Academic portfolio: reflections on nursing education in interculturality

This study seeks to reflect on intercultural care regarding the how to act in the nursing process in the face of different cultures. This is a theoretical study with reflexive approach based on the experience of the academic in building their portfolio carried out in 2020 by means of reflections based on academic portfolios of the fifth semester of a nursing program in the South region of Brazil. After analysis of the produced material and of the noted reflections in the portfolio diary, the following categories emerged: intercultural care in nursing courses and interculturality in the pandemic. Thus, after reflection and discussion on nursing care, we will focus on interculturality in the face of the courses taken, the experiences of the academic trajectory in this period, and, finally, the impacts of the COVID-19 pandemic in the process of care for people from the point of view of interculturality. This thematic becomes important for bringing up a reflection on the nurse-patient relation.

Culture can be defined as the collective construction of values in which individuals make sense of their actions based on their life experience. Thus, culture accompanies human beings throughout their lives, providing them with guidance on attitude and decision-making 1 . In this regard, it is up to nursing professionals to understand each individual's cultural dimension, complexity, and meaning of health/disease, respecting their values and beliefs 2 .
Interculturality is based on interactions between people whose social perceptions may or may not be different, whereby they promote reciprocal relationships and interactions with different groups and become capable of building transformative dialogues and appreciating different contexts 3 .
At times, intercultural relationships may give rise to conflicts given the cultural diversity of societies. Thus, dialogue is an important tool for nurses working with their team or providing care to patients to deal with barriers stemming from cultural differences or microcultures. For example, the meaning of a given term may vary from one culture to another 4 .
Nursing plays a key role in health care. Therefore, nurses must be able to recognize the cultural identity of patients to overcome barriers imposed by disrespect for different cultures or those that seem conflicting. To achieve comprehensive care, it is essential to understand individuals as a whole, with their beliefs, values, and habits, factors which condition the health-disease process 5 .
To ensure the quality of care in the face of interpersonal conflicts, nurses must draw on ethical knowledge to manage conflicts, be sensitive to them, and, consequently, ethically respect cultural diversities. It is essential to try to prevent the occurrence of interpersonal conflicts, though they are inevitable in some situations, given the values of each individual, and may become ethical dilemmas. In these cases, it is vital for nurses to not get carried away by these conflicts so as not to lose their identity 6 . At such times, the nurse, as a care manager and team leader, must ensure that the patient receives the necessary care.
Intercultural care and ensuing interpersonal conflicts may end up causing bioethical dilemmas. Such a context requires in-depth knowledge that goes beyond nursing care techniques, that is, there is a need for instruments to problematize the issues to search for solutions. This is where bioethics can be useful in health care, enabling changes and new discussions 7 .
This study comprises a reflection on an academic portfolio produced in the fifth semester of a nursing course. Culture and multiculturalism was one of the topics discussed in the subject Teaching, Service, and Community Integration II (IESC II). This inspired the following guiding question: How to behave when providing care to patients from different cultures? The goal of this study, therefore, is to reflect on intercultural care regarding behavior in the nursing process in the face of different cultures.
Discussing the subject matter required addressing personal relationships since nursing care involves at least two actors: the nursing professional and the patient. In this context, it is important to develop communication skills to enable people to interact and communicate in an intercultural context. It also involves ethics in personal relationships with a view to respecting different cultures in the provision of nursing care.

Method
This is a theoretical study with a reflective approach, based on one of the authors' experience in building an academic portfolio. A reflective portfolio, which is an active teaching/ learning methodology in the disciplines of the 2019 curriculum for the fifth semester of the undergraduate nursing course at a university in Southern Brazil, encourages an active process for the development of critical thinking. The learning, experiences, and reflections which emerged over the educational process were registered in the reflective portfolio and used as an assessment criterion for the disciplines of that semester.
Thus, it was decided to use samples from a student's portfolio and describe the perceptions, strengths, and weaknesses of using such a portfolio, in addition to reflecting on the importance of using a reflective portfolio in building knowledge, skills, and attitudes in intercultural contexts.

Intercultural care in nursing disciplines
Care must always follow the ethical and technical principles of nursing, respecting the customs, values, and habits of professionals and patients. Individual integrity must be considered if the caring process is to be effective. Thus, the question arises of how to behave in certain situations, based on disciplines of the fifth semester of the nursing course, namely: Comprehensive Mental Health Care; Comprehensive Health Care for Older Adults; Bioethics and Citizenship; Adult Nursing Care; IESC II; Psychology and Health; and Expanded Clinical Practice.
A frequent topic of discussion in Adult Nursing Care is clinical reasoning of the health-disease process, including investigation of different factors related to the patient's health. To this end, during the systematization of nursing care, nurses must understand other factors related to the patient's health, such as their cultural aspect since the provision of nursing care must meet and respect the moral and cultural values of patients.
Nursing care must consider the cultural diversity found in the area, respecting cultural differences such as customs, beliefs, rituals, life habits, and values, and the professional performance of nurses must focus on relevant care 8 . In the sphere of nursing, interculturality relates to the ability of nurses to understand and respect people's origins, offering them comprehensive care 9 .
In the same line, it is worth mentioning the work done in Expanded Clinical Practice, which discussed such topics and clinical cases, greatly focusing on care with family and community and on preparing the family for patient care, establishing the connection between those factors and the attitude of the nursing professional in situations of interculturality. It is up to the nurse to identify habits, routines, lifestyles, and beliefs before prescribing care, aiming to make the care process as healthy, efficient, and acceptable as possible.
Intercultural care implies entering the patient's world with respect and understanding, interpreting his or her reality. Interculturality is a tool which helps professionals break barriers and divergences in personal relationships 10 . That way, professionals can establish bonds and interpret the reality of patients, with care as their central goal.
It is up to nurses in their professional practice to recognize differences and know how to respect them in an integral way, behaving ethically since, in certain situations of patient fragility, they are responsible for making decisions. Such decisions must not cause further suffering and fragility to patients in their biopsychosocial dimension.
In their professional performance, and to respect the cultural diversity of patients, nurses must draw on ethics and bioethics in accordance with some of the topics addressed in Bioethics and Citizenship. Thus, in this context, ethics mainly refers to the respect for individuals from different cultures and with different particularities. This involves the field of bioethics, serving as a tool to problematize certain situations and guide professionals on how to behave correctly and identify social inequities in the care process.
From the viewpoint of humanized health promotion, nursing must address interculturality, working alongside bioethics, an essential tool for solving moral dilemmas related to cultural beliefs and habits 11 .
In IESC II, students held a seminar, mediated by the teacher, to discuss the subject of teas and their relation to the health process. As the class has students from different towns and cities, students introduced the kinds of tea consumed in their microcultures. This made it possible to identify the great cultural diversity existing in a small space, with individuals being responsible for encouraging mutual respect for their harmonious interaction.
In their role as care managers, nurses must be aware of the needs and particularities of their patients. Thus, when a patient chooses to make use of some kind of tea, this must be respected as it has a cultural value. It should be noted that this situation applies as long as the tea in question is adequately prepared and is incapable of impairing the healthcare process. Otherwise, the nurse may need to intervene.
The nursing professional must consider care in all its dimensions, free from any kind of prejudice since prejudiced behavior hinders support and bonding. Thus, in the exercise of their profession, nurses must take into consideration all factors and social determinants of health and use them to further excellence in care 12 . In aiming for care that respects the cultural diversity of each individual, the nurse's behavior in these situations may impact positively or negatively the mental health of patients, as a drastic intervention by the nursing team may potentially rekindle a trauma or trigger an attitude harmful to health.
Psychosocial care centers are health facilities responsible for health promotion and recovery. The use of tools such as art, theater, and music can be socially transformative. Thus, patients who make use of social and cultural methods will receive humanized, non-invasive care 13 .
In Psychology and Health, the topic of "ethnic differences" was discussed, which relates directly to culture, especially in a country like Brazil with a huge cultural diversity, in which its native population is disparaged and their culture is disrespected. However, in accordance with the health of older adults, it is worth mentioning the work developed in caring for people, which seeks to understand and meet the individual needs of patients according to their singularities.
Lastly, the two disciplines, Psychology and Expanded Clinical Practice, were united to study the social isolation of older adults since many of them end up having to move in with their children, undergoing a radical change in their lives, which can often be a cause of geriatric depression. The changes go against the culture of older adults, who have lived most of their lives with different habits and routines. Multi-professional care seeks to identify and be sensitive to those values and habits.

Interculturality and the pandemic
The SARS-COV-2 pandemic brought isolation, death, insecurity, restrictions, and doubts, causing changes in people's way of life and, consequently, a state of sociocultural adaptation at a time of serious health crisis 14 . In this sense, professional practice also underwent change, such as restricted contact between professionals and patients, impeding support and humanization in the care process.
The impacts of the COVID-19 pandemic are of an individual, social, collective, and cultural nature. The need for social distancing and protection and prevention measures was absorbed in different ways, according to the cultural identification of individuals. In such emergency situations, large-scale measures are of great relevance to people's health, given the consequences to cultural expressions and the way people live in society 15 .
The pandemic brought about social changes which had an impact on mental health and vulnerable groups, as well as issues related to the provision of basic items for human survival. Moreover, there were impacts due to social distancing and quarantine 16 , especially those related to cultural diversity, as different social groups showed different attitudes and conceptions during the pandemic, highlighting the need for intercultural care. Therefore, the need for mandatory restrictive measures due to the COVID-19 pandemic affected people's cultural expression as such measures forced individuals to change their social interaction patterns 17 .
Intercultural care is provided based on respect for diversity and a constant movement of social relationships. Multi-professional care, according to the culture to which it is provided, can be perceived as invasive since it requires nurses to fulfill their tasks yet interfering as little as possible in the individual's culture 18 .
Provision of care in a pandemic range from action planning to execution, always respecting cultural and social diversities. For example, the inhabitants of large urban centers have a different understanding of health compared to those of an Indigenous village. Thus, guidance on wearing face masks and on how the virus spreads must also be different.
The health approach toward older adults must be a nursing process specifically aimed at this population rather than a mere adaptation of care provided to younger adults. Care for older adults requires certain specificities, given the prevalence of noncommunicable diseases and the way in which they face their health conditions 19 . This also applies to care related to COVID-19, as older adults are a high risk group and may develop chronic diseases. Therefore, the culture of those individuals guides the way in which they will receive health care.
Health promotion requires the recognition of social differences, which also applies to the Indigenous population. In this context, in 2002, the Brazilian Ministry of Health and the National Health Foundation (Funasa) published the National Health Care Policy for Indigenous Peoples, which aims to ensure this population's access to comprehensive health care, considering the social, cultural, geographic, historical, and political diversity of Indigenous peoples to help them overcome the factors which make them more vulnerable to the more serious health problems prevalent among Brazilians 20 . Therefore, the specificities of these peoples must be considered in the development and use of appropriate technologies 21 .
Consequently, initiatives to prevent COVID-19 among Indigenous peoples gain a new dimension, ranging from the way information is distributed to the adaptation of measures since this population adheres to other forms of health care, such as the use of medicinal plants.
Care provided to patients with mental disorders requires careful support, and healthcare professionals must understand the factors of the health-disease process. Mental health care uses a cooperative model which aims at comprehensive care for these individuals. Therefore, it is essential to integrate patients into society without excluding them, as the biomedical model used to do and occasionally still does 22 . Thus, patients with mental disorders require a different approach from others in the fight against COVID-19 since the understanding and implementation of protection and isolation measures may be different for them, thus requiring multidisciplinary action.
The examples studied reveal that the pandemic affects individuals in different realities, impacting many cultures and requiring changes and adaptations of all kinds. However, such changes are absorbed in different ways by each reality, including each person, for even if everyone has to follow the same guidance, their interpretation is individual and directly interferes in each one's culture.
Given the current situation, it is up to the health services to adopt a differentiated approach to minority social groups which, for the most part, require attention to cultural differences. Thus, health programs and protocols must be designed according to the subjectivity of each individual, encouraging, for example, research to fight the Coronavirus from different perspectives.
Interculturality and multiculturalism are tools to help recognize differences. Therefore, the proposal is one of interrelation between cultures, as well as the construction of a new cultural identity. The intercultural tool is applied to societies for a proposal in which there is a relationship of respect without inequalities and conflicts 23 . In this regard, in health care, nursing professionals should nurture such a relationship with less favored groups, as provided by the Unified Health System (SUS) legislation.
It is important to stress that care aimed at interculturality will consider the individualities of each patient, making them realize their individual importance in the social context. Therefore, interculturality is a tool which unites the greatness of the individual perspective and the collective conscience of human beings.

Final Considerations
The subject matter addressed in this study is important for raising a reflection on the nurse/patient relationship since interculturality aims to minimize differences and prejudices, encouraging a condition of harmony between cultural differences in search of humanely sensitive and professionally ethical care conditioned to patient improvement.
The nursing process includes core guidelines for the systematization of nursing care, which must be fully followed by nurses. In this sense, as a nursing team leader, the nurse must capacitate its members to provide comprehensive care, considering the cultural perspectives of each individual.
It is worth noting that this form of care places patients and their concept of health at the center of the process, with their values, habits, and beliefs. Thus, health professionals will be able to propose an appropriate form of care for those individuals. This aims at achieving excellence in care without causing harm to patients. It is necessary to know and place them at the center of attention to systematize care according to their sociocultural values.
The COVID-19 pandemic required-and still does-the teamwork of several health professionals to fight the virus. Moreover, the centers with greater technological density receive patients from other regions and, consequently, from different cultures, from micro-societies with different values and habits.
Thus, the team must understand the uniqueness of patients to provide health care aiming at the common good. Also, the health crisis forced nursing to review its behavior, establishing new forms of care that would offer comprehensive health service but with the necessary care imposed by the pandemic.