Cultural Diversity in Nursing Teams: Triggers, Team Process and Contingencies / Kulturelle Vielfalt in Pflegeteams: Triggers, Teamprozesse und Kontext

Participation in the study was voluntary. The researchers informed the heads of the clinical units of the study, and they presented the project to the staff. The heads of the clinical units were not involved in any further recruitment of the staff; instead, the staff members interested in participating in the project were asked to contact the authors. The authors’ team then followed up and contacted individuals who expressed an interest in participation to agree on the time of the interview. The only inclusion criterion was individuals having a self-perception of working with individuals of a cultural background different than that of their own. In total, 18 nurses agreed to participate; two registered nurses were men, all the others were women. Their characteristics can be found in Table 1.

Semi-structured interviews were conducted, based on a predetermined interview guide (see Appendix), with open-ended questions focusing on interviewees’ experiences in culturally diverse teams. The construction of the interview guide was an amalgamation of the interview instruments used in three studies using the IPO model and focusing on teams in health sciences (Wetterneck, Hundt & Carayon, 2009), psychology (Antoni & Hertel, 2009) and organisations (Umans, 2012). The interview guide was pilot tested on one foreign-born nurse and one native-born assistant nurse, after which minor adjustments were made. Throughout the interview, follow-up and probing questions were asked when needed. The interviews lasted 30–50 minutes and were digitally recorded and transcribed verbatim by a professional transcriber.

While the initial ambition was to conduct repetitive interviews, due to re-organisation in two out of three units, sometimes, after the first waves of the interview, this was not deemed possible. Two authors of the paper were responsible for data collection. One of these authors was a female native-born specialised nurse holding a master's degree in nursing and with extensive experience in conducting qualitative research in healthcare settings. The other author was a male foreign-born researcher with a PhD in social sciences and with extensive experience in conducting qualitative research in healthcare settings. Native-born nurses and assistant nurses were interviewed by the native-born author of the paper, while foreign-born professionals were interviewed by the foreign-born author, an arrangement that was deemed to facilitate more open discussion on the sensitive issues related to cultural differences and experiences. The third author of the paper was a native-born female, a specialised nurse by profession with a PhD in caring sciences and extensive experience in conducting qualitative research in healthcare settings. At the time of the data collection, all three authors were employed at a Swedish university as teachers/researchers. Thus, the authors had different cultural backgrounds, gender, as well as work experience, and all had experience of working in culturally diverse teams in different contexts. These later experiences were of both a positive and negative nature, yet in the interview situation, the author maintained an agnostic attitude without revealing their past experiences.

The number of conducted interviews (n = 18) in our study was determined on the basis of theoretical saturation. According to Low (2019), theoretical saturation is achieved when the respondent's answers do not provide new elements or knowledge. In our study, the saturation point was reached at approximately the 15^th interview. However, given that the interview meetings were pre-booked before the saturation point was attained, we proceeded with collecting three additional interviews.

The study was conducted in accordance with the Declaration of Helsinki on ethical principles (World Medical Association, 2008). In accordance with Swedish law (SFS 2003:460, 2003; SFS 2008:192, 2008), formal approval was not sought because the data collected were of a non-biomedical nature. Prior to the interviews, the interviewees were given clarifying information about the aim of the study, their right to withdraw at any time with no personal consequences and the voluntary nature of their participation. Oral informed consent was obtained. All materials collected and personal data relating to the interviewees were treated confidentially, stored safely and available only to the authors of this paper.

The interview texts were analysed by inductive qualitative content analysis (Elo & Kyngäs, 2008); the first two authors conducted the analysis and alternated between the whole and parts of the texts. In the preparation phase, the texts were read and re-read as a whole. Impressions and reflections about the wholeness and important elements in the text were discussed. Then, all parts of the text were divided into meaning units consisting of sentences related to the aim. In the organising phase, the meaning units were open coded, with notes and headings in the margin; they were then collected on a coding sheet. The codes were critically interpreted and compared in a discussion by the authors. From this, a number of themes with sub-themes emerged. Drawing on relevant literature (e.g. Dreachslin, Hunt & Sprainer, 2000; Borrill et al. 2001; Jäger & Raich, 2011; Ancarani et al., 2016) and the authors’ experience of the context, emergent themes were aggregated to form domains. Finally, all the texts were re-read and compared with the outcome of the analysis to ensure that the themes covered the contents of the texts and codes.

In line with Lincoln and Guba (1985), the authors ensured the studies’ credibility and dependability by inspecting the field notes for potential personal bias. The field notes were taken immediately after each interview and contained both descriptive and reflective information (cf. Duffy, 2009). All the authors discussed the themes, sub-themes and the domains with each other until they reached consensus.

The analysis revealed five themes within the triggers domain that either enabled or disabled the team process. These triggers were of an internal team nature and characterised different dimensions of team functioning.

Striving for congruity, an enabling theme, represents the interviewees’ view on the value of the willingness to adapt to and accommodate each other and the spoken and unspoken rules guiding social interactions. It consisted of five sub-themes: individual congruity, in-team congruity, experiential congruity, social congruity, congruity of norms. Here, interviewees shared experiences of improving team work when the team members strived to accommodate to differences, to engage with each other on work-related matters and to discuss shared work goals. The interviewees further claimed that gaining a common understanding of social norms through interaction and seeking to understand these norms was another important sign of congruity. Finally, the interviewees, irrespective of the cultural background, said that adjustment to the Swedish norms expressed in terms of a high degree of trust and cooperation was an important enabler of productive team work. One of the interviewees explained:

So we have rules. . . . if they [immigrants] come here they have to adjust to those rules that exist, so that it doesn’t result in a conflict. Everyone here follows the rules

Figure 1

Showing goodwill, an enabling theme representing interviewees’ view of how showing goodwill related to team process, revealed two sub-themes: foreigners’ goodwill and mutual goodwill. Within these themes, the interviewees primarily discussed mutual willingness to learn, to engage, to fit into context. These aspects were particularly discussed in relation to newcomers to Swedish society. Showing goodwill was deemed to be an important enabler of team process. One of the interviewees said:

For me it is positive when we all are different, from different countries and with different experiences. I think it is rewarding. One wants to learn, and to thrive and develop

(Mis)Understanding of professional values is both an enabling and disabling theme and represents interviewees’ understanding of what constituted professional values in a culturally diverse team and how they were related to team process. This theme contains two sub-themes: divergent professional values and common professional values. Divergent professional values involved differences in the teams in understanding what care provision means, approaches to patients and perceptions of the function of professional care. Each was identified as a disabler of the team process. The nurses acknowledged that, at times, these divergences were culturally related, distorted the work flow and resulted in a team being less able to act as one unit. Within the common professional values sub-theme, the interviewees emphasised how the convergence and divergence of professional values related to commonalities or differences related to their team work. This sub-theme indicated the importance of professional values and their relationship to cultural diversity. One interviewee said:

Yet I think, [that] often those from other countries are extremely well meaning. They are kind and good. But [they] can almost be too kind and good. It becomes almost baby-like for the patients . . . it can be very tough . . . I think. Since they help way too much

Perceiving diversity is also both an enabling and disabling theme; it represents interviewees’ positive and negative perceptions of cultural diversity. Two sub-themes emerged within this theme: valuing diversity and diversity as a threat. Within the former and enabling sub-theme, the interviewees spoke of the power of awareness and of valuing diversity as having an enabling effect on the processes in diverse teams. The interviews further emphasised that acceptance of differences, be they cultural and/or of another nature, was detrimental for teams’ ability to act as one unit. Within the second and disabling sub-theme, that is, diversity as a threat, the interviews emphasised how unmet expectations, negative experiences with culturally different others or stereotypical views about people of different cultures had created difficulties feeling that the team worked as one unit. The comment below highlights one interviewee's opinions:

I can say that when one works with someone foreign, like me. They have more feelings and are more sentimental. While a Swede is a bit . . . they think . . . they are somewhat colder, not like us

Perceiving other diversities was yet another enabling and disabling theme that is represented by two sub-themes: salient team diversity and apparent team diversity. This theme represented interviewees’ views on the interconnection among different demographics, personalities and opinions and their relation to the team process. Salient team diversity was seen as a disabler of team unity or cohesion in culturally diverse nursing teams characterised by emotional, religious, ideological and task orientation differences interacting with cultural differences because it created a feeling of distance. Apparent team diversity contained both enablers and disablers of the team process. While European national diversity was perceived to enhance team unity, male tokenism, as well as non-European national diversity were perceived by the interviewees as disabling the team process. One interviewee stated:

I think it is exciting and fun meeting other cultures. But it can be a bit difficult at times and to get the understanding of each other when one starts to mix in religions. . . . Well, some women have problems with taking care of male patients . . . and that can create some issues

Opinions were divided on the relation between diversity in age and cultural diversity in nursing teams. The interviewees thought that when different generations worked with each other, it enhanced the competence base in teams. They also revealed that the same diversity led to an age-related hierarchy that distorted the exchange flows.

The theme that emerged within the team process domain is entitled team cohesion; it represents a number of intertwined processes within culturally diverse nursing teams and signifies a team's ability to unite around common goals. The sub-theme team joint decision-making was revealed through interviewees’ discussions of the importance of taking joint responsibility and joint decisions in different situations. One interviewee said:

We are two or three working [together], depending on what happens during the night. It could be that the patient has been awake the whole night so we let her/him sleep a bit longer. It all depends on how [the] situation looks in the day ahead, and how we solve it. So we make joint decisions about it

Another sub-theme within this domain was team communication, where the interviewees stressed the importance of good communication flow. During the interviews, the native Swedes discussed the importance of non-natives understanding Swedish. However, the non-native Swedish interviewees put more emphasis on the need for accommodation by native Swedes to temporary language deficiencies. One interviewee stated:

It is important that one can speak good Swedish, [. . .] I’m talking about everyday Swedish. It is important that one has it

Team socialisation, the third sub-theme, represents a sub-process related to team members’ social interaction at and outside work. Here, the interviewees said that different opinions, which were culturally embedded, were of crucial importance and stimulated the establishing of professional norms and professional relations within the teams. Moreover, interviewees felt that frequent socialising with colleagues allowed for stronger bonds between individuals involved in team work. One interviewee said:

We socialise outside work, many of us. We have very nice “after works” and other activities; it is a great team. It includes people of many different ages and [both] genders

Finally, the fourth sub-theme and a sub-process that emerged was labelled team support and recognition. The interviewees revealed that recognition of each other's competencies, complementarities and differences was important in creating well-functioning teams. It appeared that recognition and respect were important process elements that translated into a supportive team process, especially in culturally diverse nursing teams. One interviewee stated:

It is very important that one, one has it clear for oneself. That one helps others and that assistant nurses’ views are as important as those of the nurses and doctors, for that matter. We are very clear here that all are on the same level. That no one is bigger or better than another. So, we discuss it a lot, and stand for that

The interviews suggest that different processes were closely intertwined and reinforced a team's ability to work as one unit. The interviews further revealed that this ability represented an important and desirable outcome of work in culturally diverse nursing teams.

The analysis revealed six themes representing contingencies. These contingencies, representing external aspects, were revealed to be important enablers and disablers of the relationship between triggers on team processes. For example, hierarchical structures embedded in both cultural and professional hierarchies appeared to be a negative force in team functioning. Cultural hierarchies in particular were primarily experiences by non-European nurses comparing to European and Swedish nurses and nursing assistant, where former felt being infantilised due to their non-European background. One interviewee remembered:

That [foreign] doctor. He just comes and looks at my name badge and sees that I am the assistant nurse. So he doesn’t greet me. He just goes away

Positive empowerment intertwined with leadership qualities such as caring, and integrative and action-oriented leadership appeared to enable team work. One interviewee stated:

She [department head] believes us when we say we can’t manage, we can’t, we need help or extra things, or that we don’t manage. She listens. So it is good. And she is visible. It is also good for the patient's kin to have a face, to know who is a boss

The specificities of the work climate were perceived to be both enablers and disablers of the teams’ functioning. For example, family-like and inclusive environments were perceived to enable culturally diverse teams, while the complexity associated with stress and difficult conditions tended to disable these teams in their work. One interviewee said:

I would say that we are like a family. There is someone that is like one's sister, and another that one sees as a mother

The data further suggested that culturally diverse nursing teams were enabled by superiors arranging thoroughly coordinated activities. Here, the interviews discussed how clear and transparent planning helped teams to coordinate from within. At the same time, a lack of resources from superiors, that is, concerning further education for the staff and new skills acquisition, had a disabling role. These two aspects formed a theme called management systems. One interviewee said:

At times, many things happen here. Like last week . . . It was terrible; we just ran, ran, ran. We didn’t have much time for cooperation, or to talk with the nurse or assistant nurse. But otherwise, I think that we are well coordinated, actually

Patient complexity also appeared to serve as an enabler and disabler of the functioning of culturally diverse nursing teams. The clinical complexity of the patients, their needs, as well as their diversity were perceived to be very situational, and nursing team functioning appeared to improve when the team members felt that they had the tools to address patients’ needs. If the team felt they did not have the tools, patient complexity was perceived to become a disabler. One interviewee said:

It is important to understand the patient as well as possible. And if one has a colleague that comes from a similar or close culture, well, then it is a plus. Then we [native Swedish personnel] understand it better. There are many [patients] that come here that can speak Swedish or English

Numerous contingencies were perceived to play both enabling and disabling roles and represented a context for the triggers and the processes taking place in culturally diverse nursing teams. The enabling aspects appeared to neutralise some of the disabling aspects of the triggers and team processes. Similarly, the disabling aspects appeared to reduce the enabling aspects in the triggers and team process domains.

The analysis of the data revealed how triggers and team process are embedded in the context represented by different contingencies (Figure 1). Our findings depicted in Figure 1 suggest that, external to the team ‘contingencies’ and internal team ‘triggers’ enable and/or disable different teams’ processes (see Figure 1).

This study has a number of limitations, which can also be seen as opportunities to be explored. The relatively small study sample does not allow for the emergence of more robust results. Yet, the analytical generalisation presents results that could be further explored by qualitative, and even quantitative, methods. A further limitation of the study relates to the recruitment for the interviews and potential peer and leadership pressure to participate in the study, but this issue was partly alleviated by direct contact between interested participants and the researcher. However, we cannot discount the possibility that leaders of the unit, as well as the peers positively reinforce interviewees for study participation. Moreover, the study might suffer from non-participation bias, which could mean that only the most dissatisfied or most satisfied voices were represented. Yet, these concerns were partly alleviated by the relatively balanced narratives of participating interviewees. Another limitation relates to the way data were collected, that is, by individual interviews that might not capture the complexity of interactions one would have captured through participant or non-participant observations. At the same time, the individual interviews allowed for open dialogue about sensitive subject matter, while a researcher making observations might have distorted the typical flow of nursing teams’ work. One way forward would be to conduct studies using multiple methods, in which the interviews are interlaced with observations to produce a richer and multidimensional picture of the functioning of culturally diverse teams. We further acknowledge the limitation associated with over-representation of one of the two professions, that is, assistant nurses were overrepresented compared to nurses, which could have consequences for the narrative presented in the paper.

Our findings might provide inspiration for future research. For example, a future study might explore further the mechanisms through which specific team triggers relate to specific team processes. Moreover, future research could further explore the external factors and their relation to the functioning of culturally diverse nursing teams. Our finding could further encourage scholars to inquire into other multi-professional teams in the healthcare context and explore how differences in interprofessional hierarchies and multiple professional structures and intertwined identities interact with cultural differences presented in the teams. Future studies could also explore culturally diverse teamwork using methods that would give a deeper insight into these teams’ functioning. For example, observational studies or shadowing could provide a more nuanced understanding of the interactions within these teams, as well as the instruments they use to make their work more effective. Finally, future studies should consider exploring patient perceptions and experiences of culturally diverse nursing team functioning, to get an additional insight into how these teams operate.