Transcultural Communication Strategies in Nursing with Multicultural Clients in Hospital Settings: A Systematic Literature Review

Introduction : A lack of nurse understanding of cultural diversity during nurse-patient communication may cause conflicts and misunderstandings. Objectives: To analyze nurse transcultural communication strategies with multicultural clients in hospitals. Methods : Systematic literature review incorporating four databases, including PubMed, Science Direct, Google Scholar, and ProQuest. Assessed Article quality based on JBI and MMAT. Results : A total of 47.848 articles were identified, and twelve articles analyzed highlight ten transcultural communication strategies, including the usage of language translators and interpreters, communication skills training, cultural competency training, initiative to learn a new culture, clarity of communication, doing self-reflection, familiarizing to the patient, developing confidence, spending more time to consult, respecting and appreciating patient. Discussion : implementing transcultural communication strategies during nurse-patient interactions is important to achieve therapeutic communication goals. Conclusion : Transcultural communication enables nurses to understand and respond to patient needs effectively. The study suggests that nurses develop transcultural communication skills and competencies to practice intercultural communication during clinical care.


INTRODUCTION
The recently increased diverse populations in the world, effective health communication has become an important clinical skill for healthcare workers.Healthcare institutions such as hospitals are required to improve services not only for curing diseases but also required to enhance quality in providing services that can promote satisfaction (Az-Zahroh, 2017).Comfort in interaction is the key to delivering good service, creating a conducive environment, and providing mutual so that clients feel comfortable and motivated to recover (Agritubella, 2018).The success of the interaction depends on how well the communication is carried out the communication.As frontline workers in healthcare, nurses rely on communication for whole aspects of their duty.Nurses learn about their patient's needs, concerns, and health issues through communication.Communication between these parties manifests as a forum for exchanging information and assisting clients in overcoming their physical and psychological problems (Sasmito et al., 2019).Thus, it is important to deliver effective communication to clients to maintain their dignity and autonomy and to form therapeutic relationships.In a multicenter qualitative study conducted in Indonesia, Asmaningrum & Tsai (2018) found that nurses' kindhearted communication was perceived as a respectful way to maintain patients' dignity.
The importance of communication during patient care is essential for providing safe and quality health service.Conversations between nurses and patients during clinical care are a crucial component of the quality of health maintenance.Therefore, effective communication will impact quality increase and patient safety.However, many factors were identified influencing the implementation of effective nurse communication, including sociocultural factors (Sari, Hariyati, & Afriani, 2019).Sociocultural diversity becomes a crucial aspect of the interaction process and communication due to language differences inveigled by cultural background may lead to miscommunication (Crawford, Candlin, & Roger, 2017).
Cultural diversity influences the success of therapeutic communication between nurses and clients.By implication, the implementation of nursing care that does not concern the client's culture will hinder the communication process (Binteriawati et al., 2020).Multiculturalism in health services can be an obstacle, mainly due to the language diversities of clients in hospitals (Hendson et al., 2015).Based on research in the Mid-Western States of the United States, 23 out of 56 health workers (40%) believe that different cultural background between nurses and patients often makes patients feel uncomfortable, anxious, and nervous.In addition, 80% of nurses sometimes find it challenging to take care of patients from different cultures (Shepherd et al., 2019).People from diverse backgrounds have unique ways of perceiving situations, as well as particular attitudes about health care.These differences influence how people communicate with healthcare providers.To address the patient's needs from all backgrounds, nurses strive to bridge gaps in cultural understanding and ways of communicating.In terms of communication, cultural diversities between clients and nurses in contact represent cross-cultural communication (Liliweri, 2018).Furthermore, cross-cultural communication is vital role in building trust between patients and nurses, which is fundamental to delivering high-quality patient care.
Lack of communication knowledge between nurses and clients from different cultures may cause conflicts and misunderstandings.For nurses, it causes violence against nurses, decreased performance of nurses in front of clients, inappropriate nursing interventions, and available in full-text articles, and written in English.These criteria eventually sorted 15.241 articles.The researchers conducted further screening related to article titles and abstracts that were deemed relevant to the topic and eliminated articles using literature review designs, scoping reviews, and systematic reviews.Duplicate articles were also excluded at this stage.This further screening included 60 articles which were then read for further examination against the exclusion criteria.After the reading, 12 articles were included for the final review.The overall PRISMA procedure is shown in the flowchart below.

Critical Appraisal Result
The initial critical assessment was carried out independently by two reviewers.Discussions were carried out to moderate assessment differences before reaching a final necessary justification.In this study, The Joanna Briggs Institute (JBI) Critical Appraisal Tools version 2020 was used to review qualitative study (n=7), cross-sectional study (n=4), and Mixed Methods Appraisal Tool (MMAT) version 2018 (n=1).The following table displays the results of critical assessments.

Articles Included in the Literature Review
The results of initial analysis, review, and further identification finally included only 12 articles.The following table describes the details of each article.The study examined twelve articles based on studies across 9 countries Arab Emirates, Austria, Spain, Australia, Turkey, Saudi Arabia, Norway, East China, and Ethiopia.The authors grouped the findings into ten strategies of transcultural communication used during nursing practice.Those ten strategies were sequentially presented based on the number of analyzed articles supported each strategy as follows:

Using translators and interpreters
As language differences may occur during interactions between nurses and multicultural patients, barriers to communication and building trust relationships with patients may exist.Thus, the involvement of family and translators is also needed to assist in communication and interpreting the intent or information received or delivered by the patient.Six articles stated that nurses had translators or interpreters to help them communicate with multicultural clients (Berie et al., 2021;Cai et al., 2017;Kuzemski et al., 2021;Watts et al., 2018;Watts et al., 2017;Yakar and Alpar, 2018).Thus, the nurse's strategy of looking for translators and interpreters from family, colleagues, or other people were used to understand patients' communication.

Participating in communication skills training
Four articles discussed the need for communication skills training to improve nurses' knowledge, attitudes, and skills.This aimed to prepare them to take care of clients in a multicultural setting and reduce communication barriers between them (Albagawi and Jones, 2017; Watts et al., 2017;Gasiorek and van de Poel, 2018;Berie et al., 2021).Nurses who have received communication skills training feel better equipped to care for patients from different cultures.

Participating in cultural competency training
This study found four articles that discussed the nurse's strategies to prepare themselves to communicate with patients in a multicultural setting by participating in cultural competency training (Jesús Plaza del Pino, 2017; Watts et al., 2017;Watts et al., 2018;Yakar and Alpar, 2018).Through cultural competencies training, the nurse's understanding and respect for patient cultures and developing intercultural skills during nursing care could be enhanced.

Having the initiative to learn a new culture
Four analyzed articles reported the need for nurses to learn emerging markets in providing nursing care to clients in a multicultural setting.These involved learning another language, learning new communication practices, collecting cultural information related to health problems, and taking the initiative to look at client's demographic data in advance before meeting clients to avoid misunderstanding (Berie et al., 2021;Cai et al., 2017;Kuzemski et al., 2021;Philip et al., 2019).The initiative and nurses' willingness to adapt and learn new communication practices aim to minimize misunderstandings and tension between speakers.

Clarifying the emphasis on communication
Two articles were found that highlighted the importance of such strategies as clarifying the utterances in communication such as repeating the spoken word, speaking slowly, simplifying the language used or saying the keywords to be conveyed in the patient's language, and using nonverbal cues to ease communication ( Berie et al., 2021;Watts et al., 2017).To easily e-ISSN 2477-3743 | p-ISSN 2541-0024 communicate with the patient from different cultural backgrounds, the nurse uses plain language or highlights the keywords intended for the conversation using the daily patient's language.

Being able to familiarize themselves
Two articles investigated nurses' strategies to familiarize themselves, such as frequently greeting, calling clients by their first names or special nicknames favored by the client and showing intimacy to reduce tension during communication (Debesay et al., 2021;Philip et al., 2019).Adopting local communication patterns, such as using everyday language during a general conversation, enhance familiarity.When a healthcare demonstrates familiarity with the patient's culture, it contributes to a positive cross-cultural experience and allows for better cooperation in its care.

Having self-confidence
Two articles mentioned that nurses who have high self-confidence in providing nursing care to clients in a multicultural context could help to maintain good communication (Bit-Lian et al., 2020;Watts et al., 2017).Although nurses face a language barrier during nurse-multicultural patient interactions, they remain confident while providing nursing care for patients.

Spending more time on consultation
The existence of language differences may provide barriers to communication.Thus, it is essential to facilitate interaction in many forms, such as patient consultations, to ensure the information provided is better.The review found only one article argued that facilitating interaction with clients in talks related to clients' health problems by spending more time building good relationships.Given this good relationship, clients will find it easier to understand the communication (Watts et al., 2017).

Being able to do a self-reflection
Only one article was analyzed by self-reflection or self-introspection by nurses as the springboard to improve the success of communication with clients.Some strategies associated with self-reflection were reducing mispronunciations, speaking slowly, and maintaining selfemotions (Philip et al., 2019).By practicing self-reflection, nurses evaluate nurse-patient communication to improve the quality of subsequent interactions.

Respecting and appreciating clients
One article stated that a communication strategy that nurses can use is to show respect and appreciation for clients by establishing decent interactions daily basis and not imposing personal beliefs on clients (Cai et al., 2017).Nurses must treat clients equally regardless of patients' cultural backgrounds through respecting patients shown in daily interactions.Thus, it is part of the essential component of a nurse's cultural competence that enables practical work in cross-cultural situations.

DISCUSSION
Our findings unravel a variety of transcultural communication strategies that nurses use when treating clients in hospitals.This transcultural communication emphasizes the communication between nurses and patients in a multicultural setting characterized by different nations or countries, different ethnics or racial groups, and different religions (Gudykunst, 2003;Liliweri, 2018 and Darmastuti, 2020).The findings of this systematic literature review have underlined ten essential strategies for nurses to communicate with clients in a multicultural setting, including the usage of language translators and interpreters, communication skills training, cultural competency training, initiative to learn a new culture, clarity of communication, doing self-reflection, familiarizing to the patient, developing confidence, spending more time to consult, respecting and appreciating patient.The six studies found that a strategy in nursing transcultural communication in a multicultural context was the usage of language translators and interpreters are commonly used in hospital settings.The results of the present study are in line with previous research findings in India according to the importance of nurses using professional interpreters while working with culturally diverse patients and any need for more availability of interpreters at every time at the hospitals.Thus, the situation of misunderstandings would be rapidly resolved as soon as the interpreter exists.Therefore, the uses of language translators and interpreters acknowledge as a tool and technique for working with culturally diverse patients (Larsen, Mangrio, & Persson, 2021).
Four studies identified that nurses' strategy of transcultural communication in hospital-based settings was the training of communication skills, training of cultural competency, and having the initiative to learn a new culture.Cultural competence training significantly enhanced healthcare providers' cultural competence level, which significantly contributed to increased patient satisfaction (Govere & Govere, 2016).On the other hand, as discussed by Khodadadi et al. (2013), communication skills training could enhance nurses' rate of communication skills and impact the improvement of nursing care quality.Thus, in order to elevate the quality of care, nurses' communication skills should be improved.Another strategy identified was the initiative to learn a new culture.Nurses' initiative to learn new cultures, it reflects nurses' willingness to understand and interact with people of different cultures.Therefore, nurses may effectively interact with and engage diverse patients.This approach enables nurse professionals to successfully treat patients even when patients' beliefs, practices, and values directly conflict with conventional medical and nursing guidelines (Deering, 2022).
The present systematic review demonstrated that three analyzed studies show that clarity of communication is one of the transcultural communication strategies.The study suggests when communicating with culturally diverse patients, nurses must keep language clear, concise, and straightforward.Each two included studies showed that familiarizing the patient and developing nurses' confidence were important strategies of transcultural nurse-patient communication.Kamrul, Malin, & Ramsden (2014) reported that being familiar with communities' core cultural elements is nurses' activities related to cultural competence.Although nurses encounter difficulty when the patient primarily communicates in their native language, nurses gain confidence to face it.
The present review revealed that other strategies of transcultural communication in hospitalbased settings were providing time for consultation, the ability to self-reflection, and respecting and appreciating clients.Through spending more time and having the most contact with patients, doing 'connecting work' that complements physicians' consultation is important to build good nurse-patient relationships, which is a fundament of nursing work (Collins, 2015).The review shows nurses' self reflection is formed through deep reflection on the event or a particular clinical position (Pangh, Jouybari, Vakili, Sanagoo, & Torik, 2019) is regarded as a proof of e-ISSN 2477-3743 | p-ISSN 2541-0024 professionalism and is used as a skill related to clinical performance and professional behavior (Cooke, Walker, Creedy, & Henderson, 2009).The study reflects that accepting personal differences and demonstrating a nonjudgmental attitude which is essential for nurses to effectively communicate across different cultural groups (Parsons, 2002).
Communication skills are essential for nurses to provide health services.In terms of transcultural, communication allows nurses to better understand patients and respond more effectively to their needs.It plays an important role in nursing by improving a nurse's ability to accurately assess patient conditions, successfully explain medical issues to patients, give patients crucial instructions about medications, and educate patients about a diagnosis or prognosis.Transcultural communication also empowers patients to participate in and help direct their own care according to their needs and preferences, which often improves health outcomes and patient satisfaction.
The study findings can be used as a guide for transcultural communication strategies for health professionals, especially nurses, in reducing the negative impacts arising from cultural differences.Nevertheless, of these ten strategies of cross -cultural communication identified, the most effective cross-cultural communication strategies did not identify.Thus, the study suggests further studies to investigate the most effective cross -cultural communication strategy used during nursing care which improves client satisfaction upon receiving care in the hospital setting.This study draws some limitations considering the fact that only four databases were included.This implies that articles with relevant themes may uncover these relevant works may be published in other databases.

CONCLUSION
The results of this systematic literature review concluded that the 1598 recruited nurses in analyzed studies used ten different strategies to communicate with clients in a multicultural context.These strategies include involving the usage of language translators and interpreters, communication skills training, cultural competency training, initiative to learn a new culture, clarity of communication, self-reflection, familiarizing to a patient, developing confidence, spending more time to consult, respecting and appreciating patient.Nurses can use these strategies to communicate with a patient from different cultures.This initiative also involves developing positive attitudes to approach clients regardless of cultural differences.Nurses who can understand transcultural communication will be able to interact more effectively and are more likely to establish successful communication as the precursor to clients' satisfaction with nursing services.

ACKNOWLEDGEMENT
The authors would like to thank the Faculty of Nursing Universitas Jember for supporting this article's publication; we also thank those who supported the writing process.There is no conflict of interest in this article.