Influence of a Patient’s Migration Background on the Nursing Care Process in a German Hospital

The German economy, due to the exponential demographic growth, depends on the employment of various professionals’ workforce from abroad. However, with the enlarged factor of globalization, it is facing an increased incidence of unusual health problems. Consequently, the number of migrants with ill health conditions has increased in the past. In light of this situation, hospital care provision services and professionals are regularly confronted with challenges when it comes to managing patients with foreign cultural and religious backgrounds. Even though, there are specific trainings and translation services for intercultural care available, specific information on the health care of migrants is still lacking. For this reason, the current master thesis intends to investigate the potential impacts of the migrant background of patients on the nursing process. In order to gain an insight into the current situation, thirteen in-depth qualitative interviews with nurses and four with patients in the surgical department of a University hospital in southern Germany were conducted in July 2017. The Data was analyzed by using qualitative content analysis. The interviewees described challenges regarding the areas of organizational resources, communication and cultural peculiarities. Particular emphasis was placed on the pain relief, basic care, and nutrition habits. In addition, patients were found to be less knowledgeable with respect to the German health care system and the way it functions. Most of the nurses interviewed in the study knew the existence of opportunities for intercultural care, but few of them have had such training in their career. For an optimal care process of patients with migrant background, further strengthening of skills in intercultural care, is crucially needed. Moreover, an increased cooperation and information exchange between all relevant stakeholder and parties in health care, will improve the health care provision and health status of patients with migrant background. ISSN: 2637-6695 DOI: 10.32474/LOJNHC.2018.01.000115 LOJ Nur Heal Car Copyrights@ Daniela Baum. Citation: Daniela B. Influence of a Patient’s Migration Background on the Nursing Care Process in a German Hospital. LOJ Nur Heal Car 1(3)2018. LOJNHC.MS.ID.000115. DOI: 10.32474/LOJNHC.2018.01.000115. 84 Background Information Regarding The Health Care Status If Migrants Accordingly [8], global demographic changes will lead to an increased proportion of people in need of care. However, in the same time a decreasing birth rate and / or changing family structures lead to a shortage of professionals for inpatient care of migrants [9]. Since diseases are not influenced by ethnology, it is relevant to see whether all people living in Germany can count on equal treatment in the hospital [10]. This can be explained by the fact that [9] describes a lack of specific information on the health care of migrants. However, these are important because differences in culture have an impact on how individuals describe their health and disease behaviour [11]. Culture: Describe culture as a system consisting of guidelines. These are valid for all who belong to this ethnological group or society and develop in every human a valuation principle of known and unknown conditions. In order to become a recognized member of the society, everyone has to adapt their lives to these standards. This usually happens during childhood through the socialization process. Each individual who was born and raised in this context, has to go through it (ibid). According to [5], each society has its own way of expressing emotions and dealing with other people. Therefore, it can be said that these values influence how a situation will be perceived [12]. Thus, a simple greeting can already lead to uncertainty among the conversation partners [6]. Nursing Care: During the nursing care process at the hospital, different norms and values can create challenges in the interaction between nurses and patients. For example, gender-specific care, or other hygiene requirements, can have an impact on the treatment [6]. Assion (2005) describes differences in how people define their symptoms. People, e.g. from Southern Europe, suffer more with their whole body while Germans describe their pain more organ specific. Because of this, it is more difficult to identify the original problem [6]. Furthermore, a disorder can also be due to religion and personal misconduct. When this happens, sick people tend to deal with the punishment of God [7]. Another special feature is the fact that in some cultures the sick person is at the centre of the family. The family is responsible for the care and with a lot of humane care, a quick recovery shall be induced. In addition, adherence to religious guidelines is important. For the German patient, on the other hand, integration, co-determination and time alone are more predominant in the recovery process [6]. For an in-depth view on possible challenges, a closer look at the health care process is important. With the help of this, the cornerstone of trusting relationship between care and patients can be laid (German Federal Government for Migration, Refugees and Integration, 2015). According to [13], all nursing services of a patient will be summarized and structured with an individual care plan for the patient. The goal is to prevent illness and strengthen the health status of the patient. The individual needs of the patient need to be considered [14]. The nursing process is divided into different levels (Figure 1). First will be a collection of information which is necessary for the patients care. As a second step, problems that play a crucial role in the recovery process of the patient are identified. In this regard, corresponding actions and objectives of the care process are defined. During the performance the actions are then evaluated and if needed also modified [15]. However, these individual stages of development should not only be considered sequentially, but also as sometimes interdependent steps to recovery [14]. Figure 1: Care P flege, Thieme. To avoid misunderstandings in the health process tolerance is required from all sides [16]. In reality, there are fewer and fewer nurses that have to care for an increasing number of patients [7]. Ultimately, this means that every nurse has just the opportunity to do exactly what is absolutely necessary and has little time to consider what is needed for good intercultural patient care [17]. This creates a dilemma because migrants need more attention due to the difficulties in understanding the German health care system, language barriers, and cultural or religious misunderstandings. However, nurses rarely have the opportunity to understand and adequately respond to other migrants’ needs [6]. But this is important for a good recovery process [18].


Introduction
Due to demographic change, Germany is dependent on recruiting foreign workers to maintain its own economic power. This procedure is already known in Germany, since the high losses of World War II [1,2]. For long time officials thought that these would return to their home country after a certain time. Nowadays, we know that many of them have moved their centre of one's life to Germany [3]. Since Germany was not considered as an immigration country, topics of possible integration were not significant [4]. When people immigrate to Germany, it takes a great effort when it comes to integration into the German society. Here they are confronted with new norms and values and must reconcile their own concepts of life. In order for this to work well, they should receive some support from the host society [5]. If there is no active promotion of integration, migrants, in their approach to the new culture, can develop problems with their own identity. They feel insecure in dealing with the new culture and do not know how to behave properly [6]. In addition, migrants often do not have the same socio-economic background as the native population. They often live in districts with a bad environment and poor access to the education system [7]. This directly opposes good integration and leads to limitations in the use of the German language [4]. This paper uses, for a better readability, the term migrants. But this does not mean, that different groups of migrants should be standardized. Furthermore, the terminology was originally contrasted with German and migrants. This is only for readability and not as a demarcation of the different societies. Likewise, a gender-specific differentiation is dispensed with. Corresponding terms apply in the sense of equal treatment for both sexes.
In order to gain an insight into the current situation, thirteen in-depth qualitative interviews with nurses and four with patients in the surgical department of a University hospital in southern Germany were conducted in July 2017. The Data was analyzed by using qualitative content analysis. The interviewees described challenges regarding the areas of organizational resources, communication and cultural peculiarities. Particular emphasis was placed on the pain relief, basic care, and nutrition habits. In addition, patients were found to be less knowledgeable with respect to the German health care system and the way it functions. Most of the nurses interviewed in the study knew the existence of opportunities for intercultural care, but few of them have had such training in their career. For an optimal care process of patients with migrant background, further strengthening of skills in intercultural care, is crucially needed. Moreover, an increased cooperation and information exchange between all relevant stakeholder and parties in health care, will improve the health care provision and health status of patients with migrant background.

Background Information Regarding The Health Care Status If Migrants
Accordingly [8], global demographic changes will lead to an increased proportion of people in need of care. However, in the same time a decreasing birth rate and / or changing family structures lead to a shortage of professionals for inpatient care of migrants [9]. Since diseases are not influenced by ethnology, it is relevant to see whether all people living in Germany can count on equal treatment in the hospital [10]. This can be explained by the fact that [9] describes a lack of specific information on the health care of migrants. However, these are important because differences in culture have an impact on how individuals describe their health and disease behaviour [11].
Culture: Describe culture as a system consisting of guidelines. These are valid for all who belong to this ethnological group or society and develop in every human a valuation principle of known and unknown conditions. In order to become a recognized member of the society, everyone has to adapt their lives to these standards. This usually happens during childhood through the socialization process. Each individual who was born and raised in this context, has to go through it (ibid). According to [5], each society has its own way of expressing emotions and dealing with other people. Therefore, it can be said that these values influence how a situation will be perceived [12]. Thus, a simple greeting can already lead to uncertainty among the conversation partners [6].
Nursing Care: During the nursing care process at the hospital, different norms and values can create challenges in the interaction between nurses and patients. For example, gender-specific care, or other hygiene requirements, can have an impact on the treatment [6]. Assion (2005) describes differences in how people define their symptoms. People, e.g. from Southern Europe, suffer more with their whole body while Germans describe their pain more organ specific. Because of this, it is more difficult to identify the original problem [6]. Furthermore, a disorder can also be due to religion and personal misconduct. When this happens, sick people tend to deal with the punishment of God [7]. Another special feature is the fact that in some cultures the sick person is at the centre of the family. The family is responsible for the care and with a lot of humane care, a quick recovery shall be induced. In addition, adherence to religious guidelines is important. For the German patient, on the other hand, integration, co-determination and time alone are more predominant in the recovery process [6].
For an in-depth view on possible challenges, a closer look at the health care process is important. With the help of this, the cornerstone of trusting relationship between care and patients can be laid (German Federal Government for Migration, Refugees and Integration, 2015). According to [13], all nursing services of a patient will be summarized and structured with an individual care plan for the patient. The goal is to prevent illness and strengthen the health status of the patient. The individual needs of the patient need to be considered [14]. The nursing process is divided into different levels ( Figure 1). First will be a collection of information which is necessary for the patients care. As a second step, problems that play a crucial role in the recovery process of the patient are identified. In this regard, corresponding actions and objectives of the care process are defined. During the performance the actions are then evaluated and if needed also modified [15]. However, these individual stages of development should not only be considered sequentially, but also as sometimes interdependent steps to recovery [14]. To avoid misunderstandings in the health process tolerance is required from all sides [16]. In reality, there are fewer and fewer nurses that have to care for an increasing number of patients [7]. Ultimately, this means that every nurse has just the opportunity to do exactly what is absolutely necessary and has little time to consider what is needed for good intercultural patient care [17]. This creates a dilemma because migrants need more attention due to the difficulties in understanding the German health care system, language barriers, and cultural or religious misunderstandings. However, nurses rarely have the opportunity to understand and adequately respond to other migrants' needs [6]. But this is important for a good recovery process [18].

Literature Search
In order to determine the special features of the intercultural care of patients with a migration background, a mind map was prepared in advance of this work. This provided the first keywords for the general literature search. The following terms care, hospital, different cultures, religion, nurse, patient, satisfaction, care mistakes, migrants, transcultural and intercultural care in the hospital were used. In order to achieve meaningful results for this work, combinations of the keywords were formed. The procedure that led to most of the results was the keyword search in the library catalogues of the University of Freiburg and Caritas. A significant addition was the work with the database of Pub-Med. For further literature research, Internet search engines such as Ecosia and Google were used.

Problem Definition and Justification for the Research Project
In relation to the challenges mentioned above, different interests, needs and expectations between nurses and patients may be cited as complicating the healthcare provisions of migrants [19]. Furthermore, [11] assume that due to globalization, the proportion of people living with a migration background in Germany will continue to increase. Therefore, a rising demand in intercultural care in the hospital can be expected.
At this stage, there are still too few data available addressing the health care of migrants [9]. In this context, the present study is intended to provide an up-to-date impression of how migrants and German nurses are experiencing problems in the nursing process. How do the vested interests cope with the different requirements? Which resources do they have to be able to provide intercultural care and whether there is room for improvement [20]. In order to gain empirical evidence, qualitative interviews were conducted.

Methodical approach
The research question deals with the effects that a migrant background can have on the nursing care process. Since it is about the subjective feeling of the participants, the qualitative research approach was chosen for this project. The survey is subdivided into two parts on one hand the survey of nurses and on the other of patients. Both were asked about their experiences with intercultural care. The interview participants (nurses) were recruited on 5 wards of the operative department of the University Hospital. A flyer with the most important information was designed and the research project was personally presented. Interested people had the opportunity to register for an appointment using a doodle survey and printed spreadsheets. An important feature for participation was that the nurses should originally come from Germany.
Three focus-group interviews with 4-5 nurses each were planned. Due to challenges in participation, an interview was conducted with two nurses, plus 7 individual interviews. The conduct of patient interviews was approved on one ward. In cooperation with the staff of the ward potential patients were selected. An important criterion for the patients was that they should have been living in Germany for a few years and be of legal age.

Data analyses
The interviews were transcribed using the transcription programme "F4" [21]. For comprehensive insight, incomplete sentences, slang phrases, and breaks have been recorded [22]. Subsequently, the data of the nurses and patients were evaluated separately by means of the qualitative content analysis according to [21]. The aim was to reduce the material to the essential content without loss of important information.
Regarding the research questions, deductive categories such as stereotyping in nursing, challenges in everyday working life, differences in nursing care as well as a different understanding of illness, culture and religion were brought to the data materials of the interviews. For a more extensive consideration, the method of open coding was additionally used. Each paragraph of the interviews has been summarized to short paraphrases. This resulted in 18 categories for the nurses and 17 for the patients [22,23]. In the hierarchical summary, five (nurses) and six (patients) emerged as meaningful axis categories [23].

Ethical Considerations
Prior to this research work, approval was obtained from the Ethics Council of the University Hospital, the Staff Council, the Nursing Directorate and the participating ward administrators, as well as the Medical Director of the operational department. Before the beginning of each interview, the participants agreed on the declaration of consent and received information about the respective steps. Participants were informed that they could terminate their participation at any time without giving reasons. In addition, they were informed over a potential publication of the study results. All data that which were created was anonymized with a letter from the alphabet and a combination of numbers 1900 -1999.
For a better distinction within the interviews, those from nurses were also provided with "M" for employees and those of patients with "P". Due to the small study size, personal information such as gender, age, origin was anonymized. All documents are kept in a safe place.

Results
In order to properly adjust to the peculiarities of intercultural care, the nurses described that they had already heard something about this subject during their professional training. However, this knowledge transfer is only marginal so that in practice more is being used according to the method "learning by doing". In addition, they mentioned that there is hardly any further education regarding this topic. Nevertheless, they try to care for Germans and migrants on an equal footing. Regarding the question of whether there are differences in care, it is said that nurses try to care without prejudice. After all, care does not necessarily "have anything to do with the nation [5]" because every patient can be different. However, a not unbiased attitude and the feeling of being helpless cannot be completely avoided. A language barrier has an important impact on care. As this makes it difficult to start a conversation, communication with migrants will m a s s i v aufs m i n i m a l s t e gehalten" [5] However, a good conversation is "necessary to communicate more with the patient and for providing security (translated f. author) [4]. This also corroborates the testimony of a patient that er fühlt nicht gut, wenn er ist nicht, Andere verstehen nicht was er will [12] (he is not feeling well, if other people could not understand him, translated from author).

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Furthermore, it is said in this interview that the interviewee would be ashamed to ask a second time. The patients stated that learning the German language was very important to them. However, they see difficulties in the field of practical application.
For example, the German language is used only very slightly in families or in professional life. In addition, a disease event also has an influence on their language skills. By not understanding simple nursing measures, patients may not be mobilized for longer periods, or treatment may not be continued. There is also a risk that possible complications will be overlooked [6] weil sie es halt einfach nicht so äußern können. To counteract with this initial position, nurses mention the use of professional interpreters, relatives, translator lists (staff) and language boards (basic communication), own language resources and Google Translate. However, these measures do not always make everyday life easier. Thus, interpreters are reserved for the medical treatment process, as they would be too expensive for the care. Moreover, it would be associated with more effort on the part of the nurses, as doctors often would not sign the required documents in time. Furthermore, it is unusual to work together with an interpreter, because [1] talking to the interpreter more about the patient than with the patient directly.
Quick resources for translating are therefore employee lists and family members. However, this is problematic because not every language is represented and not every employee is suitable to talk to the patient about intimate areas. Similarly, it is with the relatives, because "maybe they do not want to translate certain things [4]" (translated from author). Special features are also shown in the body care. Patients with a migration background prefer here samesex care. Therefore, nurses need to pay more attention to [5] a little bit more man-to-man and woman-to-woman" care. Due to human resources, this is not always feasible, so that patients completely reject the nursing care. If family members now take care of them, nurses see risks in the quality of the care. It goes down a bit because you do not really know how far the family will do it then. In relation to this it is said the patient then developed one or two decubitus. Of course, we only saw it relatively late because we never cared for it [3].

Culture of visits
In the home countries, dealing with each other is characterized by a great willingness to help. Nurses also mention that other cultures have a stronger sense of duty to look after the sick in the family. In addition, there are differences in the number of visitors. "Everyone comes and brother, family that is normal and the neighbours also a lot too". German visitors have in this case a tendency to come alone and will leave the hospital after a short time. Family members are an important resource in the nursing process as they can minimize the additional administrative work required. In addition, the patients described that the visit distracts them from the actual illness. However, they can also significantly disrupt the everyday care of fellow patients, because you have a patient, for example, in a twin room, and then there are 10 relatives around the clock [2] and the spatial conditions are not designed for this high number of family members.

Pain
Although there are no sweeping statements, it seems that culture does have an influence in that certain societies feel the disease more intense (translated from author)7. While German patients are more likely to clench their teeth, it is normal for migrants to give their pain free rein. At this point, nurses are more required, because they must pay more attention to the expression of the pain. However, there is a risk that the nurses get dulled in their perception of pain. In this regard, it is said: so the pain experience as he expresses it, it is already, it also weighs on me, if someone suffers pain, yes, where you dulled a bit that I think that people should not be that exaggerating [2].

Food culture
Food intake plays an important role in the nursing care process. So, it is stated that [5] especially for many patients, I often feel, it is their highlight of the day. Religious rules, such as abstaining from pork or special preparation can here be named. Although no generalizations can be made, the trend is that visitors of migrants tend to bring more food from home. One reason may be that they are used to eating two hot meals, whereas in Germany it is common to make only one warm meal. It may then look a bit strange to the patients if e.g. at five o'clock (for dinner) a slice of bread with two slices of cheese" will be served and "that every day, and if it is not yours at all, yes. This is certainly not conducive for the recovery. This is also confirmed by the patients, it is said "Yes cold I ate yes, but a few times then it came out. I can eat that, I must eat that, for example salad and noodles, so cold noodles (?) and sometimes stomach does not want". In another interview it stated, "I only eat cold food when I'm well. When I'm sick I cannot, I have a stomach ache".
For enabling nurses to provide a comprehensive care to patients with a migration background, it can be said that they need more information at the beginning of the nursing care process. However, many measures are limited just to the bare minimum. Therefore [5]it is often not good enough. So, it just does not go well for the patient.

Do The Particularities Have An Influence On Job Satisfaction?
that continues during their whole stay, and somehow, a system has to be found, or approaches, to integrate migrants a bit better here". In this regard nurses mentioned, that in the admission process, a "reasonable nursing admission of a patient, will be often neglected [5]. This, leads to problems especially in the care of migrants with a language barrier, because it is difficult to determine personal wishes. This is compounded by the lack of time and resources created due to staff shortages.
During early shifts a nurse must set priorities because 20 minutes of extra work on a patient would be missed by someone else, then someone would not be washed [2]. Although there are cases where nurses know the factor in additional time (such as patients with dementia), the additional time that is sometimes needed to properly care for migrant patients is not often considered. Because of these working conditions, the acceptance for other cultural habits is lower. So, it is said [6] if I'm not really stressed out right now, then I am interested, why are they here, what is their life story and so on. In reality it looks as if we are not empathic enough, but "that's about time, but if we constantly have to run and be on one's last legs that is it, effectively (ehm), then I cannot just start a conversation with everyone.

Differences in Nursing Care (Country of Origin and Germany)
In the patients' home countries hospitals are only available in big cities. These are divided into private and state hospitals. Since private hospitals are very expensive, many are treated in state hospitals. There are also good doctors and nurses, but the local equipment is not comparable to those in German hospitals. There is no money for material, for care, for medicine for all and they do not have everything you need for shower [12] rust, rust. Everywhere rust. In addition, it was described that in other societies care is conducted quite differently than how we do it in Germany. The area of responsibility of the professional nurses in such countries is more centred on the treatment of care, while the basic care, as well as the food intake fall into the area of responsibility of the relatives. This, is said in one interview "for example my sister she go directly to hospital my other sister or her husband or daughter are going with her until my sister gets out [10].
There are also differences in the care itself, so it is very surprising for patients that a nurse even comes into the room without them ringing. In their home countries you have to [12] waiting, waiting for a long time until someone comes, nobody is asking you if you need something. You must always say something, if you cannot, nobody is coming and asking you if you need something. From this passage it is clear that patients do not have enough information about the differences in the healthcare systems, so it is unfamiliar for them to accept the comprehensive nursing care.

Limitations of the research
Due to summer vacation period, sick leave, schedule changes, as well as low interest by the nurses in the qualitative interviews, only a small number of interviews could be conducted. Therefore, the entire group of respondents (nurses and patients) may not be big enough for adequate inferences. In addition, it makes sense to generate general hypotheses that supplement the research with the methods of quantitative study design [21]. Another influence is social desirability. If the nurses come up with mistakes in the nursing process, this can be stigma-inducing because nobody likes to talk about their own imperfections. For patients, the situation may arise because, despite anonymisation, they are afraid of having a potential impact on their nursing process.

Discussion
In the context of the care of migrants, there are weaknesses in the theoretical knowledge transfer of intercultural care, because interviews revealed a lack of training in this regard. Therefore, nurses must rely on their own practical experience. Here it would be a relief for the nurses if they could get support from a specialist who is specialized in intercultural care. For the patients, it is unusual that nurses in Germany have a different area of responsibility than in their home countries. Patients are therefore amazed that nurses carry out a very comprehensive and courteous care in Germany. They do appreciate this type of care, but at the same time they describe that this is affected by structural problems. According to the nursing staff, it is not always possible to "sharpen the view for foreign cultural backgrounds and at the same time increase the acceptance and the empathy for the unknown behaviour" [6].
There is also a linguistic deficit in the interaction between nurses and migrants. Patients describe that they do not feel well when they are not well understood. In this context, it was mentioned that a disease event has a negative impact on their language abilities [24] affirm this, because when a person is sick, the world is changing. Matters that have been easy and could be dealt with at the same time, suddenly become a tremendous effort . For an improvement of a basic communication, methods such as Translation lists and own language skills are available. But on the other side, there is a lack in the availability of professional translations for nursing activities. In addition, translations that are not carried out by trained personnel or relatives do not guarantee the accuracy of the translation and ethical acceptability.
Additionally, regarding pain perception, body care and food intake there are notable differences. In the case of pain, it was shown that Germans and patients with a migration background have different pain patterns. While Germans are more likely to remain strong, other societies seem to be more vocal about their pain. According to [6], this is important, since "this expression of pain also gives every patient the attention it deserves as a patient". In this regard, nurses have described a risk of misjudgement of potential complications. Body care has limitations when patients, e.g. due to unworkable same-sex care, refuse it. In those situation relatives are an important resource. Nevertheless, there is a risk that the care of the patient suffers because care problems are often discovered too late, due to the unawareness of relatives and a lack of control by the nursing staff. Since in other societies, the family members "feel a great responsibility for each other", they " visit each other more often" [24]. This leads to higher numbers of visitors of migrants and is therefore difficult to reconcile with the care of fellow patients.
In addition to the factors mentioned, eating habits are also relevant. It can be seen that patients have difficulties in coping with the higher number of cold meals in comparison with their own eating behaviour. "But good health does not depend only on health care. It also depends on nutrition, lifestyle, [25][26][27][28]. The nurses confirm this, because they see that patients refuse to eat and prefer food from their relatives.
Nurses also mentioned that there would be no problems with the language barrier and eating habits if international patients would be attended by the international office. For these patients, an interpreter is always available and even wishes regarding eating habits can be taken into account. The influence of religion on the nursing process cannot be determined due to its low significance in the interviews.

Conclusion
The present work illustrates the influence that a migrant background can have on the care of patients in operative departments of hospitals. It turns out that the nurses try to make the care equally for all patients. However, due to organizational factors, they often reach their limits. To counteract this, training offers were considered as helpful. However, it may prove infeasible to sufficiently accommodate offers of this kind. Regarding the implementation of care measures, it seems that they do not have the same importance as an optimal treatment care. Due to the resulting costs, differences in the care of German patients and those with a migration background are accepted.
Furthermore, areas such as food intake do not seem to play a significant role at the moment. However, it is interesting that wealthy patients have a significantly better starting position than migrants with normal health coverage. Here it would be important to see what financial impact this has on the care. All in all, it can be said that some improvements are still necessary for an optimal nursing care process. In addition, increasing cooperation and information sharing among all involved professions and relatives would improve the situation.