).

Valuing cultural diversity is another class of cultural capability in professional care. As Liu and Chen state, understanding the culture of medical tourists and knowing that culture affects behavior and value is very important. In fact, patients travel to countries with different cultural beliefs and different geographical views (3). Lin et al., who explained the nurses' experience of culture, concluded that being unprepared when facing different cultures was the main issue in describing and guiding the process of examining nurses' experiences of culture. "Awareness of value differences" was identified as a key concept. Nurses showed that in carrying out their nursing work and searching for resources that show situations where interactive behavioral characteristics lead to a better understanding of the patient's culture, nurses who managed different cultural situations eventually learned to tolerate different cultures and provide culturally appropriate care to patients, which consequently increased the quality of care (27).

Knowledge level of the culture of medical tourists by nurses and client's training based on it can profoundly affect their acceptance of the information provided and their willingness to use it. Therefore, context-oriented client training is one of the classes of cultural capability in professional care. In this regard, Rockich-Winston and Wyatt state that members of a cultural group have common characteristics that distinguish them from other groups. Cultural differences affect patient acceptance of patient education and willingness to accept information and incorporate it into their lifestyle. It is important to remember that every educational interaction with the patient has a cultural dimension (28). Hordijk et al. state that cultural diversity challenges healthcare providers to facilitate cross-cultural gaps with clients. They explained that by providing cultural care and training patients based on their culture, it is possible to meet the needs of all clients with any culture (29).

Respectful communication is another class of cultural capability in professional care. Respectful communication for human-centered care and serving patients is a moral issue. Nurses must adhere to the professional oath and serve as a model for others (30). Jemal et al. conducted a qualitative study on respectful and empathetic communication and its impact on the quality of care. Compassionate and respectful care shows true humanity and kindness in patient care, improving the quality of care and increasing patient satisfaction (31). Also, various studies show that the presence of compassionate nurses with respectful communication leads to less anxiety and fewer complaints among patients, better compliance with medical recommendations and treatment plans, reduction of violations, acceleration of treatment processes, better relationships between nurses and clients, and improvement of the quality of healthcare (32, 33).

Professionalism in nursing means providing high-quality patient care while maintaining the values of responsibility, respect, and honesty (34). One of the classes of cultural capability in professional care is professionalism. International nurses pay attention to the basic needs of international patients and identify them. They also paid attention to the patients' culture to perform some procedures. Coventry et al. state that culture, leadership, and workload issues affect nurses' ability to engage in continuous professionalism. The consequences affect the competence of the operation, the provision of safe and high-quality patient care, the maintenance of professionalism, and job satisfaction (35). Tanaka et al. stated that promoting professionalization in nursing is significantly important for increasing the length of nursing experience, achieving a higher level of educational preparation, and improving the quality of care (36).

Culturally appropriate appearance is another class of cultural capability in professional care. Wills et al. conducted a study on the effect of appearance on professionalism. The results confirmed the complex nature of nursing appearance. Participants considered the nurses who spent more time improving their appearance to be professional, reliable, and active. Nurses who did not have the right appearance were described as lacking self-confidence, preparation, and less compassion (37). Pullen and Alley concluded that appearance can create a positive or negative impression of a nurse. A negative image is created when a nurse wears a wrinkled and dirty uniform, has improper makeup, is not clean, has untidy hair, and has an improper body posture. The negative image of nurses reduces the credibility and patients' trust. Nurses should create a positive image for patients (38). Fogle and Reams also stated what influences a positive image of a nurse. Patients are comfortable with nurses who project a professional image. Their study showed that patients like clean and well-groomed nurses. Patients did not like to see messy hair on the nurse's shoulders. This study showed that the positive image of nurses shows them as professionals (39).

5.1. Conclusions

Cultural capability is very important in nurses' professional care of medical tourists in Iran. Cultural capability in professional care was categorized into 8 categories: "culture-oriented language communication", "culture-oriented communication interactions", "cultural humility", "valuing cultural diversity", "context-oriented client training", "respectful communication", "professionalism," and "Appropriate and culture-friendly appearance." Being aware of factors affecting the cultural capability of professional care in medical tourists, nurses have taken the necessary measures and realized the cultural capability of nurses' professional care. As a result, it can be said that cultural capability is important in the professional care of nurses to provide comprehensive and quality care because patients come with different cultural beliefs and from different geographical areas. It is suggested to use quantitative studies to examine the concepts extracted from this study about medical tourists and nurses and evaluate the current situation.