The experience of nurses in care for culturally diverse families: A qualitative meta-synthesis 1

Abstract Objective: to understand the experience of nurses in care delivery to culturally diverse families. Method: qualitative meta-synthesis. Exhaustive search in seven databases, three repositories and a manual search in references without time limit, in English, Spanish and Portuguese, resulting in 1609 potentially relevant studies. These were assessed based on the title, summary and full text, determining the final inclusion of 14 studies. Two independent reviewers used the Critical Appraisal Skills Programme (CASP) to assess the quality. The interpretative synthesis implied permanent contrast and consensus among the authors, revealing four categories and one meta-theme. Results: "taking care of a culturally diverse family, the experience of crossing a tightrope". Conclusion: the experience of nurses in care delivery to culturally diverse families is demanding and challenging because it imprints a constant tension among barriers, cultural manifestations and the ethical responsibility of care, incipiently revealing elements of cultural competency. The omission of information in the participants' reports in the studies represents a limitation. The findings offer a baseline for professionals and organizations to focus their intervention efforts on the continuing barriers in care delivery to culturally diverse families and strengthens the need for cultural competency training for nurses.


Introduction
The cultural diversity of multicultural societies results from the coexistence of different ethnic groups in the same country or region (1) ; from the differences between and within the same groups or regions (2) ; the growth of migration flows (3) ; the social class, education, gender, language, age, religion and family structure (4)(5) .
In Latin America, white people, indigenous people of different ethnic origins, afro descendants, mulattos, people of mixed origins, European and Asian migrants live together; five official languages are spoken (Spanish, Portuguese, French, English and Guaraní), as well as 420 indigenous languages belonging to 99 linguistic families (6) . Therefore, one cannot refer to "Latinos" as a homogeneous cultural group, but the cultural diversity needs to be considered.
This cultural multiplicity confronts the health area with particular demands, not only to cope with the inequalities, promoting services in accordance with the cultural singularity (7) , but also to overcome the individual focus to deliver culturally competent care.
Attending to the families' preferences has shown to be a relevant strategy, applied to enhance the effect of culturally competent interventions (8)(9)(10)(11) , as it reflects an understanding of the beliefs and traditions (8) and takes into account the ethnic, cultural and socioeconomic plurality characteristic of the multicultural groups (10,12) .
Thus, health professionals need to feel committed to the delivery of culturally competent care, turning into a critical and essential factor in health care provision to families of all racial, ethnic and cultural origins (13)(14) .
Nevertheless, putting such actions in practice remains demanding, due to the existence of barriers (12) associated with personal and contextual factors that can facilitate or impede the care (15) .
A metasynthesis on the experiences of nurses in care delivery to patients from other cultures (16) reported on the nurses' concern with communication barriers, access opportunities and care quality; benefits of learning on other cultures and satisfaction in care delivery to patients of different ethnic origins. Based on these findings, the author suggested the conception of new meta-syntheses with more specific approaches of care delivery scenarios, cultural groups and care practices to facilitate direct comparisons (16) .
The growing production of qualitative studies on the experience of nurses involving patients of different cultural origins has highlighted findings on the familycentered culturally competent care experience, which have not been synthesizes thus far to support evidencebased practice.
To fill this void, this review was proposed based on a meta-synthesis as an interpretive product and analytic process, aimed at interpreting and synthesizing the findings of qualitative studies to understand the experiences of nurses in care delivery to culturally diverse families.
For the sake of this review, culturally diverse families were considered as family members of an adult person over 18 years of age from ethnic origins, countries or religions different from the nurse's.
In addition, in this study, family care was considered in a broad sense, considering the family as a care unit, system or context for the patient (17) , with a view to including all approaches of the family in the care environment. The nurses' experience was conceived as anything (thoughts, feelings, reflections and actions) witnessed, felt or recalled, described by the nurses during care for culturally diverse families (18) .
In the particular case of Latin American countries, the knowledge development resulting from this synthesis contributes to the production of answers to the health demands of culturally diverse families, professional training in cultural competency, and the adaptation of family intervention programs and policies that permit guaranteeing safety, quality and care compliance.

Method
Qualitative meta-synthesis with interpretive focus, according to the parameters suggested by Sandelowski and Barroso (19) . In this interpretive integration, the results of qualitative studies on the experiences of nurses in care delivery to culturally diverse families were aggregated, integrated and summarized to creative interpretive representations in a new result that is faithful to the interpretation of the particular studies (19) . This process implies the design of a review protocol proposed during a research training experiences the first author undertook in April 2014 in Sao Paulo, Brazil.
The definition of the question was guided by the PICo strategy, which JBI suggests for qualitative systematic reviews.
This strategy permits the specification of key aspects related to the population (P), phenomenon of interest (I) and context (Co) (20) , defined as follows: What has been the experience of nurses in care delivery to culturally diverse families?
The search strategy was proposed under the advice As a result of this search phase, 1,621 reports were obtained, 12 of which were repeated. Hence, in total, 1,609 reports were submitted to the selection process per title, abstract and full text based on the inclusion criteria. In addition, the manual review of the references revealed five reports. That resulted in the inclusion of a final sample of 14 studies for this meta-synthesis (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) .
To assess the quality of the studies, the Critical Appraisal Skills Programme (CASP) for qualitative studies was used, involving two independent teams of reviewers. The first team included the authors and the second an external researcher with expertise in qualitative research. The objective of this assessment was to get familiar with the reports and evaluate their methodological rigor, as none of the studies had been excluded due to methodological quality (19) . Disagreements among the evaluators were solved through discussion or, when the research report did not comply with all evaluation criteria, access to the original text was sought, which happened in one case.
This demonstrates the rigor of the studies included in this meta-synthesis, guaranteeing the quality criteria required for systematic reviews (36) and supporting the validity of the study results (19) .
To summarize the findings of this review, one of the foci suggested by Sandelowski and Barroso was adopted, which is the production of a qualitative metasynthesis through constant comparative analysis (19) . This made it possible to reduce the mistaken extraction bias of the data from the primary sources (21) .
Based on reading and rereading, the findings were simplified manually, constituting 70 codes, grouped by similarities and differences. After the findings had been reduced through the coding process, they were were key in this phase to be able to recognize, recontextualize, interpret the data and reach a consensus on the construction of the categories.
This facilitated the auditing of the analysis process (36) and the reduction of bias in the recognition of the opposite results found (21) , through the inclusion of all evidence from primary sources and the exploration of the variations in the results.
To facilitate the understanding of the data and the understanding of the dynamics of the nurses' experience, eight visual models were formulated. Based on this process, the metaphor of the tightrope emerged as a useful resource to grant meaning to the data and favor the construction of the meta-theme (name proposed by McFarland and Wehbe) (37) .
Most studies were developed in hospital care scenarios (93%) and one in a home care context (7%).
In total, 247 nurses participated in the 14 studies. Table 1 indicates the demographic characteristics of the nurses according to gender, age, country of origin and ethnic origin according to the reports. The item "not specified" indicates that this information was omitted in the primary study. The nurses' characteristics according to education level, mean professional experience in years and cultural competency training are appointed in Table   2. Unfortunately, the latter two aspects were not determined precisely due to the lack of information in the primary studies (66% and 72% of the cases, respectively), representing a limitation for the synthesis.   a) language differences (25)(26)31) b) confidentiality (24,(29)(30)33) and c) cultural particularities in communication regarding gender distinctions or patriarchal attitudes in the families (27) , use of a child as translator (34) or how to communicate with the health staff (29) .
Because of the presence of these barriers, the nurses perceive their responsibility to inform as demanding, as they acknowledge their duty to watch over the respect for the patients and families' right to be informed (27) , which gains complexity amidst the institutional policies about the use of family members as translators (23) .
Secondly, the institutional aspects that influence the delivery of excellent care to the family are considered part of the external barriers, determined by: a) lack of space in care areas to house all family members (28)(29)(30)32) limitation of resources to offer food and accommodation to all family members (32) and c) restricted time of the nurses to take care of the family (32)(33) .
The presence of these barriers for the care experience has a negative impact, since the presence of the family is considered a problem or difficulty (22,29,32) , as it violates the institutional standards regarding visits and interferes in routine care procedures (25)(26)29,32) , as (Nurse) (26) .
The above leads to the negative perception of care for the families, manifested in: a) a negative image of the family, catalogued as an obstacle (25) or a nuisance (32,35) b) emotional reactions in the nurse, such as anguish (26) , stress (25)(26) , tension (25)(26) , uncertainty (26) , frustration (25) and irritation (31) and c) a distant and superficial relation with the family (29) .

Category 2: The cultural manifestations of the family are like gusts of wind of instability
For the nurses, the family's cultural manifestations are different particular behaviors associated with culture, expressed in situations of disease, mourning, pain, acceptance or denial of a treatment. These manifestations are ranked as unexpected and different in view of their own culture as they can emerge at any time (28,30) and take different forms: a) expressive or not expressive (26)(27)(28)(29)(30) b) related to physical appearance and to the manifestation of customs (25,32) c) related to the participation in care activities (27,33) and d) associated with gender differences (27,32) , according to this participant: The information is passed on by the husband, while in our culture it is different -when wives and mothers ask for information, they receive it. That can be a problem (Nurse) (27) .
As a result of these cultural manifestations of the family, the balance the nurses maintain in encountering is threatened when no alternative answers are found. The background knowledge and experience are insufficient to approach the family, as reflected in this participant's expression: As nurses we are engaged in, or we are used to helping grieving persons. But I didn't find this consolatory role in the unit with all those family members (Nurse) (26) .
In addition, the nurses perceive that these manifestations affect the work environment and the other patients, when the alternative of cultural imposition emerges as the best answer. In that sense, one participant affirmed: Family members stayed in the room after she died and talked very loudly. We had to shut the doors, in order to prevent the voices being heard in the corridor, because other patients were really scared (Nurse) (26) .

3:
Crossing the tightrope with

understanding, flexibility and recursiveness
In response to the disequilibrium, the nurses start to consider additional tools that will help them gain skills to advance and overcome the instability that used to mark their meeting with the family: understanding, flexibility and recursiveness.
The understanding emerges when the nurses start to "put themselves in the families' place".
Through understanding, they start to discover the family's characteristics and needs and to explain the manifestations that cause instability (22)(23)(24)(26)(27) .
On the other hand, flexibility is described as "having an open mind" to the family's needs. It implies being receptive without judging the family's attitudes, behaviors, which helps to understand the cultural differences (24,27) (24) .
Through these two tools, the nurses start to plan and implement alternative interventions, which are produced through recursiveness, considered as innovative forms of acting and solving the difficulties in dealing with the family.
To give an example, the nurses mobilize all resources within their reach to accommodate the families of indigenous patients (32) , create alternatives to preserve the beliefs, values, customs and popular care of the family or by participating in some of their family rites (25) and facilitating a supportive climate (26) . On another occasion, they allowed the family members to take symbols and icons of cure (27) or devised linguistic aids to facilitate the interaction with the family (26) .
One participant commented on an example of an alternative intervention based on recursiveness as follows: Muslim women are usually covered up. When their shoulders are naked, we cover them by dressing them in a shirt back to front before the visitors arrive (Nurse) (27) .

Category 4: Involving the family is a favorable wind that helps you pass the tightrope
The tools of understanding, flexibility and recursiveness permitted reformulating the meaning of the experience positively. The nurses start to catalogue the help the family can offer them as "useful" (22,29,(33)(34) , through assistance (22,29,34) in communication (22)(23)(24)31) , patient safety (22) and support for the patient (29,31) (35) .
Feeling as if the family joined the purpose of taking care of the patient offers stability and triggers the construction and strengthening of a good relationship that offers benefits at three levels, for the patient, the nurse and the family: a) patient: benefits in terms of emotional and physical support (22,29,31) , comfort (24) , safety, trust (31,33) and emotional, social and psychological wellbeing (25) b) nurse: Overcome difficulties in communication (22)(23)29,31) , enhancing their knowledge about the different cultures (22,24) and strengthening the bond with the patient (22,28,31) and c) family: Strengthening the trust in the nurse (26) and delivering care or participating in decision making about the care of their loved one (25,29,33) .

Meta-theme: Taking care of the culturally diverse family, the experience of crossing a tightrope
Engaging in the experience of crossing a tightrope and experiencing uncertainty due to the risk of falling in a marvelous and admirable, but also demanding and challenging act. That is the experience of the nurses in care delivery to culturally diverse families ( Figure 2). Consequently, care for the family is perceived as an obligation or a requirement that is difficult to respond to. The tools they have counted on and which they take along their balance beam: knowledge and background experience ( Figure 2) are insufficient to approach the culturally diverse family, making them respond with cultural imposition.
Nevertheless, amidst the instability, the nurses take a break ( Figure 2) and start to consider additional tools to approach the family: understanding and flexibility, which are added to their balance beam and offer them stability ( Figure 2). On the one hand, the findings of this meta-synthesis suggest that the encounter with the culturally diverse family is relational, dynamic and swinging, because it permits intercultural interaction with the family (2) and constitutes the central platform where meanings are constructed (38) .
What is particular about the encountering is the characteristic of being mediated by patient care, in which the approach of the family takes place amidst the view of the family as the patient's context, despite the belief that the approach of the family as the care unit has always been a focus of interest for nursing (17) .
This evidences the prevalence of the rupture between "what should be" and the "actual practice" of family nursing (39) , amidst systems and organizations that make it difficult to include the families in care, all the more in the hospital contexts that are predominant in most of the studies included in this meta-synthesis.
The nurses' efforts to approach the families, Thus, understanding and flexibility in the light of Campinha-Bacote's Theory of Cultural Competence (2) reflect the cultural awareness, while the other elements: desire, knowledge and cultural skills (2) were manifested incipiently in the experience through the alternatives that were produced amidst the recursiveness.
Unfortunately, the omission of information in the

Implications for nursing research and practice
This meta-synthesis was proposed to have an international range, including a culturally diverse sample and different care contexts. Nevertheless, the inclusion of a single study undertaken in Latin America (32) evidences the lack of empirical literature on this theme in our background.
In addition, the prevalence of hospital-based