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Nursing Care Experiences With Syrian Refugees in Southern Turkey: A Metaphor Analysis

ABSTRACT Background Healthcare professionals' “cultural prejudices” toward individuals' cultural beliefs, attitudes, and perceptions affect the care they provide. Their awareness of their bias is closely associated with the quality of healthcare provided. Purpose This study was designed to assess nurses' perceptions regarding providing care to Syrian refugee patients using metaphors and to evaluate their views based on these metaphors. Methods The participants in this qualitative study consisted of 80 nurses who worked in Level 1 and Level 2 health institutions. Data were collected using an interview form prepared by the researchers. The form included descriptive characteristics of the nurses and two expressions used to determine the nurses' opinions on providing care for Syrian refugee patients. The nurses were given an incomplete sentence, which was “Providing care for a Syrian refugee patient…because…,” and were asked to complete the blanks. The data were analyzed using the content analysis method. Results On the basis of “providing care for Syrian refugee patients,” four categories of metaphors were determined: occupational awareness, health promotion, a difficult process/resistance, and providing service in vain. The participants generated 50 metaphors, with “humanity,” “a baby/little child,” and “a barrier” as the three most used metaphors, belonging to the “occupational awareness” and “a difficult process/resistance” categories, respectively. Conclusions/Implications for Practice The metaphors of nurses regarding giving care to Syrian refugee patients were mostly concentrated in the categories of “occupational awareness” and “a difficult process/resistance.” Metaphors generated by the nurses offer a powerful research tool to reveal, understand, and explain nurses' personal perceptions and to develop and support nursing care accordingly. In addition, the subject of transcultural nursing should be discussed more extensively in nursing education programs. Understanding the social context of refugees is very important during the nursing care process.


Introduction
The phenomenon of immigration is defined as the settlement of people to new locations by leaving their own places of living in the hope of getting employment and better working conditions (Assi et al., 2019). This situation has become a large-scale issue because of political, economic, military, social, and cultural factors (Andrews, 2016;Assi et al., 2019;Peters, 2015). Displacement because of a war is undoubtedly the worst form of migration and is accompanied by the concept of asylum seeker/refugee. A refuge is defined as a person who has been forced to leave his or her country and who cannot or does not want to return because of fear. Turkey is now the largest host country of registered refugees. According to the records of the Disaster and Emergency Management Presidency, 270,000 refugees reside in 25 camps in 10 border cities, with 10 times more living in cities such as Şanlıurfa, Hatay, Gaziantep, and Kahramanmaraş (Disaster and Emergency Management Presidency, 2017). On the basis of the records of the Directorate General of Migration Management in 2020, Istanbul is the city hosting the largest number of Syrian refugees (557,708). Kahramanmaraş, where this study was conducted, currently hosts 93,609 Syrian refugees. Being a metropolitan city within the scope of this study, being open to refugee transfers from other camps in the provinces in the region (Ministry of Interior, Directorate General of Migration Management, 2020), and the fact that the researchers know the province and the regional conditions well were all determinative factors for conducting this study in this province. The civil war in Syria, ongoing since 2010, has caused millions of people to leave their homeland and initiated substantial population movement. Immigration began in 2011 with Turkey's "Open Door" policy, and 3,632,622 Syrian refugees had migrated to Turkey by January 2020 (Ministry of Interior, Directorate General of Migration Management, 2020).
The immigration of Syrian refugees has affected the population, socioeconomic structure, and cultural dynamics of all recipient countries, including Turkey (Ekmekci, 2017). Apart from these problems, Syrian refugees experience very serious health problems, and they may change health service priorities in their host society (Savaş et al., 2016). Infectious diseases, especially seen in Syrian refugee children, pose a threat to infections and carry the risk of becoming an epidemic (Eiset & Wejse, 2017;İkram et al., 2016). At the same time, it is the responsibility of the healthcare team, especially nurses, to meet the emergency/surgical intervention, physical care, and psychiatric care needs of refugees for injuries received in the war zone (Kallakorpi et al., 2019;Willey et al., 2018). Providing high-quality care using effective time management is a priority in the face of increasing demand for healthcare services. On the basis of this point of view, this article was developed to allow nurses to express their experiences and difficulties in providing care to individuals from different cultures using a metaphor framework.
It is an ethical obligation to protect the citizenship and healthcare rights of vulnerable (sensitive) groups of people coming to Turkey and to other countries and regions. Refugees are generally vulnerable to not receiving health services because of financial insufficiency, lack of health insurance, and not knowing the language/customs of their host country. In addition, cultural differences may negatively affect individuals' access to health services (Ministry of Interior, Directorate General of Migration Management, 2020). Therefore, vulnerable groups of refugees are poorly integrated into the healthcare system of their destination country. Nurses may be the first to recognize public health problems that may be experienced during the migration process in the health system and to plan initiatives to address these problems. As nurses regularly provide care to refugees and victims of war in politically unstable regions across the world (Andrews, 2016), they must understand the culture of individuals/patients to provide holistic care. As Leininger emphasized in her "Theory of Culture Care: Diversity and Universality," healthcare professionals' "cultural prejudices" toward individuals' cultural beliefs, attitudes, and perceptions affect the care they provide. Moreover, their level of selfawareness of their own biases is closely associated with the quality of healthcare provided. In particular, nurses serve as a bridge in providing individuals with holistic care (Alligoog & Tomey, 2006;Andrews, 2016;Maier-Lorentz, 2008). Nurses have stated that beliefs and attitudes related to diseases and healthcare vary across different societies and that they may encounter problems in communicating with patients from different cultures while providing care (Yaman-Aktas et al., 2016). Studies on this subject have highlighted factors such as difficulty in communication, misunderstanding, and difficulties in providing care to different genders (Alshammari et al., 2019;Kaspar & Reddy, 2017). Thus, cultural differences between caregivers and care recipients affect quality of care.
Examining the cultural perspectives of nurses working in Turkey, which hosts more refugees from different cultures than other countries, is important to ensure they provide refugees with high-quality care. Language, tradition, mentality, and mindset, all of which relate to cultural perspective, affect nurses' perception and awareness of individuals from different cultures (Wehbe-Alamah, 2018). On the other hand, these factors may also make it difficult for nurses to care for these individuals. Furthermore, healthcare services provided without knowing the cultural perspectives of these individuals may fail to consider and accurately address existing and possible health problems. In addition, the care needs of refugees in Turkey, changing patient type, and ongoing waves of migration may lead to insufficiencies and problems in the healthcare provided (Aloğlu et al., 2017;Assi et al., 2019). Many quantitative and qualitative studies in the domestic (Karadag et al., 2018;Savaş et al., 2016;Sevinç, 2018) and international (Fair et al., 2018;Ogunsiji et al., 2018;Willey et al., 2018) literature have been conducted to investigate difficulties experienced in caring for individuals from different cultures. However, no qualitative study in which data specific to the field of nursing were analyzed using content analysis was found. Qualitative studies focus on situations of which individuals are aware but lack indepth and detailed knowledge (Cohen & Crabtree, 2008). The purpose of studies using the metaphor method in a qualitative research design is to describe the different methods that people use to experience, interpret, understand, or conceptualize an aspect of a certain reality (Cohen & Crabtree, 2008;Trainor & Graue, 2013). "Metaphoric perceptions" is one method of expressing the self-perceived difficulties of nurses in providing care for refugees to create a cognitive scheme in the minds of nurses. In other words, a metaphor is the picture of a problem that an individual has experienced. Metaphors (Trainor & Graue, 2013) that allow one to develop insight about unknown facts with this created scheme/picture can affect individuals' actions that are performed in the real world and that subsequently shape their perceptions, beliefs, attitudes, and thoughts (McGrath, 2006).
On the basis of the above, the metaphorical perceptions of nurses working in Level 1 and Level 2 health institutions were determined in this study with regard to the issue of "providing care for Syrian refugee patients." The goal was to answer the following question: "What metaphors are expressed by nurses with regard to providing care to Syrian refugee patients?"

Study Type, Participants, and Settings
A qualitative research design was used in this study, and data were collected between March and May 2018. Because health services for Syrian refugees are free, patients prefer The Journal of Nursing Research Nurcan Akgül- Gündoğdu et al. to present to Level 1 and Level 2 health institutions in their districts of residence (Gültaç & Yalçın-Balçık, 2018). Thus, nurses currently working in Level 1 (five family health centers [FHCs]) or Level 2 (one state hospital in Kahramanmaraş city center) health institutions were recruited as participants. Ninety-two nurses were enrolled as participants, and data from 80 were analyzed. The study group was selected using a purposeful sampling method.

Data Collection
Data were collected using a form prepared by the researchers. The form included questions about descriptive features of the participants (nine questions) and one sentence that included a metaphor (in accordance with the metaphor question pattern). The participants (n = 80) completed the self-report data collection form individually in the nursing room. The form took 25-30 minutes to complete. The descriptive form included questions about participants' sociodemographic characteristics such as age, gender, nursing experience, and work unit (clinics/units). After the participants answered the questions about their sociodemographic characteristics, they were given the incomplete sentence "Providing care for a Syrian refugee patient…because …" (metaphor question pattern) and asked to fill in the blanks in this sentence with a metaphoric expression. In studies using metaphors as a research tool (Chan et al., 2018;Delaney et al., 2020;Kaya et al., 2013), the word or concept used for similarity is often used to more clearly associate the link between the subject and the source of the metaphor. The participants were informed about the concept of metaphors and given an example. They were asked to express a metaphor regarding their perception of Syrian patients and about providing care to them in the first blank, and then they were asked to form metaphors along with a rationale in the second blank (after "because"). Metaphors are frequently used in qualitative studies because of their convenience in facilitating coping with highly diverse research data (ease of creating categories), establishing a connection among data, and presenting the data to the reader (Elo et al., 2014).

Ethical Considerations
For this study, approvals from the Ethics Committee of Kahramanmaraş Sütçü İmam University Faculty of Medicine (No. 2017/12) and the directorate of the institutions where the study was conducted were obtained. After the participants were informed about the purpose of the study, the informed consent form was read to them and they gave their verbal consent. Participants were asked not to write their names on the questionnaires to ensure their privacy.

Data Analysis
Ninety-two nurses enrolled to participate in the study. However, 12 of these were excluded for the following reasons: Five did not reply to the questions properly, and seven did not complete the sentences or left questions unanswered. Thus, the study was conducted using the data and metaphors from 80 participants. The sociodemographic characteristics were analyzed using SPSS software Version 18.0 (SPSS, Inc., Chicago, IL, USA), and numbers and percentages were used to present statistical data. The qualitative data were analyzed manually, and the documents were reviewed until data saturation was achieved (Braun & Clarke, 2021;Guest et al., 2020). The content analysis method was used in the analysis of the data obtained in accordance with the qualitative research design. The main purpose of content analysis is to reach the concepts and relationships through which the collected data may be explained. In this process, data are subjected to in-depth analysis, and the concepts and themes related to the subject being studied are identified. The data that are similar to each other are gathered in a logical way, clearly arranged, and interpreted (Elo et al., 2014). Metaphors described by the participants were analyzed and interpreted at five stages: identification, elimination, compilation and rearrangement, categorization, and validity and reliability.

Stage 1: Identification of metaphors
In this stage, metaphors related to "providing care for Syrian refugee patients" were sorted alphabetically, and a temporary list was created. This list determined whether the participants were able to describe a metaphor clearly. Then, the metaphors were written on a piece of paper (e.g., migrating birds, injured bird).

Stage 2: Elimination
In this stage, each metaphor was analyzed using the content analysis method and evaluated along with other metaphors in terms of analogies. Each metaphor described by the participants was reviewed and read individually. In addition, each metaphorical expression was analyzed in terms of the source and subject of the metaphor. The metaphors were classified under four basic criteria.
Twelve forms, including statements in which only analogies were drawn or the metaphor source was not included (n = 7) or metaphors that did not make sense or did not contribute to better understanding of the concept of "providing care for Syrian refugee patients" (n = 5), were excluded. The response sheets excluded by the researchers did not include statements that served the purpose of the study.

Stage 3: Compilation and rearrangement
After the elimination stage, 48 metaphors on "providing care for Syrian refugee patients" were identified. These metaphors were re-sorted in alphabetical order. Each metaphorical item was reviewed, a sample metaphorical expression was selected from expressions representing the metaphors, and a list of metaphors was prepared. These are shown using the participants' direct quotations in their original form (italicized and in quotation marks) in the Results section. Moreover, privacy was observed, and the quotations were written with explanatory abbreviations at the end of the sentences showing the person from whom they were quoted. For example, in the explanatory expression "P1-State-F," "P1" indicates Participant 1 (source person and number), "State" indicates where the nurse works (e.g., a state hospital), and "F" indicates the nurse's gender (e.g., female).

Stage 4: Categorization
In this stage, the metaphors (i.e., the words filled in the first blank) were listed and grouped, and the reasons (i.e., the words filled in the second blank) were categorized. The metaphorical expressions obtained based on "providing care for Syrian refugee patients" were separated into four categories, and a specific code was given (i.e., the source person) for each. Afterward, the codes were turned into conceptual headings. The categories were created based on the basic concepts (human, environment, health/illness, and nursing) involved in the nursing care process (Alligoog & Tomey, 2006).
The four categories related to the concept of "providing care for Syrian refugee patients" are following. 1. Occupational awareness: Giving care to Syrian refugees without discrimination, being compassionate/protective, and giving priority to human lives, equality, and humanity. 2. Health promotion: Restoring health, helping/being in need, achievement in overall health, a caregiving period requiring patience, meeting needs, and giving help. 3. A difficult process/resistance: Language barriers, having difficulty because of culture and language problems, and an infectious disease. 4. Providing service in vain: Being disturbed, making an effort in vain/providing service in vain/making an effort with no return.
In addition, it should be noted that the obtained metaphors allowed associations to be made between the categories formed within the framework of the basic concepts of "human, environment, health/illness, and nursing" (Alligoog & Tomey, 2006). In fact, the holistic view also allows meaning to be found in the nature of nursing care. In other words, nurses can plan the care they provide to a refugee patient and form metaphors in their mind within the framework of certain categories. They can provide qualified care that addresses the physical, psychological, social, and cultural dimensions along with one-or two-way transitions between categories.
Stage 5: Ensuring validity and reliability One of the most important criticisms in qualitative studies is the validity and reliability problem. First, achieving validity, or plausibility, in qualitative studies is important. The fact that a researcher reports the collected data in detail and explains how they obtained the results is a significant criterion in achieving validity in a study (Trainor & Graue, 2013). Therefore, how the data were analyzed in this study was explained in detail in the Methods section. In addition, the way the categories related to the metaphors was determined, and the rationales of the metaphors were also comprehensively explained.
All three of the researchers worked in harmony from the beginning to ensure the reliability of the study, and they reached consensus when conflicts occurred. The first author primarily coded data independently. Afterward, the other authors reviewed the analyses such as whether the codes were consistent with each other and belonged to each category. Then, the metaphors were categorized and finalized. To confirm whether the metaphors under the four categories represented the relevant conceptual category in terms of "providing care for the Syrian refugee patient," an expert opinion was obtained from an associate professor in the Department of Assessment and Evaluation. The opinions of the expert and researchers were checked for equivalency. For all of the comparisons, the number of disagreements and agreements was determined and the internal reliability of the study was calculated using Miles and Huberman's (1994) internal reliability formula, which is Reliability Percentage = Agreement / (Agreement + Disagreement). According to Miles and Huberman, the desired level of reliability is deemed to be achieved when the agreement rate between an expert(s) and a researcher(s) approaches 90% or exceeds 90. The reliability rate in this study was 97.5% (78/[78+2]). The expert, who is an academic, associated the "endless road" metaphor with the category "a difficult process/resistance" instead of "professional consciousness" and the "garden" metaphor with the category "health promotion" instead of "occupational awareness." These results showed that the desired level of reliability was achieved in the study.
The qualitative data were analyzed manually. The sociodemographic characteristics of the participants were analyzed using SPSS software Version 18.0 (SPSS, Inc., Chicago, IL, USA), and numbers and percentages were used to present the statistical data.

Results
The mean age of the participants was 32.66 (SD = 8.29) years, 83.8% were female, 52.4% had been educated to the bachelor's degree level, and 70.0% worked in a Level 2 health institution. The mean years of work experience of the participants was 10.02 (SD = 8.16), and the mean work experience in the same organization was 5.31 (SD = 6.00) years. Nearly half (46.3%) said they could understand/ communicate in English at an intermediate level, 93.7% said their Arabic was poor, and 36.2% said they had never provided care for an individual from a different culture (Table 1).
Four Categories and Metaphors Related to the Concept of "Providing Care for Syrian Refugee Patients" Occupational awareness As shown in Table 2, the occupational awareness category consisted of 9 metaphors that were generated by the seven participants who worked in FHCs and the 19 participants who worked in state hospitals. Seven used "a baby/little child," three used "an orphan," and one used "love" as a metaphor.

The Journal of Nursing Research
Nurcan Akgül-Gündoğdu et al.
Providing care for a Syrian refugee patient is like caring for a child, because due to communication problems, the child service to God does not understand what is to be done and waits without moving and patiently. (P75-FHC-M) Ten of the participants used "humanity," one used "being a humanist," one used "service to God," one used "universal," and one used "a matter of conscience" as a metaphor.
Providing care for a Syrian refugee patient is like a human, because it does not matter for me that the person is Syrian or from another race and I can give as much care as possible in terms of humanity and health. (P43-FHC-F)

Health promotion
As shown in Table 2, the health promotion category consisted of 17 metaphors that were formed by 10 participants who worked in FHCs and 13 participants who worked in state hospitals. Three of the participants used "a bird with a broken wing/injured bird/dove," one used "a torn sweater," one used "a door waiting to be repaired," one used "a clock with dead batteries," and one used "a broken machine" as a metaphor.
Providing care for a Syrian refugee patient is like caring for a bird with a broken wing, because I think just like a bird trying to fly but cannot. Similarly, Syrians are struggling to do so. Just as treatment is needed to heal an injured bird, they need support for their illnesses but also financial and spiritual support. (P50-FHC-F) Two of the participants used "watering a tree/Tree," two used "a sapling," one used "sowing seeds in a field," one used "a child just beginning school," one used "a flower," and one used "a garden" as a metaphor.
Providing care for a Syrian refugee patient is like caring for a sapling, because, like watering and fertilizing a sapling, people need to be given a new life and care. (P48-FHC-F) Two of the participants used "a withered flower/flower," one used "life," one used "finding a nest for a bird," one used "migrating dove," and one used "neighborly duty" as a metaphor.
Providing care for a Syrian refugee patient is like nature giving a nest to a dove, because, just like nature shares its resources for birds to survive, we share our opportunities and sustain life, which is a basic right. (P5-FHC-F) A difficult process/resistance As shown in Table 2, the difficult process/resistance category consisted of 12 metaphors that were generated by 4 participants who worked in FHCs and 13 participants who worked in state hospitals. One participant used "a grenade with a pulled pin" and one used "music" as a metaphor.
Providing care for a Syrian refugee patient is like a grenade whose pin is about to be pulled out, because it is not clear what kind of danger you will be faced with. They have many contagious diseases and they never say this while receiving healthcare. They inform about them only when they are asked, and they do not care about transmitting their diseases. (P60-State-F) Five of the participants used "a barrier," two used "getting blood from a stone," one used "torture," one used "a mute and blind person," one used "attempting to do the impossible," one used "beating the odds," one used "an endless road," one used "patience/self-sacrifice," and one used "diamond" as a metaphor.
Providing care for a Syrian refugee patient is like a diamond, because a diamond is a solid substance that is difficult to process due to the number of carbons it is made up of and its bonding style. It is very

Providing service in vain
As shown in Table 2, the providing service in vain category consisted of 12 metaphors that were generated by three participants who worked in FHCs and 11 who worked in state hospitals. One of the participants used "a burden," three used "service in vain," one used "an insecure spouse," one used "a selfish person," one used "a bottomless well," one used "trouble," one used "a robot," and one used "a cracked glass" as a metaphor.
Providing care for a Syrian refugee patient is like throwing a stone into a bottomless well, because you care for it. However, it never ends. They are finished, then their relatives come; they go, some other acquaintances come, and this goes on. (P4-FHC-F) One of the participants used "a mandatory situation," one used "a neighbor," one used "unwanted guest," and one used "mother-in-law" as a metaphor.
Providing care for a Syrian refugee patient is like hosting your mother-in-law, because, no matter what you do, she always finds something to complain about. She is always dissatisfied. (P24-State-F)

Discussion
In this study, 80 nurses generated 50 different metaphors related to the "providing care for Syrian refugee patients" concept. These metaphors were analyzed using the four categories of "occupational awareness," "health promotion," "a difficult process/resistance," and "providing service in vain." No other studies have been conducted with similar groups, and no similarly designed study that could be used to compare the study results was found. Therefore, the results of the study are discussed below in terms of the extant quantitative and qualitative research related to Syrian and other refugee patients.
Turkey is the primary destination country for Syrian refugees and hosts the highest number of refugees in the world. On the basis of an earlier qualitative study, difficulties in "communicating, meeting individual needs, and following treatment instructions correctly" are faced by nurses who provide care for asylum seekers/refugees in Turkey (Sevinç et al., 2016). These difficulties are similar to the metaphoric perceptions of "health promotion" and "a difficult process/ resistance" expressed by the participants in this study. Similarly, Alshammari et al. (2019) developed two main themes for patient-nurse communication, including "current communication practices" and "the effect of communication on patients." The same study also reported that many non-Saudi Arabian nurses have limited knowledge of Saudi Arabian culture and that patients face difficulties understanding and respecting cultural and religious practices (Alshammari et al., 2019). Furthermore, Arabian culture is not as flexible as Islamic teachings and sets strict rules for women regarding communications with men. In addition, among Arabs, the concept of honor is more often attributed to women, and they are expected to honor their families throughout their lives. Therefore, a male nurse touching a female patient in Arabian culture can be regarded differently than in other cultures (Alharbi & Al Hadid, 2019). Akkoç et al. (2017) examined the problems faced by health workers in providing health services to refugees living in Turkey and reported that health personnel faced gender discrimination, were exposed to violence by asylum seekers/refugees or their relatives, and encountered the problem of refugees not following hospital rules.
Other studies investigating how the civil war in Syria and the obligatory immigration of the refugees affected the health system and health services found that the workload of health personnel increased, intensive care unit capacity and the number of inpatients increased, more complications developed in refugee patients, infectious diseases and hospital infections increased, and, accordingly, the workload increased even more within this framework. In addition, health-worker desire to work decreased by 58.9% (Savaş et al., 2016), health workers In "P1-State-F," "P1" indicates Nurse-1 (source person and number), "State" indicates where the nurse worked (e.g., state hospital here), and "F" indicates the nurse's gender (e.g., female). FHC = family health center.
did not feel safe, they experienced difficulties in communicating with patients (Robertshaw et al., 2017;Savaş et al., 2016;Sevinç, 2018), and nurses' and midwives' burnout levels were high (Dumit & Honein-AbouHaidar, 2019). These findings may be associated with the study group's "language barrier" and "infectious diseases" analogy in the "a difficult process/resistance" category and the "being disturbed" analogy in the "providing service in vain" category.
A study examining perceptions of health personnel who provide care to refugees found that the highest support was received from nurses and midwives, and the barriers against providing care included language and cultural barriers, lack of knowledge, difficulties in accessing suitable translator services, and mistrust of patient groups (Ross et al., 2016). Perceptions of the health personnel in the abovementioned study overlap with the categories "meeting basic human needs" and "occupational awareness," "health promotion," and "a difficult process/resistance" and the analogies "priority to make human beings live/equality," "meeting needs," "helping," and "language barrier, helping, care requiring patience," respectively. Another study emphasized that nurses experience communication problems while caring for patients with culturally and linguistically diverse backgrounds (Kaspar & Reddy, 2017).
Although there are negative perceptions toward immigrants, positive attitudes have also been reported. A descriptive study found that nurses had positive perceptions about their attitude toward their caregiver roles for Turkish and refugee/immigrant patients and provided healthcare without making a distinction, thereby abiding by their oaths, although they experienced the most difficulty in communication (Aloğlu et al., 2017). These results can be associated with the analogies in the "occupational awareness" and "health promotion" metaphor categories in this study.
Healthcare provided by each health professional differs based on patient-centered priorities. However, there is a common language for providing care to all sensitive groups, including refugees/asylum seekers. Similarly, the difficulties and barriers related to offering services display similarities based on common care needs. A literature review study conducted by Ahmad (2018) and investigating the difficulties and barriers that nurses experienced highlighted language, cultural differences, lack of education, and admission processes as barriers to providing care. These factors are similar to the language barrier, helping, and care requiring patience analogies in the "a difficult process/resistance" metaphor category generated under the concept of "providing care to Syrian refugee patients." On the other hand, refugee/asylum seeker patients' lack of understanding of the host country's health system and social and economic limitations directly affect the difficulties faced by health personnel in providing services to refugee patients (Ahmad, 2018;Fair et al., 2018). In one previous study, nurses noted that they needed extra time and more home visits to meet the needs they identified within the scope of mother-child health services and required comprehensive in-terviews with families to establish accurate communication (Willey et al., 2018). A qualitative study examining the experiences of nurses who provide care to refugees reported that the refugees had problems such as HIV positivity, eye and dental problems, nutritional disorders, and diarrhea and that vaccination, mother-child health problems, and infectious diseases were common. Australian nurses who organized care to address these problems expressed that they experienced problems coordinating home visits with refugee families and contacting these families for planned visits. In addition, these setbacks delayed providing care, the wasted hours were not included in official records, and they were not paid for this spent time. The nurses added that, despite the dissatisfaction they felt because of traumatic experiences and the increased workload, they did not lose hope and carried out their caregiving service with a sense of occupational awareness (Ogunsiji et al., 2018). A study conducted by Young et al. (2016) put a different perspective on these traumatic experiences with the statement that, despite the political conflict between Israel and Syria, Israeli nurses provided care to Syrian patients within the framework of occupational awareness and without discrimination. These results dovetail with the analogies in the "occupational awareness" and "health promotion" metaphor categories in this study.
Another study found that refugees had problems because of factors such as negative attitudes of health personnel, communication problems, and setbacks in providing health services (Sevinç, 2018). Healthcare personnel in the aforementioned study held a similar perspective to the perceptions/ analogies in "providing service in vain" and "a difficult process/resistance" metaphors under the concept of "providing care for Syrian refugee patients" in this study.

Limitations
The subjectivity inherent in defining metaphors and interpreting their basic meanings means that the approach taken in this study is open to criticism. People with different social experiences and different cultural backgrounds may interpret metaphoric expressions differently (Ritchie, 2003). Metaphors are the determinants of underlying meaning and of how this meaning is perceived (Littlemore et al., 2011). For this study, various metaphors were created using content analysis, and the themes were selected according to the research team's own interpretation. Differences in metaphoric interpretation are predicted to emerge because of personal experiences, vocational training, and the other characteristics of team members. However, this is an inherent attribute of qualitative studies. Another limitation of this study is that the results obtained from the participants were not reconfirmed by the participants.
providing care to Syrian refugees using the metaphor of "humanity" without discrimination. In addition, nurses stated that they faced difficulties in providing care because of culture and language problems, using the metaphor of "a barrier" in the "a difficult process/resistance" category. They also noted that they lost time and increased their workload using the metaphors of "service in vain" and "burden" in the category of "providing service in vain." In addition, nurses reported that healthcare workers were at risk because of the contagious diseases of the refugees using the metaphors of "a grenade with a pulled pin" and "music" in the "a difficult process/resistance" category.
The metaphors provided by the participants related to providing care to Syrian refugee patients were both positive and negative and may be used to further identify, understand, and explain nurses' personal perceptions. In addition, transcultural nursing issues should be addressed in nursing education programs based on the conditions in that country. Furthermore, providing expert translation services and integrating modern technologies to overcome language barriers to facilitating effective communication are critical. Understanding the social context of refugees is very important during the treatment process. Having a familiarity with refugees' common health problems and their previous health experiences, cultural health concepts, cultural values, and cultural beliefs is important to providing care to vulnerable groups within an atmosphere of cultural harmony.