Representations of health,illness and care by Eastern European,South American and Italian nurses: A qualitative study

Abstract

This qualitative study analyses the social representations of health, illness and care, considering the similarities and differences between 30 nurses from different regions. We conducted three intra-ethnic focus groups and two inter-ethnic focus groups. This study shows similarities between the nurses’ representations. All participants believed that the psychological sphere affects individual’s health, that disease is an imbalance between physical and psychological factors and that interpersonal aspects are essential for care. Differences emerged regarding many facets. Eastern European nurses placed more importance on psychological aspects, South American nurses emphasised interpersonal relationships and Italian nurses focused their attention on economic aspects and their impact on health, illness and care.

Keywords

care health illness nurses social representation

Introduction

Several studies (Bowen and Gonzalez, 2008; Karademas et al., 2017; Mondragon et al., 2017; Roios et al., 2017; Woith and Rappleyea, 2016) have investigated the cultural differences in concepts of health and illness, focusing on ethnic minorities’ perspectives with the aim of improving the effectiveness of health intervention programmes and the response to migrant healthcare needs (Pace et al., 2012). Moreover, the trans-cultural model of nursing, which is based on the study of the diversity and universality of care culture, highlights the need for medical staff to account for the standards and values of their patients’ cultures – including their perceptions of illness – and to plan ‘culturally consistent’ interventions (Leininger and McFarland, 2002; Pace et al., 2012; Turabián and Pérez-Franco, 2014). However, in recent years, migrants have become health service workers as well as health service users. In Italy, there has been a massive recruitment of migrants into healthcare services to satisfy the demand for elderly care and care for sick individuals living at home (Velotti and Zavattini, 2008). The XXIII Italian Report on Immigration (Caritas-Migrantes, 2013) indicated that there were 4,387,721 migrants in Italy (7.4% of the population). This demand was corroborated by data emerging from the National Association of Nursing that indicated a serious shortage of nursing staff; on average, there is a shortage of 2225 employees per region across Italy. Foreign personnel have been employed to address this deficit in both public and private health service systems. A number of studies have underlined the role of these personnel’s representations of the healthcare system. Santos et al. (2014) investigated nurses’ representations of health and illness and found that nurses who care for patients suffering from AIDS were vulnerable as a result of the high level of responsibility that they experience. This vulnerability could be influenced by the nurses’ representations of illness, which are affected by factors such as the economic wealth or poverty of the country in which the patient is being treated and whether the patient is in a public or private hospital (Hamid et al., 2014). Van Hulle (2007) also showed that paediatric nurses treating pain intervene in non-medical ways, such as showing care and affection for the child and trying to involve the family in the patient’s care (Van Hulle, 2007). In Israel, a study showed that nurses working with patients suffering from Alzheimer’s disease had different representations of the disease compared to colleagues in other professions, for example, social workers. Nurses viewed the psychological consequences of the disease as the most important factor for patients, whereas social workers considered the somatic aspects more important. Of all the health-related professionals, nurses were the group most likely to provide emotional support to patients. Nurses felt very strongly about the power of their profession to provide care (Shinan-Altman et al., 2014). In contrast to earlier research, a study conducted in Italy (Montali et al., 2011) showed that nurses tend to concentrate on the organic origins of an illness and to view illness as subordinate to the diagnosis and treatment of a disease; they tended to underestimate the psychological and psychosocial aspects of illness, suggesting that they viewed the patient’s subjective experience as a secondary aspect of the disease (Montali et al., 2011). Additionally, a study conducted in Pakistan found that the three main ways in which nurses represented care were ‘working to serve humanity’, ‘working against the odds’ and ‘working in a functional system and facing increased pressures of accountability’ (Hamid et al., 2014).

In sum, studies have highlighted that the representations of health, illness and care are vast, emerging from cultural, social and economic elements and showing different types of collective cognitions among groups of people (Höijer, 2011; Huet et al., 2018). As Moscovici (1973) stated,

A social representation is a system of values, ideas and practices with a twofold function: first, to establish an order which will enable individuals to orientate themselves in their material and social world and to master it; and secondly, to enable communication to take place among members of a community by providing them with a code for social exchange and a code for naming and classifying unambiguously the various aspects of their world and their individual group history (Moscovici, 1973, p. xiii).

In this context, it would be very interesting to further investigate nurses’ representations of health, illness and care – used as interpretive guides based on the moral and social rules of the home country (Moscovici, 2001) – as these representations can influence the care relationship and affect the outcome of care (Hem and Heggen, 2003). Nevertheless, very little research has considered the representations of health, illness and care of nurses from different countries (Papastavrou et al., 2012; Wagner et al., 2015). Furthermore, as social representation (SRs) are constructed through a process of communication, some authors (Farr et al., 1996) recommend studying them through tools rooted in a social nature in order to use a method that reflects the theory (Farr et al., 1996: 23). Thus, focus group interviews represent a suitable method to study SRs, as they obtain ‘material from samples of conversations’ (Moscovici and Duveen, 2000: 62). In this vein, the main goal of this qualitative research was to describe and analyse the representations of health, illness and caring according to nurses from different countries using focus groups to illustrate the ethnic and collective meaning-making as well as the negotiated meaning. This study is part of an extensive research project involving nurses and other caregivers (Pace et al., 2012).

Method

Participants

The participants included 30 nurses; 10 (33.3%) were born in Italy, 10 (33.3%) were born in South America and 10 (33.3%) were born in Eastern Europe. South Americans and Eastern Europeans are the most frequently represented ethnic minority groups in the nursing profession in Italy (Caritas-Migrantes, 2013). A total of 21 participants (70%) were women, a figure in line with the gender profile of the profession, which is largely dominated by women. The age of the participants ranged from 25 to 55 years (M = 38.6 years, SD = 8.4 years). The South American nurses were the youngest (M = 35.5 years, SD = 5 years), followed by the Eastern Europeans (M = 38.1 years, SD = 6.6 years), and the Italian nurses were the oldest (M = 40.7 years, SD = 12.4 years). All the participants were recruited in Rome, the province with the largest number of immigrants (currently 8.7%). Participants were recruited using the ‘snowball technique’. Initially, we contacted nurses through institutional organisations.

Measures

Focus group

We chose the focus group technique because it is considered suitable for studying SRs and for ‘exploring people’s own meanings and understandings of health and illness’ (Wilkinson, 1998: 20). We conducted a total of five focus group discussions, each lasting about 2 hours. Separate, ethnically homogeneous focus groups’ discussions were conducted with nurses from each different ethnic background (focus group A: Eastern European, focus group B: South American, focus group C: Italian). In this phase, the questions were very general and related mainly to participants’ representations of health, illness and care considering their cultural background. Two ethnically heterogeneous focus group discussions were performed. In this second phase, the questions concerned satisfaction with the nursing profession, emotional involvement with patients and difficulty managing diseases.

Procedure

First, participants were interviewed by telephone to obtain their biographical information. All participants had an adequate grasp of the Italian language. Participants were told that the research involved focus groups with participants from the same or different ethnic backgrounds and that the study intended to explore their ideas about health, illness and care. The group discussion was guided by a moderator using a designed interview. The discussion started with opening questions, and after reflection, the moderator asked more in-depth questions for clarification. Approval for the study was obtained from the ethics committee at the Sapienza, University of Rome. All participants provided informed consent.

Data analysis

Data were coded using Atlas.ti software; for manual coding, the material was divided into main conceptual categories reflecting the central themes of the research: health, illness and care. The endpoint of the analysis – saturation – was reached when two coders agreed that no new information pertaining to the categories was emerging.

Inter-rater reliability

Two members of the research team who were blind to the source of the data coded 1047 quotations after developing and using a set of 113 codes to identify the more general concepts, thus creating a codebook. A total of 1153 individual quotations were assessed, and the two coders agreed on the codes for 1146, indicating that the codebook had very high inter-rater reliability (Neuendorf, 2002).

Results

Comparative analysis of the SRs of health, illness and care in the three ethnic groups

In the first phase of the study, three groups of nurses participated in a mono-ethnic focus group, and each group discussed health, illness and care starting with opening questions. Focus groups in the first phase consisted of 10 Eastern European nurses (group A), 10 South American nurses (group B) and 10 Italian nurses (group C).

Similarities

In the focus groups, 141 entries emerged describing health for all nurses (Eastern Europe: 43, South Americans: 43, Italians: 55); 148 entries described the representations of illness (Eastern European: 39, South Americans: 37, Italians: 72) and finally, there were 165 entries regarding care representations (Eastern European: 79, South America: 86, Italian: 80).

All three ethnic groups shared the same general framework of representations of health. All the participants defined health similarly, describing it as general psycho-physical well-being central to life; the participants used phrases such as ‘health is important, health is life’ (the South American group) and ‘health is the greatest thing in the world; you can be rich and have everything, but if you do not have your health, you’re nobody’ (the Eastern European group). The nurses also considered health from both positive (well-being, personal autonomy, self-efficacy) and negative perspectives (lack of health, illness; Herzlich, 1969/1973), and these two aspects were reflected in comments about the importance of maintaining good health and the importance of preventing illness or poor health. They used phrases such as ‘you should have a check-up every year; many do not, but it should be done’ (the South American group) and ‘illness prevention should be improved and preserved’ (the Italian group). Additionally, all the participants offered similar definitions of ‘what illness is’; they considered illness mainly to be a negative phenomenon. All the participants, particularly in the Italian group, stated that people’s reactions to disease vary and do not necessarily depend on the severity of the disease. The participants also recognised different causes of disease: genetic, environmental and social. Furthermore, the participants identified six main categories of factors contributing to illness: psychological, somatic, social/contextual, interpersonal, socio-economic and individual. There were group differences again in how strongly these categories were linked to the concept of illness. Finally, all the participants expressed similar ideas about caring for patients. More specifically, they recognised that patients’ self-care depended on diverse facets (i.e. healthcare organisation). Additionally, there was a consensus that physicians are not very aware of patients’ needs. All the groups highlighted the problem of excessively long waiting lists and the resulting potential for a deterioration in the patient’s condition: ‘if a person chooses public services, he or she waits a year to get an appointment with a doctor’ (South American group). Other problems mentioned were the failure of primary assistance and the impact of socio-economic factors.

Differences

Comparing the three cultural groups revealed that the main differences between the groups related to the factors considered relevant to health, illness and care. These differences were often related to group differences in the perceptions of a broad category, and some content was specific to particular ethnic groups. The group of Eastern European nurses considered psychological factors (psyche category) to be a greater influence on health and illness than somatic factors. The most important psychological factors in health were identified as ‘having the will to live’, ‘inner strength’ and ‘health is a balance between disease and desire to live’, and these factors were identified only in comments made by the Eastern European group. The Eastern European nurses often mentioned the somatic category in relation to the concept of illness, referring to the fact that illness may be directly related to somatic factors (Pace et al., 2012). The Eastern European group considered social conditions (social category) to be very important. In fact, even compared to the psychological aspects, social factors were considered to positively or negatively affect the state of health of the individual. The group identified two themes central to health: the equilibrium between the individual and his or her environment and scientific advances in medicine, as illustrated by this comment: ‘thanks to research, in thirty years, many diseases will be eliminated’. Relationship factors were considered important (especially family relationships) but less important than psychological and social factors. All three groups agreed that psychological and somatic factors were the most important factors in illness. The Eastern European group highlighted the negative influence of social factors on care. According to them, the most important factor in ‘caring for patients’ was the personal qualities of the carer; these qualities could have a positive or negative influence on the patient’s health and determined the extent to which the patients’ needs were addressed. The group of South American nurses recognised the importance of psychological and somatic factors in health, but to them the most influential factors were in the social category. They emphasised the negative impact of stress, arguing that stress negatively affected health even in the absence of an organic disease. In contrast to the Eastern European group, the South American group emphasised the importance of relationships outside of the family to patient care. According to this group, the most important aspect of patient care was ‘responding to the needs of the patient’ (e.g. helping the patient maintain personal hygiene), and the presence of family members was identified as a potential barrier to healthcare. The Italian group considered the relationship between the individual and his or her social environment to be important to health. According to them, the most important factors in health appeared to be psychological factors, in particular the influence of relationships with people outside of one’s family. The Italian group paid little attention to the somatic sphere. All three groups placed particular emphasis on the role of cultural background in health. The South American and Italian groups expressed that individual behaviour influenced health and that ‘health is affected by lifestyle’. According to these groups, the most important aspects of patient care were the mental and physical status of the patient and the care relationship.

Differences emerging in the ethnically heterogeneous focus groups

All participants also discussed the SRs of health, illness and care in an ethnically heterogeneous group. This second stage enabled us to explore the cultural differences in the representations of health and illness in greater depth, as all our participants were practising the same profession in the same country at the time of the study despite having different national backgrounds. One of the main features of these focus group discussions was the attempt to identify and describe the cultural differences in behaviour, habits and lifestyle. Most of these contributions were made by the migrant groups, usually in the form of comparisons between life in their country of origin and life in Italy, their host country (Pace et al., 2012). Five nurses from each ethnic group participated in the ethnically heterogeneous focus group discussion in the second phase of the study. These focus groups considered two issues: nurses’ beliefs regarding quality of care and the role of nurses in multidisciplinary medical teams. The first focus group phase, composed entirely of migrant nurses, highlighted that, for nurses, establishing a relationship with a patient when he or she was admitted was important to good care. According to the Eastern European participants, caring for patients regardless of their nationality or culture was at the heart of the nurse’s role: ‘there is no difference; you have to treat everyone equally, regardless of religion’. They also felt that knowing the culture, habits and religious practices of a patient helped facilitate good communication between nurses and patients. Compared with the Italian and Eastern European nurses, the South American group considered the nurse’s relationship with the family to be a more important factor in care. To them, the nurse’s relationship with the patient’s family was a very important way of promoting health because the family provides emotional support to the patient: ‘the family is a stimulus for the patient’. According to the Italian group, it was inevitable that nurses would become emotionally involved: ‘with some patients, it seems like we’re becoming friends’. Nurses reported that they sometimes thought about the patients when they were not working. According to the Eastern European group, however, nurses failed to engage emotionally with their patients because of the high workload and the lack of time. They reported that this lack of engagement made them feel guilty for not giving the patients enough attention, as it made them feel they had not performed their job well. Both the Italian and Eastern European participants thought that it was important to find time to spend with patients: ‘even if I do not have time, maybe I can find a couple of minutes for him or her’. The last key aspect of this issue was the extent to which the patient’s attitude determined the tone of the nurse–patient relationship. Not every patient was willing to establish a more personal relationship with the nurses, and the nurses recognised that the relationship ‘depends on the patient, on if he or she gives you the chance to have a conversation’. Both the Italian and Eastern European groups emphasised that they had to balance their emotional involvement in the patients with their own psychological needs to prevent being overwhelmed by patients’ problems and illnesses.

In the second part of the focus group, the participants listed the factors that contributed (positively and negatively) to their job satisfaction. Motivation seemed to play an important role; there was consensus that being a nurse required a substantial amount of passion and that sacrifices are required. There was also general agreement that people’s choices of employment are often heavily influenced by the prevailing economic climate and that many people opt for a profession with good employment prospects, such as nursing. The Italian group reported that doing a job for which one had no motivation would be very stressful. Additionally, the temperamental characteristics needed for nursing were considered. According to the Italian group, a nurse needs to be sensitive to other people’s problems. According to the South American group, temperament is important because due to personal factors, no one can get along well with everyone. One nurse commented, ‘I happened to assist a child who was very sick, and it was difficult to leave him alone’. There was also agreement that working in healthcare makes people more apprehensive about getting ill. According to the Italian group, working in healthcare eventually takes a physical and psychological toll. The groups also argued that interpersonal relationships with patients and their families could influence job satisfaction. Nurses’ relationship with patients and their families could also be a source of great stress: ‘it is one thing to work with pen and paper; [it is] quite another to work with people’. The Eastern European and Italian groups complained that patients often looked down on nurses, and this made them feel inadequate and frustrated. The South American nurses also found satisfaction in being able to provide effective care. The ability to change departments if there were problems in one’s current department was considered a positive aspect of the job. In contrast, the Italian group considered changing departments a source of stress because it resulted in chaos and limited the development of close relationships with colleagues, thus hindering teamwork. There was consensus among the three groups regarding the most negative aspects of their work: (1) close contact with disease and with sick patients, (2) overly stressful pace of work and (3) inadequate remuneration for the duties performed. Poor management and legislative constraints were among the other generally agreed upon negative aspects of nursing. The participants complained that while patients are protected by laws regarding their personal protection and privacy, nurses had relatively little legal protection. Finally, participants discussed ‘teamwork’. All participants suggested that other staff were a resource that required collaboration but that they also promoted development of professional skills through comparison with colleagues. Conflict about working styles was considered the most negative aspect of teamwork. There was considerable diversity among the nurses in terms of professional training and background, and recently graduated nurses often had very different opinions from those of their colleagues who had been working in the profession for longer. Some Italian and South American participants felt that a multi-ethnic team could have a positive impact on patient care because immigrant nurses often came from the same countries as immigrant patients, and this cultural commonality helped create a good relationship between the nurse and patient (Figure 1).

Figure 1.

Profession and teamwork in the ethnically heterogeneous focus groups.

The facilitator had not introduced the theme of racial discrimination against immigrant nurses into any of the focus groups, because this was not within the scope of the study, but it would undoubtedly be interesting to investigate this important issue.

Discussion

This study was an extension of a previous study (Pace et al., 2012) that investigated the representations of mental health, illness and care among nurses from three different ethnic backgrounds. Applying the SRs’ theory (Moscovici, 2001) framework, we investigated whether nurses from different ethnic backgrounds shared similar views of health and disease and also examined their cultural differences in approaches to patient care. The need for research on these issues was based on the emergence of a ‘multi-cultural identity’ (Wilkinson, 1998). Data provided by the National Association of Colleges of Nursing, Health Assistants, Children’s Nurses (IP.SA.VI, 2013), indicated that in contrast to even a few years ago, immigrants are no longer only users of Italian health services; they also hold important roles in healthcare and contribute to the functioning of their host society. This finding has prompted many scholars to investigate the impact of the increasing cultural diversity in the healthcare workforce (Watson et al., 2003). This study was one of the first attempts to depict the values of native and immigrant workers; however, more detailed research using other instruments is required. Finally, when discussing care, all the nurse groups emphasised the importance of self-care, which encompassed the ability to access health services and follow preventive practices. Nurses’ belief in the importance of access to a well-organised healthcare system clearly emerged from the discussions. The Italian and South American groups emphasised the strong links between the organisation of healthcare and prevention campaigns and noted that the nature of prevention campaigns varied according to context (school, household, hospital). All nursing groups also noted that patient wealth and a good nurse–patient relationship promoted good care. The cross-sectional analysis revealed that although all three groups believed that there was a psychological component to health and disease, the Eastern European group placed more emphasis on this aspect of health than the other groups. The Eastern European group was also the only group to mention that nurses cannot expect to get along with every patient because of differences in personality. Another factor specific to the East European group was the emphasis they placed on social and scientific progress associated with the care system. The South American group placed the most emphasis on the contribution of somatic and relational factors. They believed that extra-familial relationships had a strong influence on health. Finally, the South American nurses also stated that people only think to take care of their health when they become ill. The Italian group’s discussion focused on the role of autonomy and self-efficacy in preventive healthcare. Unlike the South American group, the Italian nurses believed that health is not always determined by factors internal to the individual. Different issues were discussed in the ethnically heterogeneous focus groups, in particular regarding the importance of the nurse–patient relationship. The groups explored the benefits of emotional involvement with patients and the barriers to building a close relationship with patients. Interestingly, although the South American group placed more emphasis on relational factors and extra-familial relationships than the other groups in the first phase (ethnically homogenous focus groups), the South American nurses have not contributed to the discussion of emotional involvement in the ethnically heterogeneous focus groups. The Eastern European and Italian nurses voiced conflicting opinions: the Italian nurses considered that emotional involvement promoted good care, whereas the Eastern European nurses believed that it was better to limit or avoid emotional involvement to not be caught up in or overwhelmed by the patients’ problems and illnesses. Finally, all the participants agreed that teamwork was a very positive factor in patient care and that having workers from different ethnic backgrounds tended to be beneficial. This result has highlighted the need to promote greater integration of the values that characterise the personal backgrounds of different ethnic groups. The conceptions of health, illness and care and their descriptions were related to different characteristics of nurses, implying that patients’ experience will be influenced by the specific SRs of their nurse. These data underlined the need to better explore nurses’ SRs of all aspects related to their job. This study investigated nurses’ SRs while considering people from different countries. The results have highlighted a shared sensitivity to the psychological and relational components of care among all nurses as well as evidence of differences between mono-ethnic groups. These differences changed in the multi-ethnic focus groups; in this group, the opinions are shared. We have believed that connecting the SRs of peer groups (nurses) from various backgrounds (mixed ethnicity) would be an interesting means to promote integration between specialists with specific professional skills but different cultural beliefs. The main limitation of this study was that the group context may have discouraged the participants from voicing their real opinions and induced a degree of socially desirable responding, leading respondents to conform to what they perceived to be the group norm (Pace et al., 2012). Another limitation of this study was the lack of knowledge of the nurses’ cultural background. Although this topic is understudied in the literature, some authors believe that cultural differences are associated with religious beliefs, personality and desire to work abroad or in one’s homeland. Migrant nurses may experience miscommunications differently, especially with the elderly; this language barrier can be a stressor for nurses and a barrier to care and nurse–patient relationships (Walsh and O’Shea, 2010). One more necessary distinction should be considered: the training’s differences between younger and older nurses. Training of younger nurses is geared towards professional development, while training of older nurses is geared towards patient care. These issues should be further explored to facilitate a description of the background of the nursing population. One study found that nurses from different nationalities and cultures gave special meaning to care work, including reciprocity, religious beliefs and intergenerational benevolence (Gao et al., 2014). Although these results were not based on data from a representative sample, they constitute one of the first attempts to investigate the impact of an ethnically diverse workforce on health services and could inform health policy and treatment strategies.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was part of a research project entitled ‘Comparing culture care: Differences as a resource for building a shared professional identity’, which was supported by PRIN-COFIN 2006–2008 funds – Italian Research Programmes of Relevant National Interest, co-financed by the Ministry of Education and La Sapienza University.

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