Keywords

1 Introduction

Nurses have been undertaking the informal intercultural mediator functions in many health settings, in the relationship between the client and other professionals, and even between the client and their own imposed organizational rules. This intercultural mediation role has been informal; especially if we consider that the presence of formal mediators is a very recent and scarce phenomenon in Portugal.

In addition to recent (1990s decade), intercultural mediation is scarcely present in Portuguese hospitals strategy, but according to Herbert (2012) it has been an important resource for the social development of countries with a diversified cultural matrix, aimed for intercultural contact through communication. However, intercultural mediation makes sense not only when it comes to cultural diversity but also within the same family, in which each member can assign different meanings and adopt different behaviors from those expressed by the cultural norms of the group he belongs to (Campinha-Bacote 2007, 2011; Leininger 1981). Thus, even identifying cultural patterns (Leininger 1985), each individual should be cared for as a unique being, which, given their nature and life contexts, has a particular way to feel, see, think and act (Leininger 1981).

However, there is still a great lack of knowledge about the roles of nurses and their relationship with the medical practice. Nightingale’s vision of the beginning of the 18th century, in which the nurse assisted the doctor in his profession, was closely linked to the biomedical model which marked the history of nurses and of the nursing profession. Dissatisfaction with the dualistic approach to the human being did raise new currents of thought. It redirected the focus of nursing practice and nursing as a human science of care has evolved and developed a humanistic perspective that is focused not in the medical practice but in human responses to health conditions, disease and life transitions, such as set in 2007 by the Order of Nurses (Ordem Enfermeiros 2007). On many different conceptual models, philosophies and theoretical models, care emerges as the essence of the discipline with the user as the center of their attention. Leininger (1970, 1981, 1985), a nurse and anthropologist, permanently influenced nursing globally and the way nurses guided their practice, making cultural care an imperative. This view holds a holistic concern that the care is significant and consistent in response to health needs and the individual nursing care, and that professionals respect the lifestyles, cultural values and family of the costumer (Leininger 1970, 1981, 1985).

In this sense, Campinha-Bacote (2011) considers it necessary and important to adopt a customer-centric approach and culturally competent in that there is a “winning and losing” by the customer and a “winning and losing” by nurses. According to the author, in addressing the cultural conflicts, or prevention, it is advisable that nurses develop the ability to distance themselves, their own cultural values and focus on the client and may, to this end, adopt different cultural skills as proposed in the LEARN mnemonic where L (listen) refers to listen to the customer, their perspective, and E (explain) refers to explain to the client what one perceived from what he said, A (acknowledge) refers to recognizing similarities and differences between the two perspectives, R (recommend) refers to recommend considering the customer’s perspective, and N (negotiate) refers to negotiate with the client a treatment plan, a client-centric plan.

The maternity context is, by nature, wrapped in rituals and particular cultural practices taking on different meanings depending on the participants. In the health organizations, in the course of the interactions inherent to the care process and to the system of values, positions, interests, needs and expectations of the parties involved, which may have different views of the world, there may be constraints, which call into question the quality of care. Therefore, considering the transdisciplinary training and the fact that they continuously monitor those who need it, on a daily basis, the nurse sometimes assumes the role of informal intercultural mediator.

The care involves those who care and who are taken care of; it only makes sense when it develops beyond the technique and is guided by respect and solidarity (Polak 1996; Silveira and Fernandes 2007) by the competence with sensitivity (Herbert 2012; Polak 1996), but also by the availability (Silveira and Fernandes 2007) “attention, responsibility” (p. 79).

The essence of care in obstetrics is the act of being with the other, respecting them, demonstrating authentic presence in true interaction (Silveira and Fernandes 2007). This care allows a broader view of the environment where the woman is, (Silveira and Fernandes 2007) “her anxiety and fear she feels during the internment, the rapprochement between the nurse and the woman, non-verbal language, willingness to help, the service provided and the response that is given to every situation” (p. 79). When this environment of trust cannot be achieved, establishing a therapeutic relationship, an openness towards the other, misunderstandings can happen, as stated by Polak (1996).

Intercultural mediation is the act of a third person between two parties when, in some contexts, they cannot agree, on an issue that, due to fears, suspicions and differences, does not allow the communication between them, and who can provide the environment of trust for the parties to understand each other in order to reach a solution ACCEM (2009).

Intercultural mediation is, according to Giménez-Romero (2010), a type of intervention of a third element, oriented to the recognition of the other and to bring the parties together, “communication and mutual understanding, learning and development of coexistence, regulation of conflict and institutional adaptation, between culturally different social and institutional actors” (p. 23). The author understands that the mediator must hold some key principles required in intercultural mediation as “respect, trust, communication, language skills and intercultural competence” (p. 12). Considering the principle of impartiality the mediator cannot side with any party to advise or give instructions on what to do; he/she should only show mutual understanding and above all should not judge (Herbert 2012).

In this context, Giménez-Romero (2010) emphasizes the importance of socializing, of being with the other, being at the same time and same place as the other, with whom one interacts actively with whom one shares common features and among whom there is an understanding, empathy. For Matos (2011) it is essential to get the parties, when experiencing a mediation process, to acquire a new understanding of themselves and each other, so “they can interact more efficiently in a situation of conflict, in order to strengthen social relationships and promote the community’s quality of life” (p. 23). He also understands that intercultural mediation is a voluntary process that originates from the common knowledge that objectively establishes rules of mediation, that are confidentiality, mutual respect, the recognition that “the mediator cannot suggest, decide or advise, and that the mediator should be someone who demonstrates willingness and ability for intercultural dialogue with people from different backgrounds” (p. 24).

Therefore, the aim of this study was to understand the intercultural mediation in nursing care in obstetrics.

2 Methodology

Qualitative research study, drawing on semi-structured interviews to collect data. The sample consists of 15 nurses working in obstetrics service, belonging to two districts of Portugal, one in the central region and another in the Southern Region of Portugal. The interviews took place in the period between August and October 2015, using the recording and subsequent transcription of verbatim. The guide questions were: What does informal intercultural mediation mean for you? What is your experience in informal intercultural mediation? In what context did you feel the need to resort to informal intercultural mediation? In content analysis of verbatim interviews, we used the Qualitative Analyses Software Certified Partner Program (NVivo version 10). We abided by the ethical principles with the study participants, the institutions involved and the National Data Protection Commission (Case 8981/2015, No. 9430/2015). It should be noted that 87 % of nurses do not have training in intercultural mediation.

3 Results

From the analysis of interviews to the nurses, different categories of analysis emerged: meaning of intercultural mediation, principles of intercultural mediation, functions of the informal intercultural mediator nurse, and reasons for intercultural mediation. Each table presents the category, the corresponding subcategories, the number of nurses who manifested in each subcategory (text units: TU) A number of text units greater that n means that one or more nurses mentioned more than once the same category.

For the nurses, cross-cultural mediation has different meanings, as can be seen by Table 1; finding strategies is the most referenced, for about half of the participants, followed the meaning of being an approximation. Some also mention that intercultural mediation is to find a balance and some say it is managing conflicts.

Table 1 Meaning of intercultural mediation
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The principles of intercultural mediation emerge as a category of cultural significance. Respect is appointed by two-thirds of the nurses, and the principles the most noted in this category, followed by communication, referred to by one third of the participants. Other principles are highlighted by the nurses, in particular sensitivity, impartiality, language skills, trust, the primacy of the relationship, availability, active listening, legitimation, validation and not judging the costumer, cf. Table 2.

Table 2 Principles of Intercultural Mediation
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The preventive approach to the conflict assumes greater importance in the meaning of intercultural mediation in subcategories: to inform; to understand cultural differences; and to meet individual needs, cf. Table 3. It should be noted that more than half of the nurses interviewed mentioned to inform as an important aspect of the functions of an informal intercultural mediator nurse and nearly half mentioned the understanding cultural differences. Direct action on the conflict is referred to by one third of the participants in the subcategory to moderate.

Table 3 Functions of informal intercultural mediator nurses
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In clinical practice, there are sometimes situations of conflict that influence negatively the care and the relationship between nurses and clients. Despite being the category presenting lower frequencies, from the speech of some nurses, grounds for intercultural mediation emerge, cf Table 4, such as: women adopt practices that in the opinion of the nurse are not beneficial to the child’s health, nurses do not adapt to the needs of women, the difficulty and complexity of care in obstetrics, service transfer of nurses as punishment, the devaluation of work in obstetrics, nurses have an obligation to self-control emotionally, to understand that women have to make sacrifices, to understand that setbacks are natural, to understand that people do not want to be counteracted, the women hide the precarious situation for fear of removal of their child, women hide their financial situation due to shame, the nurse understand that Gypsies are always transgressing institutional rules and the imposition of professional culture.

Table 4 Reasons justifying the intercultural mediation in obstetrics
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4 Discussion

Four main categories emerged from the analysis: Meaning of intercultural mediation; Principles of Intercultural Mediation; Nurse Functions while an informal mediator; and Reasons justifying the Intercultural Mediation in obstetrics.

Meaning of intercultural mediation: Just under half of participants considers intercultural mediation as finding strategies “Usually I think that any nurse arranges strategies to facilitate communication and care, basically everything that has to be solved, namely the difficulty felt” (EN), five nurses consider it as an approach “Is trying to get the culture of the women we are faced with” (ED) one defines intercultural mediation as a balance “Is trying to find a compromise between the way we think and act and the way of thinking and acting of users of other cultures” (EL), and another views intercultural mediation as managing a conflict “Often trying to mediate what we intend, or what we have to do, with what the other also intends to or not” (EJ). These findings are corroborated by Matos (2011), who defines mediation as a strategy based on communication that allows individuals to be actors and builders of consensual solutions to their conflicts, and where the conflict arises with a new connotation, as something positive, as an opportunity for change. Giménez-Romero (2010) also defines intercultural mediation as a method, with the use of a third party, geared to achieving the recognition of the other and to bring the parties together.

Principles of Intercultural Mediation: Some principles of intercultural mediation emerge from the data analysis. Respect appears as the principle of intercultural mediation referred to by most of the nurses with 17 registration units. The speeches of two nurses are highlighted, “The mediation is related to it, it has to do with us respecting the other” (EJ); “In a conflict situation… it has to do mainly with respect. If we know how the respect… we are half way through to mediation. To solve any problems that may arise resulting from these cultural differences, it goes mainly through respect” (EO). Giménez-Romero (2010) highlights respect as an important principle in intercultural mediation.

Five of the nurses interviewed, stressed the importance of communication as a principle of intercultural mediation “Anyone who in any way that facilitates communication” (EN). Also Giménez-Romero (2010) states that the communication is defined as an important principle of intercultural mediation.

Three of the nurses said it is important for nurses to have sensitivity to detect situations that need to be worked “Sometimes we have situations where the mother is very plaintive and sometimes we did not even realize that there is something else that exacerbated that complaint. And if we can get to the bottom, we can resolve the situation differently” (EL). In this context, Herbert (2012) states that in the process of mediation, it is necessary that the mediator develops a “third sense” in order to capture and decode encrypted messages, a hidden message that transmits an instruction or information on relationships.

Impartiality comes through the report of two nurses “No discrimination of users. All users have the right to be cared for with courtesy, respect, dedication and impartiality.” (EN), “try to find a compromise between our way of thinking and way of doing things in the way of thinking and acting of the users of other cultures” (EL). Both the Fundación Secretariado (FSG 2007) and Herbert (2012) describe impartiality as an important feature of intercultural mediation, that the nurse should ensure it, considering it as an ally in the establishment of true mediation.

Active listening was reported by a nurse as an important principle in mediation “They have to know that there is someone who hears them, which gives them strength” (EN) “Most of the time… I try to listen to exhaustion, let the person speak all they feel” (MS). According to Morin (2002) it is important to improve the understanding we have of each other and realize that understanding is the middle and end of human communication. Domingos and Freire (2009) stress this active listening as an asset to the outcome of the conflict. Active listening is defined as an interview driving method in which the parties are on an equal footing. Through questioning and, above all, constant reformulation, “this form of listening allows the nurse to get a good grasp of the facts” (Phaneuf 2005, p. 157).

Two of the nurses consider that one of the mediating principles is to have language skills “If there is close proximity of the language, it will be easier to perceive or know something more of them to manage to provide the nursing care” (ED). One nurse said that trust is an important principle in intercultural mediation “a nurse with whom they can talk, with whom they can expose all the questions, all those more complicated situations, in the core and be able to establish a therapeutic relationship that allows this approach, in the sense that they can trust me” (EN). Trust is an emotion is the (OE 2014) “feeling of believing in goodness, strength and reliability of others” (p. 43). Herbert (2012) considers that trust is constituted as an important principle of intercultural mediation.

The therapeutic relationship is often referred to by several authors, and one nurse believes that the establishment of a therapeutic relationship is essential as a principle of intercultural mediation, with three recording units “Only if there is a therapeutic relationship they will accept what we say” (EN). Giménez-Romero (2010) also gives emphasis to the relationship, when stating that socializing is not limited to the presence of groups in a given time and place, but refers to the interaction and positive relationship between them. One of the nurses also mentioned the availability as an essential principle “Often it is not possible on the run; we have to arrange that little bit (of time) that the person needs” (EN).

Matos (2011) states that the availability must be a principle of intercultural mediation, which is understood as (OE 2014) “being prepared or available for action or progress” (p. 49). Legitimation was also identified as a principle of intercultural mediation “Not long ago I had a situation, they called me to care for a baby with trisomy 21 and the fact that I had previous experiences helped to convey a word of comfort, warmth and force. I know what it is to have in the family a child with special needs due to trisomy 21 and when I realized the situation, I managed somehow to open enough for her to accept my contact and the contact of the association trisomy 21” (EN). According to Giménez-Romero (2001), immigrants demonstrate their desire for recognition of legitimacy and competence on the part of the mediator. Validation was also reported in this category “What matters is that I realize that she understood but sometimes it is complicated because I do not speak, I speak little or no English” (EB). For Phaneuf (2005) this validation is an important mediating principle; it is a way to accept the behavior of the person and to seek it meaning (p. 543). Non judgment also arises as a principle of intercultural mediation “Above all nonjudgmental” (EH). Herbert (2012) reveals that non-judgment reflects a principle of intercultural mediation. In this sense the nurse should try not to make value judgments on the client.

Functions of informal intercultural mediator nurses: the duty to inform is the most referred function of informal intercultural mediator nurse “The key is to inform the user because even though she has a different culture, if well informed and enlightened we always end up getting the balance” (EL). Thus the nurse should be responsible not only for the care it provides, but responsible to inform the woman who is more fragile, to calm her; the nurse should be responsible, considering that woman has the right to information when it concerning her. In accordance to the OE (2014) to inform is defined as the action of “communicating something to someone” (p. 101).

Six of the interviewed nurses consider that for an informal intercultural mediator nurse it is important to understand cultural differences “Realize that not all people are like us” (EE). For Giménez-Romero (2010), it is important a mutual understanding between ethno culturally differentiated social and institutional actors. For a third of nurses, a nurse’s role is to moderate “I think it’s one of the nurse’s role is to be the moderator of these situations” (EH), three nurses consider it to meet the individual needs “I am careful to take care of each user individually in order to meet the needs of each one, as long as I have the perception of how that user wants to be helped” (EN).

Reasons for Intercultural Mediation in obstetrics: There were several reasons, justifying the need, by the nurses, calling for the use of intercultural mediation strategies that meet the above-mentioned principles.

Women adopt practices that, in the opinion of the nurse, are not beneficial to the child’s health, was one reason given by two nurses “It is still very hard to get the information through, because for a long time, it was taught to put the newborn in decubitus ventral. Afterwards they taught the lateral position on one side and the other. Due to the results of research, for many years we have been teaching to put in dorsal position, there are mothers who continue to have difficulty in accepting the supine position instead of the ventral “(EN). The nurse being unable to meet the needs of woman referred by a nurse “We sometimes do not suit to their needs and they feel needs that we cannot satisfy” (EK), and the nurses’ inability to assess the satisfaction of the women’s needs “we ended up not quite understanding if we managed to reach and satisfy that person the way she was expecting” (MS). The devaluation of work in obstetrics “Our peers from other areas, do not value the work of nursing in obstetrics” (EN). Bonadio et al. (2002) even refer to a sense of devaluation of midwives regarding other professionals due to non-financial recognition of their work and a certain position of submission within the team.

Situations where nurses in the past were transferred to the obstetrics service as punishment “When I started working for twenty or so years, when there was a nurse, that somehow, was in conflict with the administration, with the nursing directorate, they were placed in the puerperium” (EN). Therefore, we can understand that there was a need for mediation, for dialogue, which would lead to the resolution of these conflicts in order to avoid the punishment of nurses.

Difficulty and complexity of care in obstetrics “It is increasingly difficult. For various reasons. Because people are first time mothers increasingly later in their years” (EG), or the idea that the nurse has an obligation to self-control emotionally when he says “Professionally we ultimately strive a little more because we are working and want to present a good image to the person; in addition, we are representing a team; we cannot let down all the team” (MS).

The idea that a woman has to make sacrifices, declared by a nurse “There are circumstances that require some sacrifice, a very great gift, which sometimes causes dissatisfaction by the women because they wanted it to be all right” (EG), the setbacks are natural, referred to by the same nurse “sometimes eventually there may be some setbacks, that are natural” (EG) and yet again by the same nurse, people do not want to be counteracted, “currently they do not want to be in pain, do not want to have setbacks; They do not want to have a no, they always want yes; in obstetrics not everything is always yes” (EG).

The women hide their precarious situation for fear that their child may be removed from them. “There are situations where there is fear because they realize that their situation is very precarious, even very bad, and are afraid that somehow it means to the take the baby from them. Thus, they prefer to hide to keep their baby” (EN). Women hide their financial situation due to shame “They were unemployed, and somehow are ashamed to expose the situation, the needs they have, and they think that to resort to social worker gives a negative, and often embarrassing feeling” (EN).

To understand that gypsies are always transgressing institutional norms “There is a strong tendency to say that the gypsy culture is different, but they are keen to make a difference in their behavior, in everything; it is their culture and we have to respect it, but there are things in which not so much because they always want to be in violation of institutional rules; sometimes they come out of the visiting hours, want to stay from morning to evening” (EN). The importance of avoiding stereotypes, to non-stigmatize as regards Kleinman and Benson (2006) is emerged, justifying the need to promote dialogue and active listening in order to be able to help her overcome her fears.

The imposition of the professional culture also emerges in the speech of a participant “We also want them to respect us and it has to be us to go around them or make them understand that they also do not need to do it the way they do and maybe even they could change their habits, change something” (EE). For Rodrigues Martins and Pereira (2013) understanding and awareness of the extent of the moral and cultural aspects is required and the professional must expropriate up prejudices and stigmas that are built into the culture in order to ensure maintenance of multicultural identity and minimize the cultural imposition.

It is thus justified the need to resort to intercultural mediation and to train professionals and future health professionals for this reality. In a situation of hospitalization, of postpartum, the woman is more fragile, more sensitive and preventive intercultural mediation enables professionals to prevent conflicts, promote dialogue, demonstrating readiness and have an attitude of active listening promoting positive maternity experience.

As Kirmayer (2012) stated “there is a great need for research on the processes of implementation, clinical effectiveness, wider social impact and outcomes of culturally competent services and interventions” (p. 161).

5 Conclusion

Cultural inconsistencies arise with regard for intercultural mediation in health. On the one hand the appreciation and recognition of their nurse role with an informal mediating function, visible in categories such as significance of intercultural mediation, intercultural mediation principles, functions of the informal intercultural mediator nurse; and on the other hand the constraints experienced in some health settings that call for greater training of professionals in intercultural mediation, visible in the category reasons for intercultural mediation. We must invest more in training in intercultural mediation of nurses in order to provide opportunities for dialogue and active listening in maternity experience, which can preemptively prevent the emergence of constraints or leading to its resolution.