The nursing department ’ s view towards moroccan patients *

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2017;51:e03227 * Master’s Thesis, 2015, Universidad de Granada, Spain. 1 Universidad de Granada, Facultad de Enfermería de Melilla, Melilla, Spain. 2 Universidad de Granada, Facultad de Ciencias de la Educación y Humanidades de Melilla, Melilla, Spain. ABSTRACT Objective: To determine the Melilla Hospital Nursing Department’s attitude towards Moroccan patients. Method: Descriptive ex post facto study. A questionnaire has been handed over to staff, on the Immigration Attitude Scale for Nursing. Results: In general, nurses exhibit negative attitudes towards Moroccan patients, such as: the increase in crime is caused by the arrival of immigrants, those who commit offenses must be expelled from Spain, they take advantage of the Spanish health system and too many resources are devoted to immigration. The worst-rated immigrants are the Moroccans, considering that they do not pay much attention to their personal hygiene and do not adapt to their host countries. Conclusion: It is necessary to work with the nursing staff to change these attitudes. Future degree students must be trained in cultural skills and the care of immigrants will improve with a greater commitment towards cultural differences.


INTRODUCTION
Migratory movements have taken place both throughout human history and at present, motivated by the need of populations to seek a better present and future (1) .Spain has -in a very short period of time -undergone a significant transformation in terms of immigration, going from being a country of emigrants to receiving many immigrants (2) .From 2000 to 2015, the number of immigrants in Spain increased from 748,953 to 4,933,231, respectively, the main nationality being Romanian and the second largest group being Moroccans (3) .
One of the consequences of this phenomenon is the growing cultural diversity in our society (4) , as immigration brings changes that make societies increasingly multicultural.This migration situation is evidenced in the health sector, where multiculturalism becomes visible.Therefore, it is important to know the patients (culture, traditions, religion), since their beliefs about health / illnesses can affect the nurse-patient relationship, influencing a more contextualised and individualised attention (5) .
In Spain, as expressed in the Spanish Constitution (6) , all citizens -whether Spanish or foreign -have the right to receive healthcare.The 1986 General Health Law also states that all Spaniards and foreigners residing in Spanish territory (7) have the right to health protection and healthcare.
In studies carried out in Spain on nursing staff (8)(9) , prejudices are evidenced towards immigrants, the worst-rated being those of Moroccan nationality.Amongst the results we find that nursing professionals have prejudices such as: immigrants are collapsing the Spanish health system and too many resources are being allocated to the care of immigrants.
The city of Melilla has a population of 85,584 inhabitants (10) , with its foreign population accounting for 15% of the total coming mainly from the neighbouring country of Morocco, in addition to the 30,000 Moroccans who cross the border daily to work, trade or wander around the city (11) , with many of them making use of the health services provided by the only hospital in the city, which sometimes results in the Accidents and Emergency unit collapsing.
The characteristics of Melilla are different to those of all other cities in Spain, since within only twelve square kilometers, different cultures coexist, being those of European and Berber (and Muslim) origin the predominant ones.Many health professionals are of Berber origin -they share the same culture as Moroccan immigrants -, with many of them being taken care of in the Regional Hospital.Therefore, it is necessary to enquire about the attitude of the nursing staff of the Regional Hospital of Melilla towards Moroccan patients, and determine if there are prejudices towards these patients in order to develop intervention programs with the health professionals to develop cultural competences with the purpose of offering optimal care in a multicultural context.

METHOD Design
An empirical-analytic methodology has been used for the accomplishment of this work.It is a descriptive ex post facto study.

stuDy variables
According to the aim set out, two types of variables will be considered: Attributive variables: These are socio-demographic variables, such as: age, gender, culture of origin, hospital department, years of experience and years of experience working within the hospital department.
Dependent variable: the attitudes of nurses towards Moroccan patients.

ParticiPants
The study was developed amongst the Nursing staff of the Regional Hospital of Melilla, in all its hospitalisation areas: Surgery, Internal Medicine, Traumatology, Gynaecology and Obstetrics, Laboratory, Accidents and Emergency and Labour Room.
A decision was made to carry out the study amongst the hospitalisation areas, as in these spaces the nursing staff have a closer relationship both with foreign patients and their family.

tool
The data collection tool used was the modified (1) Immigration Attitude Scale for Nursing (12) (IASN), which consists of 35 items, which are distributed amongst six different dimensions.The questionnaire uses a 4-point Likert scale, with values ranging from 1 "I strongly disagree" (SD), 2 "I moderately disagree" (D), 3 "I moderately agree" (A) to 4 "I strongly agree" (SA); thus, the higher the score, the better the attitude towards Moroccan immigrant patients.

ProceDure
In order to carry out the study, a written request was made to the Management of the Nursing Department and the Melilla Regional Hospital in order to administer the questionnaires to the nurses.They were handed out throughout all the areas -for a week -in order to access all the personnel that agreed to fill out the questionnaire.

Data analysis
The SPSS 20.0 statistical package was used for analysing the data, and descriptive and inferential analyses (nonparametric tests) were performed.

RESULTS
The number of study participants was 63 nurses.To complete the questionnaire, we visited the hospital in all the different shifts to obtain a greater participation.The number of nurses, the hospitalisation area, gender, cultural background, age and years of experience are shown in Table 1.
In relation to the objective of the study, the attitudes of the male and female nurses of the Regional Hospital of Melilla towards Moroccan patients were analysed.
First, the reliability of the questionnaire was analysed through Cronbach's alpha, being in this case 0.862.Subsequently, the average, standard deviation, asymmetry of the items that make up the questionnaire and the sum total of these were analysed.The data indicates that, both in the total score and in most items, the asymmetry is positive, which shows that there is a higher concentration of responses showing low scores and, therefore, negative responses towards those items.In addition, 50% of the sample surveyed is below the average score (M = 83.69,PC 50 = 80.00).
The questionnaire was analysed through items that show both positive and negative attitudes, distributed among the six different dimensions (Table 2).After analysing the descriptions of the attitudes of the Nursing Department staff, we hereafter show whether there are differences in this group according to the variables under study.Given the size of the sample, non-parametric tests were used.
The data indicates that there are no significant differences in attitudes towards immigrants in the variables of culture, service, years of experience at the department and age on the IASN.Although the difference is not significant, we must specify that men presented better averages than women (M Man =86.4,M Woman =83.41).
But if the questionnaire is analysed according to the dimensions proposed by Plaza-del Pino (1) , we find the following results: when analysing each item in relation to the gender variable, we found a significant difference on item 20 "To a large extent, the collapse of the public health system has been caused by the rise in immigration", pertaining to the dimension of Immigration and social rights, with women having a worse score than men (χ2=.001,M Woman =1.59, M Man =3).
In terms of analysing the service variable, although no significant difference was found, we can observe that the Labour room nurses have the best scores (M Labour room =37.80).Those with the lowest scores are the Traumatology Department nurses (M Traumatology =17.25).
When examining each item according to this variable, we find significant differences in: Item 1: "Immigrants who commit crimes should be expelled from Spain", which belongs to the dimension entitled The arrival of immigrants and the rise in crime.
The Labour room nurses obtained the highest average and the Traumatology nurses obtained the lowest (H=.020;M Labour room =2.40, M Traumatology =1.0).
On item 12: "Moroccans do very little to integrate into our society", which belongs to the Immigration-integration dimension, the Laboratory nurses reached the highest average and the Traumatology nurses the lowest (H=.033;M Laboratory =3.0, M Traumatology =1.17).
On item 26: "Immigrants should enjoy the same working conditions as the native inhabitants of the country", pertaining to the Immigration-Social rights dimension, the Labour room nurses obtained the highest average and the Acc. and Emergency Unit (A&E) nurses the lowest (H=.029;M Labour room =3.70, (M A&E =2.24).
In terms of the age variable, we only found significant differences on Item 27 "If we continue this way, the customs and beliefs of immigrants will prevail over ours", which belongs to the Immigration-culture dimension.
Here, the highest score was obtained by the youngest group and those over 50 years old attained the lowest (H=.035,M 26-30 y-old =2.80, M >50 =1.58).
Where we most found significant differences was in the years of working experience at the department variable.
Examining each item, we found differences in the items that appear on Table 3, where the same results were obtained, that is, the highest score was reached by the nurses with the least experience (between 1 and 5 years) and the lowest score was attained by the nurses with the most experience (more than 20 years).

DISCUSSION
In relation to the attitudes of the Nursing staff of the Regional Hospital of Melilla towards Moroccans, in the dimension of Immigration and prejudicial attitudes towards the immigrant population, the results confirm that they do not value positively the birth rate rise in Spain due to immigration, in accordance with the study carried out by Plaza del Pino (13) .Also, they do not perceive that the native population is taking advantage of immigrants by offering them the jobs that Spaniards consider to be more precarious, data which does not coincide with another similar study (14) , since its participants do not consider immigration as the cause of unemployment.
On the other hand, the Melilla Hospital nurses may have preconceived ideas and stereotypes regarding immigrants which leads them to value Moroccan patients negatively, by considering that they are not very careful with their personal hygiene and that they are a source of social unrest (9) .
The surveyed group also perceives that the arrival of immigrants leads to a rise in crime in Spain and they believe that those who commit crimes should be expelled from the country, coinciding with other authors, whose work associates the arrival of immigrants with a rise in crime (14) .
Although the statement "the coexistence of diverse cultures promotes knowledge and mutual respect" is considered positive in our sample, the same does not occur with the idea of devoting more resources to the integration of immigrants.In addition, the nurses value Moroccan people negatively, coinciding with other studies showing that in Spain -as in other European countries -Maghrebi immigrants, especially Moroccans, are the worst valued and the least willing to adapt to their host countries (14)(15)(16)(17)(18) .This attitude can be explained by the great social divide between them and the native population due mainly to their Islamic religion, as immigrants of Muslim origin are less successful socially (19) .
In relation to culture, most of Melilla's nursing staff consider that ethnic diversity enriches a country's culture, but they also agree with the assertion that immigrants' customs and beliefs will prevail over ours, considering them as a social and cultural threat.This result is in line with several authors who conclude that immigrants have an obligation to adapt to our customs (14,20) .In the case of cultural carefulness at the hospital, nurses agree that we should enable and respect the customs of immigrants in line with nurses of other studies (14) , data which paves the way for nursing professionals to introduce care that fits the patient's culture.It is essential to get acquainted with their customs and religion as in the case of Moroccan patients, whose Islamic religion is so ingrained in their daily habits, since it is a way of life and guides Muslims in their daily activities, in order to provide quality care and motivate healthy behaviours (21) .
It is very important to emphasise that nurses consider immigrants as citizens with the same rights and obligations as the native population, and that they should have the same working conditions.At the same time, nurses themselves think they should continue making an effort for immigrants to have a better quality of life.But these ideas are in contrast with the perception that immigrants receive more social assistance than Spaniards and that too many resources are devoted to the care of this social group, with immigrant patients being considered responsible for the collapse of our health system, which could in a not too distant future lead to serious health and social problems, coinciding with ideas obtained by different studies (1,17,(22)(23)(24)(25)(26) .Although this is the perception of nurses, it has been demonstrated that immigrants do not use hospital services more frequently than the native population nor is this use more burdensome for the health system, and that, as in other cases, they do not use it excessively or inappropriately (22,27) .
It is necessary to point out that the nurses of the Regional Hospital of Melilla are overloaded with work, which may be a key factor influencing their attitude, as denounced by the Nursing Union in relation to the collapse of the Maternal and Child Care Unit, since it is one of the most demanded services with 1,125 births per year as well as the number of emergencies dealt with (28) , data which coincides with other studies (22,25,27) .Due to all this, and given the importance of the subject matter of this work, it is necessary to continue working in this line by expanding the research both in terms of the healthcare staff who work at the Hospital and university nursing degree students, in order to analyse prejudiced attitudes and, if necessary, develop intervention programs to improve their perception.

CONCLUSION
To conclude this work, and without forgetting the context in which we find ourselves -where multiculturalism is an irreversible fact -, nursing staff should take a holistic approach to healthcare, where all the needs of immigrant patients are covered whilst providing the highest quality.
The proximity of Melilla to the neighbouring country leads to many Moroccans crossing the border in order to be treated at the Regional Hospital of Melilla.This has always been the situation and will continue to be so.Perhaps because of Spain's economic situation, nursing professionals think that the increasing number of Moroccan patients in our hospital makes healthcare difficult, as there have been numerous budgetary cuts and the health system has also been significantly affected.Training in cultural competencies is essential for nurses to change their attitude towards patients from different cultures, enabling them to develop communicational and understanding skills.The professionals who are currently working at the Regional Hospital studied their degree long ago, meaning there was no subject related to cultural competences, which could explain why these professionals exhibit prejudicial attitudes.
We hope that in the near future, with new nursing degree students being guaranteed training in cultural competences, new nurses will have less prejudicial attitudes than those currently working, thus influencing the need to train present professionals in order to obtain the necessary cultural competences for the correct understanding of the healthdisease, communication and cultural knowledge processes, as well as healthcare professionals recognising their own attitudes in order to manage them effectively and modify them when necessary.

Table 1 -
Participants of the Hospitalisation Areas of the Regional Hospital of Melilla, Spain.April, 2015.

Table 2 -
"Immigration Attitude Scale for Nursing" questionnaire, distributed by dimensions.Regional Hospital of Melilla, Spain.April, 2015.Dimension 1: Immigration and prejudicial attitudes towards the immigrant population.SA/A* SD/D* Positive attitudes 17 -The birth rate rise due to immigration is beneficial for Spain 44.4% 55.6% 31 -We take advantage of immigrants by offering them the most precarious employment 38.1% 61.9% negative attitudes 13 -Immigrants occupy jobs and leave many Spaniards unemployed 41% 59% 23 -A European citizen based in Spain brings more benefits to our society than an African, Asian or South Dimension 2: The arrival of immigrants and the rise in crime.SA/A SD/D 1 -Immigrants who commit crimes should be expelled from Spain 85.7% 14.3% 15 -The arrival of immigrants has led to a rise in crime 88.9% 11.1% Dimension 3: Attitude towards Moroccan immigrants.SA/A SD/D 32 -On public transport, if I can choose, I prefer not to sit next to a Moroccan * SA/A= Strongly Agree/Agree; SD/D= Strongly Disagree/Disagree.…continuation

Table 3 -
Attitude Scale: the years working at the department variable and dimensions showing significant difference, Regional Hospital of Melilla, Spain.April, 2015.