Postawy polskich pielęgniarek wobec przedstawicieli społeczności romskiej na przykładzie województwa małopolskiego

Introduction

Public health covers numerous multidisciplinary activities that are related to various aspects of health. The World Health Organization, by defining the essential public health functions, inter alia, indicates its functions in terms of ensuring the quality of health services. The quality of health services is affected by many components, among which nursing care, including the religious and cultural values of the patient, plays an important role. It is care during which persons professionally providing help, among others, do not follow stereotypes, because following of stereotypes by nurses (often inadvertently and not necessarily associated with the intention of stigmatizing others) affects the satisfaction with care. Stereotypes particularly concern representatives of national, ethnic, or religious groups. They lead to distancing from persons from minority groups, marginalizing their position, delaying and weakening the possibilities of providing them with effective help, and sometimes consolidate their unsuitability. It is even more dangerous, as representatives of minority groups often tend to back away on their own.
The Roma are a minority inhabiting Polish lands for centuries, but such a long “neighborhood” has not contributed to their assimilation, as they remain faithful to their traditions and culture [1]. They are a minority around which many stereotypes and prejudices have accumulated in Poland [2, 3]. The centuries of rejection and persecution of the Roma have shaped specific defensive mechanisms among the population to maintain their own identity, i.e. numerous social taboos that do not allow contacts and revealing community secrets to non-Roma, and conscious cultivation of cultural and social isolation [1, 4–6]. The consequence of isolation is an insufficient level of knowledge about Roma and a different lifestyle, system of values, traditions, unwillingness to receive institutionalized education and medical care and lack of permanent professional work, causing a high level of distance towards Roma [1, 7]. The specificity of Romani culture and the Roma approach to health, illness, and therapy make them be perceived as a special group that does not want to cooperate during therapy and with which contacts result in problems. As a result of cultural, ethnic and racial stigmatization, the Roma minority experiences limitations in providing high-quality medical care. Such discrimination results from the historical socio-cultural and economic isolation of the entire European Roma diaspora and leads to a higher incidence of diseases and mortality among members of this ethnic group [8, 9]. The consequence of the lack of knowledge about the cultural diversity of the Roma, ethnic identity, social situation, as well as the deficit of cultural sensitivity to differences among nurses, is culturally maladjusted care. For the authors of the research, it was important to find out if the prejudices towards the Roma also concern nurses, and if so, to what extent. This research may be the starting point for the development of a training program for nurses, “Care of patients with different cultural backgrounds”, containing elements of anti-discrimination training based on the real needs of the respondents.

Aim of the research

The purpose of the research was to evaluate the attitudes of Polish nurses, in the example of nurses living in the Lesser Poland region (southern Poland) towards the Roma.

Material and methods

Study design

The research had a cross-sectional study nature, carried out using the method of the diagnostic survey as well as a method of estimation. The choice of cross-sectional studies was supported by the fact that they provide results in a relatively short time on a large group of respondents. The selection of the study group was purposeful. The research was carried out as a part of the statutory project Attitudes of nurses living in Małopolska towards culturally different people (K/ZDS/007098 2017-2019) conducted in Polish. Part of the statutory project results has already been published [10]. The research tools used in the studies were as follows: Bogardus’s Social Distance Scale modified and adopted by Jasińska-Kania and Staszyńska [11]; Social Dominance Orientation (SDO) by Sidanius and Pratto [12] in the adaptation of the Polish version by Klebaniuk [13]; the Social Approbation Questionnaire (KAS) – Polish version by Drwal and Wilczyńska [14]; and the authors’ questionnaire, which included questions about experience when it comes to contact with Roma, participation in training in the range of transcultural nursing, and social-demographic data.
The purpose of using the Bogardus scale was to determine to which areas of life and to what close contacts the respondents are ready to let a person of Roma origin. As modified by Jasińska-Kania and Staszyńska [11] the Bogardus scale contains 5 components – the distance in the macro-social, micro-social, private, intimate and biological sphere. On the Bogardus scale adapted for the needs of this study, it was decided to separate four components; the component distance in the macrosocial sphere (allowing other people to stay in Poland, apply for jobs and Polish citizenship) was abandoned. This was done due to the fact that Roma are a local minority living in Poland for over 600 years. Four components were used [15]: Distance in the micro-social public sphere (accepting the Other in the role of a co-worker, neighbor, boss, and a political representative at the level of local authorities). Distance in the private sphere (allowing for friendship with the Other). Distance in the intimate sphere (accepting the Other in a relationship with another member of the respondent’s family). Biological distance (consent to accept a blood transfusion from the Other). Each variable was measured on a five-point Likert scale, from strong acceptance (5 points), through indifference (3 points), to a firm opposition to the proposed situation (1 point). Thus, the higher the score on the scale of a given distance was obtained by the respondent, the more positive attitude towards Roma he had.
In the study, in order to diagnose the level of acceptance of inequalities between groups the Social Dominance Orientation (SDO) scale was used. SDO measures the level of the orientation of an individual towards social dominance – to what extent is it believed that social inequality is in some way natural and certain groups deserve more social benefits. It allows one to accurately determine attitudes towards foreign groups, especially minority ones. It is, therefore, a good instrument to assess xenophobic, authoritarian and racist attitudes [16]. The authors of the SDO divided it into 3 subscales: violence; oppressiveness and anti-egalitarianism. The scale consists of 16 statements to which the respondents respond on a five-point Likert scale (from 5 = strong consent to 1 = strong negation for items 1–8; for items 9–16 (anti-egalitarianism subscale) – from 1 = strong consent to 5 = strong negation). Assuming that the results of the scale of attitudes may be influenced by a tendency to deliberately or unconsciously presenting in a favorable or unfavorable light, the KAS was used in the study. KAS is designed to measure the need for approval, understood as a personality trait and as a tendency to present oneself in a falsely favorable light. The questionnaire consists of 29 statements that require the respondent to answer “true” or “false”, describing behaviors and traits with explicit social approval or disapproval [14].

Setting and sample

The studies were carried out in the year 2018 among professionally active nurses working in various positions and in various hospital departments. The questionnaires were distributed among nurses working in hospitals in 15 powiats of the Lesser Poland Voivodeship (in Bochnia, Brzesko, Chrzanów, Dąbrowa Tarnowska, Gorlice, Kraków, Limanowa, Nowy Sącz, Nowy Targ, Sucha Beskidzka, Olkusz, Proszowice, Tarnów, Wadowice, Zakopane). A total of 2,778 questionnaires were distributed, 1,794 questionnaires were received back (survey response rate 64.57%), of which 1,621 questionnaires were fully completed. The analysis of KAS (Cronbach’s  for the presented study = 0.772) allowed us to identify 350 persons with a tendency to simulate or dissimulation that could affect the falsification of the Bogardus Scale results. It was decided to exclude these respondents from further analyses. Thus, 1,271 people were included in the analysis of data.

Ethical Consideration

The study was approved by the Bioethics Committee – approval No. 1072.6120.196.2017 of November 30, 2017.

Data analyses

The analysis of quantitative variables was carried out by calculating the mean, standard deviation, median, quartiles, minimum and maximum. The analysis of qualitative variables was carried out by calculating the number and percentage of occurrences of each value. The comparison of distance to Roma was made by ANOVA analysis with repeated measurements or Friedman’s test. Correlations between social distance and quantitative variables were analyzed using the Pearson (when both had a normal distribution) or Spearman (otherwise) correlation coefficient. The strength of the dependence was interpreted according to the following scheme: |r| ≥ 0.9 – very strong dependence; 0.7 ≤ |r| < 0.9 – strong dependence; 0.5 ≤ |r| < 0.7 – medium strong dependence; 0.3 ≤ |r| < 0.5 – weak dependence; |r| < 0.3 – very weak dependence (negligible). Interpretation scheme after: Hinkle et al. [17]. The normality of distribution of variables was examined using the Shapiro-Wilk test. The significance level for the analysis was equal to 0.05. The analysis was carried out in the R program, version 3.5.1. [18]. For the purpose of analysis and strengthen the credibility of the conducted research, the Cronbach’s  level was specified in all the tools.

Results

Sample characteristics

The majority of respondents were women (96.70%), the age of respondents ranged from 21 to 75 years, the average age was 46.13 ±10.09 (Me 49). Work experience in the profession ranged from one to 53 years, average 23.68 ±11.31 (Me 27). Most often, the respondents had a secondary vocational education (43.04%), followed by a higher undergraduate (39.18%) and higher master’s degree (16.68%), 1.1% of respondents did not answer the question about education. 16.44% of respondents had the specialization in nursing. Transcultural nursing training was reported by 15.50% of respondents. Most often the income of the respondents per family member was between 1000 and 2000 PLN (45.00%), then above 2,000 PLN (36.74%) and below 1,000 PLN (12.20%). Only 6.06% did not respond to that question. Almost half of the respondents lived in the countryside (49.17%), 28.09% of respondents lived in cities with up to 20,000 citizens and 20.54% of respondents lived in cities with over 20,000 citizens. Only 2.2% of respondents did not answer that question. In the past, 12.43% of respondents had lived abroad, of which only 2.36% worked there as a nurse. The vast majority of the respondents were Catholics (92.29%), while only 0.55% of respondents (Protestants, Orthodox, Muslim, Greek Catholic) declared another religious affiliation. Atheists accounted for 1.34% of the study group, and 5.82% did not answer that question. Most often, the respondents referred to religion as “moderate believers” (55.31%), then “deeply believing” (36.74%), “difficult to say” (6.45%), and no answer (1.49%). Believers in religious practices participated most often (60.11%) once a week, 21.95% participated less often than once a week, 15.97% participated a few times a week, and 1.97% did not answer.

Bogardus Scale analysis

The modified version of the Bogardus Scale used in the study turned out to be a tool characterized by high reliability – Cronbach’s  = 0.952. The obtained data showed that the respondents obtained results (mean ± SD: 2.69 ±1.04, Me 2.8, Q 2–3.4) slightly below the middle point of the scale (3), which indicates a slight predominance of neutral and negative reactions over positive ones. Analyzing individual subscales of the scale, it turned out that respondents declared the greatest distance towards the Roma in the Intimate distance subscale (mean ± SD 2.45 ±1.24; Me 2; Q 1 3), followed by Public distance micro (mean ± SD; 2.51 ±1.11; Me 2.5; Q 1.5–3), Private distance (mean ± SD: 2.81 ±1.26; Me 3; Q 2–4), and the smallest in the subscale Biological distance (mean ± SD: 3.05 ±1.38, Me 3, Q 2–4). As a detailed analysis of the questions shows, the most approval (40.99%), and at the same time the least opposition (32.73%) from the respondents, was expressed for a situation in which they would receive a blood transfusion from Roma and would become their friend (acceptance 30.45%, opposition 37.92%). The lowest indication of approval was given to the situation in which a Roma would be elected to local authorities (16.60%) and be their superior (19.04%); similarly, they were the most common disapproval indications (56.64%, 52.24%). For a little more than half (50.59%) of respondents it would be difficult to accept a situation in which someone from their immediate family would become a Roma spouse and then in order, a Roma: would become their nearest neighbor (45.16%); would be their co-worker (39.26%) (Table 1). It is surprising that respondents more willingly allow friendship with a Roma than they would see him in the role of a neighbor, boss and political representative (Table 1).

Social Dominance Orientation analysis

In the present study, SDO proved to be a reliable research tool (Cronbach’s  for subscales: violence 0.701, oppressiveness 0.772, anti-egalitarianism 0.898). The respondents in all three subscales obtained average results below the middle point of the scale (3), indicating a low level of violence (mean: 1.82), oppressiveness (mean: 2.46) and anti-egalitarianism (mean: 2.24). In the violence subscale, 85.75% of respondents obtained average results below the middle point of the scale, and 5.43% above that point, in the oppressive subscale 69.28% below the middle point of the scale, 19.62% above that point, and in the anti-egalitarianism scale below the center point of the scale 83.04%, and above 10.30%. Statistical analysis showed that there is a relationship between SDO and the modified Bogardus Scale. All SDO subscales correlated significantly and negatively with attitudes towards Roma (p < 0.05); the greater the orientation towards violence, orientation towards oppressiveness, and orientation towards anti-egalitarianism, the greater the social distance towards the Roma (Table 2). The analysis of the impact of selected variables on attitudes towards the Roma showed that attitudes significantly correlate (p < 0.05) with: frequency of contact (the more frequent contact with Roma, the smaller the social distance); participation in religious practices (persons participating in religious practices less frequently than once a week had a smaller distance towards Roma than people who participated in such practices once or several times a week); the deepness of faith (the deeper the feeling of faith, the greater the distance towards the Roma; non-believers and those responding “hard to say” had a slightly smaller distance towards the Roma than those who were “moderate” and “deep” believers); education (the higher education, the smaller the social distance); place of residence (people from cities with over 20,000 inhabitants had a smaller social distance towards Roma than people from the countryside); income per family member (the higher the income, the smaller the social distance); care (in the past or at the moment) for a person of Roma origin (people who had such experiences had a smaller social distance towards Roma); training in transcultural nursing (people who had such training had a smaller distance towards the Roma). The level of social distance did not significantly correlate with: age, job seniority, living in another country, specialization in nursing, work in another country, participation in cultural events, gender or confession of respondents (however, the results should be approached cautiously, because the study took participation of only 32 men and only 17 atheists and 7 followers of non-Catholic religions).

Discussion

The studied group of nurses well represents the population of nurses in Poland, where the average age is 50.79 years (in our research 46.13 ±10.09 years), the majority are women 97.93% (in our research 96.7%), the specialization rate is 13.69% (in our research 16.44%), and they most often have secondary vocational education [19]. The majority of respondents were Catholics (92.29%), in the National Census of 2011 [20]. 87.7% of Polish society declared being Catholic. Therefore, it can be presumed that the results of the social distance of nurses from Lesser Poland voivodeship towards Roma will also apply to nurses in Poland. In recent years, there has been an increase of interest in the subject of cultural competence in medicine. It is important to mention many articles that make a significant contribution to knowledge on this subject, unfortunately, unrelated to the attitudes of health care workers/nurses to Roma. In order to search for the results of other researchers, three reference databases were introduced (without time limit): MEDLINE – PubMed, Scopus, and Google Scholar keywords: nurses, attitudes, Roma, Gypsies, social distance, dominance orientation. The titles and abstracts were checked, revealing many articles regarding Roma attitudes and views regarding medical care and therapeutic methods; Roma traditions, customs and identity; Roma traditional methods of treatment; relation to preventive vaccinations, contraception, reproduction; Roma access to healthcare, health insurance; indications for culturally sensitive care for the Roma; problems in the care and communication with Roma; nurses’ knowledge about the care of Roma, etc. Only two articles by G. Francis met the search criteria and referred to the issue of attitudes of nurses towards people of Romani origin. Unfortunately, the articles do not show what attitudes the respondents showed towards health care workers (including nurses) from the United Kingdom, and were focused on methods to overcome the negative attitudes and benefits that it can bring in the care of patients with Roma origin [21], and supporting the development of cultural competences in health professionals working with Romani travelers [22].
One article by Belak et al. [23] shows discriminatory practices by healthcare professionals from Slovakia (including nurses) towards the Romani. One qualitative study by Heaslip et al. [24] conducted among 23 nursing students in the UK, Spain, Belgium, and Turkey shows their negative perception of the Romani. Furthermore, there were 3 articles revealing negative attitudes, prejudices and stereotypes towards Romani functioning among healthcare workers (but not nurses) in Greece, Slovakia and Hungary [25–27]. Due to the inability of comparisons of attitudes of Polish nurses with attitudes towards Roma people of nurses of other nationalities, it was decided to compare the results obtained with CBOS surveys from the year of 2008 [7] and the year of 2017 carried out on a representative random sample of adult residents of Poland. This comparison will make it possible to deduce whether the occupational group of nurses differs in terms of attitudes towards Roma from the Polish society. The limitation of this comparison is the fact that the CBOS surveys were conducted using a different methodology. The CBOS Survey from 2008 was conducted with a questionnaire containing 6 statements concerning Roma, to which the respondent was assigned points from a 5-point Likert scale (none of the statements was identical to the Bogardus scale questions); therefore we can only refer to its final result. In our study, the surveyed nurses achieved a general score of the Bogardus Scale below its middle point (2.69), while the Poles surveyed by the CBOS score achieved a score not much above the middle point of the scale (3.11). This may indicate a less favorable attitude of nurses towards the Roma than in the general population of Polish society; however, due to the above-described restrictions, this result should be treated with caution. However, like in the presented studies, also in the CBOS surveys from 2008, the respondents with higher education and declaring that they personally know or knew a person of the Roma nationality usually had a more favorable attitude towards them (although the differences were not significant). In the CBOS surveys from 2017 [28], Poles were asked about the attitude towards 22 nations and ethnic groups. According to this study, the Roma were a group which (along with the Arabs) had the least sympathy of Poles, and at the same time, the most Poles stated that they dislike them. Reluctance towards the Roma was expressed three times more often than sympathy (57% vs. 17%). The analysis of the answers of the respondents in the present study of nurses also indicated an advantage of negative feelings towards approval (39.73% vs. 25.64%), although not as significant as in the CBOS surveys. The Bogardus Scale (a modified version of which was used in the study) is a cumulative scale, which means that the respondent is asked questions that should cause more and more resistance. The one who gives an affirmative answer to the last question is characterized by the highest level of tolerance and is likely to answer the other questions affirmatively [15]. However, in this study, these predictions have not been confirmed. The respondents most often would not mind that Roma blood (consent for transfusion) would flow in their veins and that he would become their friend, but in the slightest degree would approve of the situation in which a Roma would be their representative in local authorities and the superior at work. The authors of such a study result see in the stereotypical perception of Roma in Polish society as people with lower intellectual or organizational abilities. Negative attitudes towards the Romani do not concern only Polish society – according to the Pew Research Center, unfavorable views of the Roma people are widespread in Central and Eastern Europe (they were rated worst in Italy, best in Sweden, while Poland was in the middle of the scale) [29]. This is also demonstrated by reports from Italy [30, 31], Spain [32], Hungary, Slovakia [33], the UK [34], England, Scotland, Wales and Northern Ireland [35].
The main limitations of the cross-sectional study included the inability to determine the cause and effect relationships and the risk of error (memory error). Only the fact of the existence of dependence between the variables studied and the attitudes of nurses was determined. Another limitation is the fact that the study took place in only one voivodeship of Poland, so the obtained results may not apply to the whole country. This study provides evidence that the training in transcultural nursing significantly influences the formation of positive attitudes towards Roma. The results of the research can be used to initiate actions that change the attitudes of nurses towards Roma, for example to develop a training program for nurses: “Care of patients with different cultural backgrounds”. Such preparation is necessary to practice the nursing profession in a global society. These results can also be used during the selection of training institutions for practical classes for students. The choice of such facilities should be determined, among other factors, by the attitudes toward Others presented by nurses who act as role models for students to imitate. Nurses with positive attitudes toward Others will likely exercise culturally sensitive care.

Conclusions

The respondents obtained results just below the middle point of the modified Bogardus scale, which indicates a small advantage of neutral and negative attitudes towards the Roma over positive ones. The respondents declared the greatest distance towards the Roma in the Intimate distance subscale, and the smallest in the Biological distance subscale. There was a significant dependence of the level of the social distance of the respondents from place of residence, education, income, frequency of contact, care for a person of Roma origin, participation in religious practices, sense of faith, and improvement in transcultural nursing. The relationship between SDO and the modified Bogardus Scale has been demonstrated. All SDO subscales correlated significantly and negatively with the Bogardus scale. The results of the research indicate the need to train nurses in the field of transcultural nursing and health promotion in Roma society.

Acknowledgments

The authors thank the nurses who took part in this study, for their patience answering questionnaires.

Conflict of interest

The authors declare no conflict of interest.