Cultural competence in Swedish paediatric hospital care

Background: Ensuring equitable access to care and enabling individuals to achieve optimal health is a fundamental goal of healthcare. Increasing global population diversity has led to corresponding cultural and linguistic diversity within healthcare systems. Culture and cultural backgrounds influence perceptions of health and illness, and hence it is important that cultural factors are acknowledged and integrated into clinical practice. The existing research in this area recognises the challenges in cross-cultural care encounters, primarily due to communication barriers. These challenges might impact the quality of care provided to children, raising concerns among parents and healthcare professionals about care outcomes. Cultural competence is essential for effective cross-cultural communication and for achieving equity and addressing disparities in healthcare. Cultural competence is important in paediatric care, as the cultural beliefs, values, and practices of healthcare professionals and family units shape their expectations of care relationships and the care provided to the child, ultimately influencing both the delivery and outcomes of care. The notion of cultural competence in nursing originated from Leininger's theoretical framework for transcultural nursing, emphasising the importance of understanding cultural factors in providing care.Aim: The overall objective of this thesis was to examine the experiences of culturally competent care and cross-cultural care encounters from both the parents and the healthcare professionals within Swedish paediatric hospital care. By highlighting these experiences, the intention is to contribute to a more inclusive healthcare environment and, ultimately, to promote safe, just, and equitable care for all children, regardless of cultural background.Method: This thesis is based on four studies: three qualitative (I-III) and one quantitative, cross-sectional study (IV). Semi-structured interviews have been used to collect data in the three qualitative studies. Study I employed an inductive exploratory qualitative design. Studies II and III were descriptive qualitative studies. The participants in Study I were 14 parents of Swedish ethnic background; in Study II, 12 parents from minority ethnic backgrounds; and in Study III, 21 nurses, nine of whom identified their cultural and linguistic background as being other than Swedish. Study IV was a cross-sectional study using the Cultural Competence Assessment Instrument-Swedish (CCAI-S)-to measure the perceived self-reported level of cultural competence among healthcare professionals. A total of 441 healthcare professionals participated in this study. All studies were conducted within Swedish paediatric hospital care. Qualitative content analysis was used to analyse data in Studies I and II, while Study III was analysed using the Framework approach. The data in Study IV were analysed using statistical methods. Bivariate associations were assessed through correlation analyses, independent Student's t-tests, or one-way ANOVA tests. Additionally, linear regression analyses were used to identify the factors associated with the three domains of cultural competence: openness and awareness, interaction skills, and workplace support.Results: The results indicated that Swedish parents did not feel that the ethnic background of the nurses influenced their experiences of the care provided to their child. The parents emphasised the importance of the nurses' professional knowledge, their language proficiency in Swedish, and their ability to adapt to Swedish norms and values (Study I). For parents from minority ethnic backgrounds, the cultural sensitivity of nurses and access to nurses who shared or understood their culture was important (Study II). Studies III and IV reported a high level of self-reported cultural openness, awareness, and sensitivity among participating healthcare professionals. Cultural encounters played a central role in increasing both cultural awareness and developing skills among healthcare professionals. Nurses described these encounters as fostering the recognition of personal biases and deepening the understanding of cultural differences (Study III). Healthcare professionals felt that cultural competence is primarily developed through practical experience in professional practice (Studies III practical experiences in professional contexts; and collaborative and experimental learning. Both participating healthcare professionals and parents of hospitalised children expressed satisfaction with cross-cultural care in Swedish paediatric settings, despite persistent challenges, primarily those related to language barriers. Experiences of cultural encounters, cultural competence, effective communication, and adequate organisational support were all found to be essential for providing culturally competent care and for facilitating effective cross-cultural encounters. Together, these factors might contribute to ensuring that all hospitalised children receive safe and equitable care and treatment.List of scientific papersThis thesis is based on the following studies, which are referred to in the text by Roman numerals.I. Tavallali, A G., Kabir, ZN., & Jirwe, M. (2014). Ethnic Swedish parents' experiences of minority ethnic nurses' cultural competence in Swedish paediatric care. Scandinavian Journal of Caring Sciences. 28 (2):255-63.https://doi.org/10.1111/scs.12051II. Tavallali, A G., Jirwe, M., & Kabir, ZN. (2017). Cross-cultural care encounters in paediatric care: minority ethnic parents' experiences. Scandinavian Journal of Caring Sciences. 31(1):54-62.https://doi.org/10.1111/scs.12314III. Tavallali, A G., Jirwe, M., Johansson Stark, Å., & Eckerblad, J. (2025). Nurses' experiences of cross-cultural care encounters in Swedish paediatric hospital care: A qualitative study. Journal of Pediatric Nursing. 81 (2025):74-82.https://doi.org/10.1016/j.pedn.2025.01.014IV. Tavallali, A G., Klompstra, L., Holstein, J., Johansson Stark, Å., Jirwe, M., & Eckerblad, J. Cultural competence in healthcare professionals in paediatric hospital care: A cross-sectional study. Submitted