TRANSCULTURAL NURSING ANALYSIS IN THE CONCEPT OF HEALTH TOURISM : A Literature Review

Background : Health tourism is a topic that is starting to be looked at in various parts of the world. The increase in the expectations of health tourists for the quality of health services certainly also has an impact on increasingly quality nursing care services for various clients from abroad. Nurses are required to handle the increasing number of visitors and migrants from abroad due to this globalization. This certainly has an impact on cultural factors which are a very important component of nursing competence where nurses are increasingly required to be able to carry out appropriate and appropriate nursing care to clients of foreign nationals. This study aims to describe health tourism and transcultural nursing concepts from the perspective of nurses and to find out how they interpret them. Methods : This literature uses inclusion and exclusion criteria using article data sources obtained and reviewed from the Google Scholar, PubMed and Willley Library databases. Results : The score obtained on the nurse's cultural sensitivity scale is a low average, cultural sensitivity also has no correlation with gender, marital status, age, educational level, professional title and background of transcultural nursing training. The cultural competency scores were significantly higher due to work experience treating foreign patients. Conclusion : Lack of language knowledge and experience of foreign cultures is an obstacle for nurses in caring for foreign patients. Improving foreign language skills, skills and work experience treating foreign patients is absolutely necessary in the context of meeting the needs for health tourism services.


INTRODUCTION
Over the past decades people have traveled from their home country to other countries to obtain or protect their health (Çalışkan, 2009).Travel for this purpose is known as health tourism which is described as traveling from the country of origin to another country with the intention of obtaining health protection and health promotion which includes disease treatment and rehabilitation services.Health tourism began to experience sustained growth since the early 1990s and has become a significant contributor to the healthcare industry.The existence of quality care services with international standard safety standards is the target of tourists who want the best health care.Patients' expectations are no longer limited to diagnosis and treatment but also to the care services they receive while in the hospital.Patients who decide to take health tourism are generally patients with good knowledge and are also at the economic class level, as well as their ability to consider and see health services from various perspectives of the needs and expectations they want.
The concept of transcultural nursing has the goal of obtaining culturally congruent care which is defined as nursing actions or decision making according to culture and specifically tailored to the needs of clients in order to improve or maintain their health and well-being (Leininger 2002in Ping Zou 2016).Leininger assumes nursing as a profession that also determines cultural harmony with health services both in concept (George & Yulia 1990, in Nursalam 2015).In other words, nurses have an obligation to have cultural competence outside their own culture.and also required to be able to integrate knowledge, skills, attitudes and values as a whole.So that the cultural competence of nurses can be seen and felt through the attitudes, knowledge, and skills of nurses in providing quality nursing care to clients with diverse cultures.Cultural competence in nursing is also defined as the competence to respect the client's culture by providing effective care from the perspective of medical and nursing culture, as well as between the nurse's culture and the client's culture, so that this encourages the need for cultural competence in health care.According to previous researchers Biyikli (2020), stated that within the scope of health tourism, nurses must have some knowledge and cultural skills in order to provide appropriate and adequate care to people who wish to receive health services from other countries.
There is a dearth of research, literature and a lack of clarity between concepts related to health tourism, raising questions about how nurses explain this transcultural concept in relation to health tourism.

METHODS
The method used in this paper is a literature review study using article data sources obtained and reviewed from the Google Scholar, PubMed and Willley Library databases.Search for articles by collecting the theme of the concept of health tourism associated with transcultural nursing.Restrictions on the search for articles taken are in the range of 2011 to 2021.The search results found 10 journals, after a simple analysis of titles and abstracts, only three articles matched the inclusion criteria.

RESULTS
Based on the results of various studies from the literature studies obtained, the results of the nurse's cultural sensitivity scale score are in the range of 81.39 ± 4.84 which is below the average value.The Spearman Rho test results were used to assess the relationship between nurses' cultural sensitivity scale scores and nurses' socio-demographic characteristics.The results obtained show that the score on the cultural sensitivity scale of nurses is not significantly correlated with gender, marital status, age, level of education or professional title.
The results of a qualitative study of 16 nurses with the theme of health tourism, transcultural nursing and the experience of nurses in providing nursing care to foreign patients, obtained the results of 5 respondents when asked about the concept of health tourism saying that nursing care needs to be emphasized on the concept of roles and responsibilities of nurses in the context of tourism Health.Even if nursing care is one of the main roles of nurses, participants mentioned that the role of nurses cannot be limited to nursing care and is very important for professional advancement and personal development for quality improvement in nursing care.In the second theme about transcultural nursing, on average, almost all respondents gave the same answer both directly and indirectly about the difficulties of providing nursing care to foreign patients and emphasizing the importance of knowing foreign languages.They stated that their biggest challenge when providing nursing care to foreign patients was the language problem.Knowing a foreign language is not only needed to understand patients, to improve the quality of nursing care, it is also necessary to improve the growth of the personal and professional qualities of the nurses themselves.Based on the experience of nurses, most of them have communication problems and cultural differences when treating foreign patients.Knowledge, skills, positive attitude and awareness are some of the components of communication and are especially important when interacting with people from different cultures.The results show that most of the respondents face language and communication difficulties when treating foreign patients.They try to use alternative ways of communication such as using pictures, internet translators, and body language to overcome language difficulties.Subsequent research on the comparison of cultural competence status of nurses in Thailand and Japan.An educational need that requires further improvement for the care of foreign patients is language assistance.Both groups thought that communication was difficult when nurses and patients spoke different languages.Another problem is cultural education and nursing care related to patient life in hospitals such as hygiene, nutrition, and rest.Nurses also consider culture.In Thailand, many patients come from different ethnicities, so the overall score of cultural competency is significantly higher for nurses in Thailand than nurses in Japan.This could be caused by Thai nurses having experience in treating foreign patients compared to nurses in Japan.In respondents aged > 50 years between the two groups of Thai and Japanese nurses who had a lot of experience treating foreign patients as criteria, it was found that both had a significantly high cultural score.Educated nurses having a high level of culturally specific knowledge of transcultural nursing and also related information about situation knowledge in the patient's country obtained high scores in both groups of Thai and Japanese nurses.

DISCUSSION
Qualitatively, participants considered that nurses have an important role in health tourism, apart from being frontline officers they are also very necessary as a bridge between patients and doctors.Participants also mentioned the importance of nursing care, skills in communication, and the importance of fostering therapeutic relationships so as to be able to convince patients who are interested in doing health tourism as part of the roles and responsibilities of nursing.
Quantitatively, the level of cultural sensitivity of the participants was below average.In addition, other findings show that nurses who do not have transcultural nursing education greatly affect the ability of nurses to care for foreign patients.For nurses, knowledge is as important as foreign languages, so that by mastering these two competencies, nurses can take an effective and appropriate attitude to treat patients in the context of health tourism.So that as a solution in the future, the concept of transcultural nursing, foreign languages such as English as well as several foreign languages, the concept of ethics and geography can be of particular concern to be added to the nursing education curriculum, so that it is hoped that the results will be graduates who are competent in caring for multicultural patients.and useless to compete in the tourism context.In addition, an equally important component of nursing care is transcultural nursing training which will move the nursing profession and the quality of nursing care to become more advanced and able to compete in health tourism.The experience of nurses in overcoming language difficulties using the help of translators remains very risky and can increase misunderstandings between nurses and clients where translators are required to convey the meaning of spoken language in a complete and systematic manner, but in reality in the concept of nursing communication it is not just an interpretation of spoken language and delivery of verbal messages, Al-Amer et al. (2016).
Nurses' cultural competence can be developed by offering multicultural nursing education, enhancing multicultural experiences both directly and indirectly, as well as sharing problem-solving experiences to enhance nurses' experience and coping abilities.Therefore, nursing education has a major role in terms of developing capabilities related to cultural competence in nursing.

CONCLUSIONS
Nurses must improve their foreign language skills and knowledge of transcultural nursing.The existence of the phenomenon of health tourism and the provision of nursing care to foreign patients is not only a challenge for nurses but also offers many opportunities, because knowing different cultures and languages can motivate the personal and professional development of nurses.The quality of nursing care will increase patient satisfaction and the demand for health care will not only be limited to the domestic market but also abroad.It is estimated that nurses who are able to communicate in foreign languages and have cultural competence will make an extraordinary contribution to health tourism, where it will also encourage the nursing profession to become more professional in providing nursing services.Apart from language, it is also necessary for nurses to improve other professional skills such as ethical skills, the ability to provide intercultural nursing care and also supporting knowledge such as geography.
Increasing knowledge about culture for nurses in the context of transcultural nursing is very necessary in relation to the concept of health tourism.Likewise with increasing foreign language skills which are absolutely necessary, and finally is increasing the skills and experience of nurses in caring for foreign clients.This can be pursued starting from the world of education to increase knowledge and learning about transcultural nursing as well as increasing mastery of foreign languages.