Characterization of the articles

Twelve articles published in scientific journals were selected. These materials integrated Ethnonursing and/or the Theory of Culture Care as frameworks in the surveys. 58 % were written in Portuguese, 30 % in English and 17 % in Spanish. The articles were published in the following countries: Brazil (7), United States (3) and Colombia (2).

According to the studies, it was possible to identify that not all were based on Nursing theoretical grounds that allowed understanding the cultural phenomena researched. This is added to the need to methodologically support using Ethnonursing faithfully to the proposal set forth by Madeleine Leininger et al., where its concept, usefulness, facilitators, data production strategies and data analysis phases are detailed. Among all 12 studies, it was found that only eight used the Ethnonursing methodology ^{11,12,13,14,15,16,17,18} -some of them employed analysis methods other than Leininger’s proposals- and only six resorted to the Theory of Culture Care to understand the cultural phenomena that were researched.^{11,15,19,20,21,22} According to the aforementioned, only half of the studies that addressed culture were grounded on Leininger’s theory, which is an invitation to acknowledge the need for intellectual and academic training in Ethnonursing and in the theory supporting its theoretical thinking, with the article by Lima¹⁹ as an example. Training and knowledge will not only allow improving research reports, but also supporting culture care as proposed by Leininger from the Nursing discipline.

COREQ análisis

The consolidated criteria for reporting qualitative research (COREQ) is a checklist with three domains to promote full and explicit reports of qualitative studies.⁹⁾ All 12 articles included were analyzed with the COREQ checklist; the results of this analysis are presented in Table 2 T3.

Table 2: Analysis of the articles by means of the COREQ checklist 

In the first domain, which refers to the interviewer’s personal characteristics, no information reported by the articles was obtained, as only two of the twelve studies mentioned the interviewer’s occupation and only one their gender; the researchers failed to consider this aspect. Regarding the researcher’s relationship with the participants, the articles do not report the interviewer’s characteristics or what the participants know about him/her. However, the relationship established between the interviewer and the participants is in fact reported, although in only 30 % of the cases. In this sense, in qualitative research it is important to acknowledge the need for proximity, trust and relationship in all cultural knowledge processes for the results to be trustworthy and for the phenomena to be revealed as the informants experience them; an investigation as to why this is not documented in research reports is pending.

The criteria for which the articles included comply with the most items are found in the second domain. At first instance, all the articles reported the methodological framework that guided the research. Similarly, information is presented about the selection of participants, which is reported in all articles, with the exception of the non-participation report, described in only one article. Regarding the study loci, all the articles reported how data production was developed, the characteristics of the final sample were reported in 58 % and only 16 % indicated if there were other people present during the interview. The last section in the domain explores data production: only one third of the studies mention having an interview script, repetition of interviews and their duration and return. Slightly more than half of the articles reported audio-recording the interviews (58 %) and using field notes (66 %); only seven articles indicate how data saturation was reached. From the methodological point of view, this aspect leaves doubts because strictness can be impaired when these issues that have been discussed by researchers from all world countries in qualitative research are not reported in the articles that are being published in the Nursing area.

Finally, the third domain shows the gap in qualitative reports referring to data analysis, the information about the number of coders, a description of the coding and the software used; in addition, coding of the findings is virtually non-existent. The most frequently found criterion was the one related to Derivation of the topics, which was reported in 58 % of the articles. The last section of the checklist is also the most reported: all the articles clearly reported data and findings in the topics; 92 % included verbatim quotes from the participants’ testimonies; and minor topics were discussed in 58 % of the articles integrated in this review. In general, only 5 of the 12 articles complied with at least 50 % of the COREQ criteria; the rest only met one third of the checklist. Of the 37 criteria to be assessed in the qualitative studies, the mean of criteria complied with was 14 in all 12 articles included in the review. The lowest number corresponded to the article by Lima ¹⁹ with only 9 criteria present in the report, whereas the most complete article according to the checklist was the one by Valderrama and Muñoz, ¹⁴ with 20 of the 32 COREQ criteria.

Final categories

Four categories emerged from the results obtained in the review; their grouped codes were presented in Table 1.

Category 1. Need for training in Ethnonursing and in the Theory of Culture Care

From the review that was conducted, an invitation is made to acknowledge the need for intellectual and academic training in Ethnonursing and in the theory that supports its theoretical thinking. Culturally Congruent Care (CCC) requires that professionals be trained in the conceptual grounds that are integrated in the Theory of Culture Care; therefore, Nursing professors face the challenge of integrating education on this aspect into the curriculum, so that people are offered care that is congruent to their needs without forgetting their culture and its relationship with health results. ¹⁰

In the region of the Americas, this aspect is addressed when the Social Determinants of Health and their influence on people’ health are reviewed, as well as the integration of this knowledge into the care provided in real-life and hypothetical cases. However, the study by Moreno et al. ²³ mentions the need to deepen on knowledge, as the American continent presents various health inequalities and complex epidemiological situations, such as child malnutrition due to deficient living conditions in communities. These health needs require an approach not only from the biomedical model focused on pathologies and their treatments, but comprehensive care that sizes and acknowledges people’ life reality, with the challenge for professionals to include social, cultural and subjective aspects in their actions in order to provide CCC. ^17,23

Culturally congruent care involves knowing the values, beliefs, practices, meanings and symbols based on the culture; this is relevant for people because they shall receive individualized care that is sensitive and appropriate to their context and health status.²⁴ Therefore, it is crucial that students/professionals in the health area include these aspects as indispensable in Nursing care. Belem et al. ¹⁷ are consistent when they mention the urgent need to adapt the initial and graduate training processes so as to provide Nursing professionals with theoretical, methodological and sensitization elements related to health and care as cultural phenomena. Leininger⁵ stated that cultural competence is important to be able to provide Culturally Congruent Care (CCC); this should be up to Nursing professionals through their training, thinking and research from the cultural perspective. ⁽²⁵ The results after using the COREQ list revealed methodological deficits in the research studies, based on the criteria accepted by the scientific community. As for the aforementioned, Mixer¹¹ highlights the role of Nursing educators, as professors that provide Culturally Congruent Care are more prone to teaching this care model to their students.

However, Culture Care teaching not only involves the determinants that are the social and health dimensions for Leininger;⁵ it requires theoretical thinking that grounds the decision-making process and the understanding of the cultural phenomena related to health. It is known that when these methods for self-care from etic care are discovered, three ways of guiding this care can be selected according to the theory: preserving it, negotiating it or restructuring it. The Theory of Culture Care supports practice and research by grounding the phenomena that are researched and discovered. The study by Motta and Munevar serves as an example: the theory allowed understanding the meaning attributed by a mother to her participation in the care of her premature son, involving her emic care.²⁵ This study evidences the Nursing thinking to provide congruent care, which in turn helps and teaches the mother to care for her son. In this case, the theory supports understanding and involves its concept of etic care derived from the professional training taught and imparted in a university to meet needs from a cultural perspective. Other studies are consistent in asserting that medical care providers are responsible for ensuring mutual understanding.¹⁵ In this sense, Nursing should develop the assistance it provides to people according to their cultural values and to their health contexts from the Culture Care perspective.²² It is for this reason that, when care and culture research is involved, reducing the gap based on the need for training in the Theory of Culture Care and in Ethnography will allow warranting the development of new surveys towards providing CCC.

Category 2. Recognition of the cultural context and of barriers to culturally congruent care

In this category, people’s life context was identified as a source from which culture care is derived; in some cases, culture care was a guide but, in others, situations such as absence of health institutions in rural areas, difficulties transporting people through highways or lack of opportunities in health were identified. Leininger mentions that care constructions are embedded in values and practices which are specific to each culture and that, therefore, they tend to remain invisible until researchers unveil them.⁵ According to Mixer,¹¹ a professor stated that his Nursing Head knows how to deal with the university’s policy for it to be effective; this aspect shows understanding of the work culture, where when the leader respects cultural conditions such as workload or breaks (among others), healthy cultural practices are recognized.

According to Lima et al., the cultural context is recognized when the practices adopted by a puerperal woman come from her life context, although there may be behaviors that arise from the guidance provided by some health professional. ¹⁹ Care for puerperal women is an action supported on family historicity; it is reflected in the way of caring and involves the cultural knowledge acquired across generations, with greater influence from the closest family members. The family is a vital context for every human being; it involves emic knowledge, traditions, practices and care taught among its members, determining their health results. It is therefore up to health professionals to understand how these care practices are routinely implemented in the family environment, which resources caregivers resort to and, from there, devise realistic care proposals that are feasible and close to people.

The articles included in this review revealed that culturally congruent care contributes to better results in assistance, communication and comprehensive health care. Analyzed from the perspective of Madeleine Leininger’s Nursing theory, the Kangaroo method reflects a commitment to cultural competence and to sensitivity regarding neonatal care in cultural congruence, diversity and family-centered care. The method embraces cultural diversity and is in line with Leininger’s theory offering comprehensive assistance that considers the physical, emotional, social and spiritual dimensions.¹⁹ It was found that the perception about health situations has different connotations, regardless of each person’s sociocultural context.²⁰

Thus, at the onset of certain diseases (although the situation is not clinically characterized as urgent), it is the subject’s perception that will modulate their response. In this logic, it is important to analyze etic care when guiding the health practices that should be preserved, the ones can be negotiated and those that must be restructured to avoid health ailments. Thus, the results of research studies conducted in traditional communities acknowledge the role of beliefs, practices and historical cultural context in the configuration of health perceptions, such as in quilombola communities in terms of pediatric emergency care and breastfeeding.^20,22 The results have shown that acknowledging and incorporating cultural considerations can lead to more effective and compassionate care practices that are in line with the various needs of caregivers and populations.²¹ The studies also reveal certain weakness between acknowledging the importance of culture care and the challenging barriers faced by the professionals when they realize about applicability of the theory in their practice. The social and economic aspects and accessibility to health services can be difficult factors in planning care; in addition, they sometimes require political reforms to mitigate the barriers.¹²

Regarding the barriers to CCC, it was found that insurance companies do not manage or guarantee the assistance and care measures it requires, that it is not timely and lacks the quality and safety needed, and that there are obstacles to access maternal and child health services.¹² Nurses need to be sensitive enough to be actively willing to understand cultural diversities, such as linguistic ones.^14,16 The varied nature of the cultural challenges inherent to the assistance to be provided include barriers related to language, diversity of beliefs and multiple health practices in each culture. This leads to work overload, coupled to scarce knowledge about the different habits and routines, and implies that nurses should address these challenges adapting their approaches to ensure that the assistance provided is culturally adequate, sensitive and inclusive of people’s sociocultural diversity. ¹⁵

Category 3. Culture Care diversity and universality

Some of human beings’ social characteristics are their cultural values, specificities, subjectivities and particularities that are reflected in health care. Respect and appreciation for the unique aspects inherent to different cultures indicate the need to respect differences. People are diverse, as are their life, work, leisure and religion spaces. The studies highlighted the possibility of implementing culturally congruent actions in different health contexts: from health promotion actions²² to the care provided in intensive, acute or chronic emergencies.^15,19,20

With different perspectives, the interpretations that only value hegemonic knowledge to the detriment of other types²⁶ should acknowledge that diversity means adapting therapeutic planning to each person’s subjective needs and particularities. This can include adapting treatments, taking into account cultural preferences and involving family or community members in the decision-making process. This implies considering religious, family and diet-related aspects, as well as recognizing and adapting to the language, rituals and everyday practices.^14,16,17,18 When addressing the personality of children with Type 1 Diabetes Mellitus, didactic care was promoted using instructional therapeutic toys in the culture care negotiation process, when recognizing the children’s and families’ cultural values, as well as their way of life, behaviors and habits, with the purpose of discussing care practices for the children and families.¹³

Despite the differences and singularities, there are cross-sectional aspects such as human needs, which are understood in diverse cultures but that are present due to the need for care and survival. This universality does not mean establishing strict care rules but valuing aspects inherent to rights, in addition to guaranteeing access to the services and ethical principles. For Leininger,⁵ human care follows the path of Humanity; it is universal, as care is present in different ways and in different environments, territories and communities. Universally, and as reported in the articles included in this review, human beings are caregivers as per their own cultures and social experiences,⁵ revealing different environmental, social and health organization contexts. The Theory of Culture Care provides assistance reflectively in a transcultural mutuality context.⁵ Nurses serve as mediators between health systems, professionals and populations by gathering these different social environments and actors.²⁷ Historically, CCC has been used to study the best way to serve various cultural groups, such as individuals, families and communities.¹¹ A study conducted in Chile with indigenous communities revealed the importance of considering the ethnic aspects, the wisdom of ancient knowledge and the presence of women as care referents.¹⁸

Category 4. Actions for culturally congruent care

Nursing should have its own theoretical framework for CCC, which eases planning and implementing Nursing interventions.¹¹

Health care should be focused on CCC.²⁸ Based on the review, it can be stated that Nursing professionals perform certain CCC actions mindfulnessly and others unaware of doing so. Among the studies reviewed, it was found that care is close to people’s beliefs and traditions, from the concern to understand the language spoken by the other person to knowing the cultural practices and inter-generational influences.^16,17

Studies conducted with pregnant women and caregiving mothers show that when Nursing acknowledges inter-culturality and provides counseling and care close to people’s health preferences, a sensation of well-being, satisfaction, peace of mind and trust is generated.^13,17,18,22 The individuals that were offered CCC were able to adhere to good health practices, recovered effectively and increased their trust towards nurses, improving their evaluation of the assistance received.^12,21,22 Culturally congruent Nursing care represents a therapeutic opportunity to combine cultural and professional knowledge for the sake of people’s, families’ and communities’ well-being, satisfaction and health.²⁴ Health-disease processes require the participation of various actors with different roles and ages; hence the consideration regarding their cultural beliefs, values and practices.^18,19,21,22 Nurses that understand this situation recognize that there should be certain union between conventional and culture care, an action by which it is possible to promote health and well-being and even prevent complications.^13,18 In CCC, it is necessary to respect diversity of beliefs and to adopt practices that support health maintenance or recovery, as well as the spiritual dimension, reason why it should be nurses’ concern to implement it in their care actions.²⁹

Integrating culture care into conventional practices is not only an invitation to implement spiritual, emotional and physical care practices for the people cared for; it requires education in health respecting beliefs and traditions, as well as other people’s ways of expression. ¹⁶ Speaking clear language and showing interest in the person and his/her culture are CCC actions. ^14,21

However, CCC not only depends on nurses’ training and capability; it requires institutional support for all people to enjoy access to consultations, medications and health care; otherwise, negative feelings emerge against conventional health systems and care.^12,13,17

Conclusions

This review allowed describing four categories, namely: Need for training in Ethnonursing and in the Theory of Culture Care; Recognition of the cultural context and of barriers to culturally congruent care; Culture Care diversity and universality; and Actions for culturally congruent care. Health assistance respecting and integrating culture care should become a way of performing any health profession. In this context, Nursing must assume a guiding and support role in this integration of culture care to conventional assistance. The studies included in this review acknowledge that Ethnonursing has been used in scientific research and reveal methodological aspects that were described with indications for Nursing scientific applicability and practice. The proposal is to expand and use Nursing education to create environments that value the students’ cultural diversity and that may strengthen the learning strategies in Ethnonursing and in the Theory of Culture Care.

The study would imply the care practice, as it shows that culture care should be implemented based on appreciating the people subjected to the assistance provided, allowing to unveil beliefs and practices that can exert an influence on their health. In addition, it contributes a synthesis of the literature from the last 10 years on how Ethnonursing and the Theory of Culture care are used; in turn, it simultaneously reflects about the need to conduct more studies. For Nursing education, evidence was contributed that serves as an invitation for methodological rigor, which should be incorporated into the curricula from Nursing undergraduate studies.

It is necessary to value due respect for different cultures in health services; for this, the recommendation is to conduct Ethnonursing studies identifying emic and etic care. There is also a need for intervention studies that identify culture as the core of human beings, in order to enhance the implementation of public policies that protect culture care at all health care levels.

The articles included met the selection criteria defined; however, these criteria might have limited representativeness of the results for not including studies located in university repositories or written in languages other than English, Spanish and Portuguese.