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2012 23: 397 originally published online 16 July 2012J Transcult NursAnne H. Outwater, Edith A. M. Tarimo, June E. Miller and Jacqueline C. Campbell

NursingMeanings of Care by Bereaved Relatives of Homicide Victims in Dar es Salaam, Tanzania : Implications for

  

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Few studies have been conducted on injury mortality in Tanzania (TZ). This qualitative study was part of a larger project focusing on risk and protective factors for violent death in Dar es Salaam (DSM), TZ (Outwater, 2009). The rates of homicide death of adult women and children were discovered to be much lower than the world average. Male risk was found to be greater in DSM than the world average but lower than in South Africa or estimates for the African region. Of all homicide victims, 77% were men between the ages of 20 and 45, although this group is only 15% of the population in DSM. Homicide victims in DSM were killed as a result of individual assault as victims of thieves or by community mobs as alleged thieves. These data, earlier reported (Outwater et al., 2008), provide the context for this transcultural nursing study examining care in the aftermath of those homicide deaths.

In 2005, a Tanzanian’s life expectancy at birth was 46 years and 90% of the population was living on less than $2/day (Population Reference Bureau, 2006). Secondary school enrollment for females was 5.0% and for males 6.0% (Population Reference Bureau, 2006).

In DSM, about one third of adult men (31.5%) were for-mally employed. Another fifth were self-employed with at least one employee (9.1%) or were students (10%). The rest

were petty traders selling things on the street (23.6%) or were farmers (2.8%). A quarter (23%) were totally unem-ployed or receiving no salary (National Bureau of Statistics Tanzania, 2002). Students, unpaid family help, and self-employed individuals with more than one employee were murdered far less often than chance would predict (Outwater et al., 2008). More than half of male homicide victims were unemployed, had an unknown work status, or were described as thieves; many others were underemployed. They were the same cohort as those who have been reported in local news-papers (e.g., Kimati, 2010) as being targets for recruitment by nonnational armies such as al-Quaeda, al-Shabaab, and other such groups operating in neighboring countries.

In addition, violence is known to have serious and long-lasting repercussions (Campbell et al., 2003) and poten-tially destabilizing effects on survivors. Interactions after an

451602 TCNXXX10.1177/1043659612451602Outwater et al.Journal of Transcultural Nursing 23(4)

1Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania2Johns Hopkins University, Baltimore, MD, USA

Corresponding Author:Anne H. Outwater, School of Nursing, Muhimbili University of Health and Allied Sciences, PO Box 105211, Msasani, Dar es Salaam, Tanzania Email: aoutwater@muhas.ac.tz

Meanings of Care by Bereaved Relatives of Homicide Victims in Dar es Salaam, Tanzania: Implications for Nursing

Anne H. Outwater, PhD, RN1,2, Edith A. M. Tarimo, PhD, RN1, June E. Miller, PhD, RN2, and Jacqueline C. Campbell, PhD, RN2

Abstract

Purpose: The purpose was to describe the meanings of care, kutunza, for the deceased and the relatives of homicide victims. The secondary aim was to identify ways in which nurses could best console the families. Method: An ethnonursing method was employed. Relatives of homicide victims in Dar es Salaam, Tanzania, were interviewed at a mortuary, using an interview guide constructed with Leininger’s enablers as major elements. Content analysis was performed according to Leininger’s phases of ethnonursing analysis of qualitative data. Findings: Families of 30 homicide victims were studied. The mean age of the victims was 30.7 years, range 17 to 47 years. All victims, except 1, were male. The informants included 29 relatives and two close friends. The following four themes were identified: (a) providing basic needs, (b) paying attention as if one were kin, (c) consoling through gathering, and (d) caring for each other. Conclusions: Care is manifested by respectful attention to the preparation of the deceased and by providing an environment by which the community can gather to console the bereaved family. Implications for Nursing: Respectful preparation of the deceased’s body is essential. Nurses can provide emotional support to the families and find an area where the extended family can grieve and console each other.

Keywords

homicide victims, Tanzania, end-of-life care, transcultural nursing, Leininger, ethnonursing, Swahili

Research Department

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unexpected death event have significant impact on the survi-vors’ grief processes (Dubin & Sarnoff, 1986). The rationale for studying culture care after a homicide is to find ways to mitigate negative repercussions and increase well-being.

EthnohistoryTZ’s political history is different from many other African countries. Even though TZ encompasses about 125 tribes, and many Moslem and Christian sects, a national identity has been formed. TZ’s purchasing power parity in 2005 was the fifth lowest in the world (World Bank, 2005). However, in spite of poverty—which usually increases the likelihood of violence (Le Billon, 2001)—TZ mainland has not suc-cumbed to lethal forms of severe conflict such as civil wars and social strife that have defined the political experiences of its neighbors.

Most Tanzanians and scholars attribute TZ’s historic sta-bility, to the legacy of the first president Julius K. Nyerere (Aminzade, 1998). During the early years of nationhood, Nyerere set TZ on a unique path of “African socialism.” Through this governing philosophy, social policies of unifi-cation were instituted that were presented as authentic and indigenous (Askew, 2002). Policies included the adoption and development of a single language (Swahili) and what became known as ujamaa (family as community; Sutherland & Meyer, 2000). Although some aspects of ujamaa—notably the scheme of communal villagization—were eventually discredited, a legacy valuing social cooperation remained (Askew, 2002).

It is impossible to generalize about religious or philo-sophical concepts in Africa because they are determined by each ethnic group (Anderson, 2011). However many ideas are, or have been, approximately similar. For example, Lothe and Heggen (2003) have written that in the African context, “family bonds and personal history seem to have particular importance, interaction in a social and cultural relationship seems very important for forging an individual’s identity” (p. 320). In TZ, as in many other African cultures, the indi-vidual is seen as part of his or her environment including the family (Savage, 2002) and community.

Likewise, concepts around death have, in many cases, been altered through the influences of Christianity and Islam. Nevertheless, many religious concepts and practices con-tinue to persist (Anderson, 2011). In the religions of Africa, life does not end with death but continues in another realm. The concepts of “life” and “death” are not mutually exclu-sive, and there are no clear dividing lines between them. Death is viewed paradoxically—a person is neither alive physically nor dead relative to the corporate group (Mbiti, 1990). When a person dies, the whole person continues to live in the spirit world, receiving a new body identical to the earthly body but with enhanced powers to move about as an ancestor (Anderson, 2011).

Gaps in the qualitative literature around homicide death and effective nursing care for the homicide bereaved are

large. This study was designed to help address those gaps by discovering care values, how those values manifest in homi-cide bereaved families in DSM, and how they might inform competent nursing care.

MethodConceptual Framework

Leininger’s theory of culture care diversity and universal-ity was developed to guide researchers in discovering meanings, patterns, expressions, and practices that influ-ence the health and well-being of cultures in order to pro-vide appropriate care. This study used Leininger’s definitions and the sunrise model as a cognitive map (Leininger, 1991; Leininger & McFarland, 2002). The domain of inquiry was care of homicide bereaved families at the mortuary.

The research questions of the ethnonursing inquiry guide were developed from the transcultural nursing framework. Of basic importance was to define the central variable, to care: What is the meaning of kutunza? How did you care when the death happened? Following the sunrise model to the practice of care, respondents were asked the following question: Describe the traditional (generic) and modern (pro-fessional) care practices used to console yourselves? The final question to meet the goal of the theory was the follow-ing: What strategies can nurses use to help?

SettingThe study was conducted in the DSM region (which includes TZ’s largest city). Originally the Zaramo people inhabited this equatorial bay on the Indian Ocean. During the 19th and 20th centuries ever-increasing immigration occurred from India, Oman, and Europe but mostly from other parts of East Africa. At Independence, the region’s population was 272,821 (Kithakye, Mutashubirwa, & Kayani, 2009); in 2005, it was estimated to be 2.84 million (Outwater, 2009). Most residents of DSM are immigrants still connected with their family village; the population has become a mix of the country’s ethnic groups.

Data were collected at the mortuary of the national refer-ral hospital (where all homicide victims in the DSM region were brought). Renovations were occurring at the time. Permanent mortuary staff included: the head of the mortuary and her deputy, both diploma-educated nurses, as well as mortuary attendants. Physician pathologists and police attended daily for autopsy and formal identification of the deceased.

SampleThe study population consisted of families who had experi-enced an adult homicide death by assault or through mob violence in 2005.

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Informants

Thirty-one informants, of whom four became key infor-mants, were selected conveniently at first and then purpo-sively. Since victims of mob violence were more often buried unidentified, special attention was made to interview their families. General informants were interviewed once; key informants at least three times.

Ethnonursing MethodologyEthnonursing is a qualitative research method developed to guide evidence-based transcultural nursing care. It is suitable for sensitive subjects because of its emphasis on listening for the emic voice, which in itself is therapeutic, by interviewers who are educated and trained to care for the vulnerable. It focuses on the informants’ worldviews and Leininger’s enablers leading to truths through people’s voices and stories. Specific enablers used were the following: (a) an ethnonurs-ing inquiry guide as described in the Conceptual Framework section, (b) the Observation–Participation–Reflection Entry, and (c) Stranger to Friend. Acceptance into the daily rhythms of the mortuary was gradual. First the principle investigator (AHO) observed and listened. After about 2 months, she was invited to help at the reception desk, registering bodies and releasing them to relatives.

Data CollectionInformants were part of the violent death surveillance that took place in DSM in 2005 (Outwater et al., 2008). Demographic variables collected with the surveillance instrument included sex, age, place of residence and death, occupation, cause of death, precipitant of death, and victim–perpetrator relationship. After answering the surveillance questions, the informants were asked if they would be will-ing to be interviewed further. These data were collected through an open-ended interview guide. Thirteen interviews were audiotaped; the rest were noted by hand and expanded the same day.

Interactions with the informants usually took place over 3 days. On the first day, the first author often helped register information given by family members who came to make a preliminary identification of a missing relative. This was a very shocking time, especially for those whose relative was killed by mob violence and fire.

Several days later, a group of relatives returned to legally identify the body in the presence of police and pathologists. At this time, while waiting for other procedures to take place, they were interviewed. The interviews were conducted in Swahili by the first two authors, nurses experienced in quali-tative interviewing techniques. EAMT is a native Swahili speaker; AHO is a fluent Swahili speaker, having lived and worked as a nurse in TZ for 15 years.

Interviewing started slowly with one interview in April 2005 and three in June, which were transcribed, translated,

and preliminarily analyzed. Thereafter, until December 2005, one to seven interviews were conducted monthly, until saturation of the relevant variables occurred for both inter-viewers. Four general informants became key informants who returned to be interviewed at the mortuary. Third inter-views were conducted at places of residence in three cases and at the mortuary in one. Ongoing relationships were formed with three key informants who were later able to confirm analysis results.

Ethical permission was granted by the U.S. university’s institutional review board and the TZ university’s research and publications committee. Informed written consent was obtained from all informants.

Data AnalysisInterview data were transcribed from Swahili and then trans-lated into English by the first two authors, with assistance from a professional Swahili translator, as necessary. A team approach as described in Harkness, Pennel, and Schoua-Glusberg (2004) and Smith (2004) was used for translation of the interview guide and the interviews. They recommend a process including translation (usually by a person working from the source language to their primary language, which was the first author), review (by a person with translation skills as well as research skills, the second author) and approval (by a person who understands the research subject, research skills and usually some proficiency in the lan-guages involved, both authors and the professional transla-tor). The original scripts and the translations were entered side by side into NVivo Version 7 (QSR International, 2007).

Leininger and McFarland’s (2002) Phases of Ethnonursing Analysis for qualitative data were used. Interview data and field notes were first classified by the research questions. Then patterns and emergent themes were identified by assigning a code to words and phrases to their domain of inquiry. Finally, the codes were categorized, synthesized, and interpreted into major themes. The categories and themes were discussed and negotiated between the first two authors. Themes were presented, discussed, and validated with key informants at several stages of analysis.

FindingsSample

The mean age of the 30 victims was 30.4 years; their ages ranged from 17 to 47 years. All victims, except 1, were men. Sixteen were killed by mob violence, 12 by assault, and 1 legally by the police and the woman died as a bystander as shown in Table 1.

The 31 informants (27 general and 4 key) ranged in age from 26 to 71 years. Twenty-nine declared themselves rela-tives; 2 were the closest friends of a deceased without rela-tives. Key informants were drawn from this group to give insight into the context of the lives of the deceased.

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Themes

When informants were asked about the meaning of “caring,” they reported that it was an important cultural, and even survival, value. There were two negative cases of informants who did not seem to want to talk about caring. Caring as described by the informants was an action primarily expressed through kinship and social relationships within community. From the time of death to burial, there was an integrated response manifesting in cultural and social struc-tural dimensions that manifested through values, beliefs and lifeways, kinship and social, religious and philosophical, and, in the case of an unnatural death, legal factors. Four themes were discovered: care as (a) providing basic needs, (b) paying attention, (c) consoling through gathering, and (d) caring for each other.

Caring as providing basic needs. The most commonly reported meaning of care, was kulea, related to helping the vulnerable, especially in raising a child. Care was associated with a person’s basic necessities: safety, enough food to eat, a place to sleep, clothes, and medical care. Providing for the vulnerable is done without expectation of immediate return. Care can fail. Some parents of youth killed by community

mobs explained that their child had left their care. The father of a youth killed by a mob for stealing a chicken, explained,

For example if you bear a child, you raise him well [unamtunza vizuri], you show him good ways of doing things [utaratibu]. But if that child evades your proce-dures, then your care for him is defeated . . . You school him, and if he graduates it is necessary he fol-lows the procedures of humanness.

Caring as paying attention (kuhifadhikwauangalifu). Care meant being concerned and paying attention as if you were kin. The 54-year-old uncle of a 23-year-old assault victim explained that kutunza is to watch over somebody as if you were their father. First warning to the possibility of a homi-cide death often occurred to people who were watching out for a person as a matter of course. If persons were absent from their daily patterns for more than a few hours, relatives or fellows started searching. The uncle of a taxi driver killed for his vehicle explained, The first news they (the family) got that something was amiss was that a taxi driver came to tell them (about 10:30 p.m.) that they had not seen him since 7 in the evening. Then they themselves went to the police.

Less often, caring was associated with the wise use of inanimate objects, as was explained by an uncle of a 24-year-old victim of mob violence: “If you have a cell phone, you will put it gently on a table and not throw it or let it drop.” Remembering events that have passed, such as the date of somebody’s death, is a way of expressing care, as is tipping somebody at a celebration if he or she pleased the audience by his or her singing or dancing. Kutunza can also refer to renting land.

Caring as the act of consoling through gathering. The com-fort and relief offered by people gathering together—whether it be a party, a wedding, or a funeral—was a way of express-ing caring. This was affirmed by the uncle of a 30-year-old killed by mob violence: “This is the native way. We talk to each other.” In the event of a death, communication with relatives and neighbors started quickly, as the brother of an assault victim stated, “As a family, we informed each other by way of phone. The father in the village with no phone got the announcement through the radio.”

There was no hesitation about what to do. The father of a Christian male victim of mob violence described,

Relatives, community, friends, gathering, eeeh, and how to do the thing until today is understood. Meaning that even though the calamity is a sudden thing, a thing like this (large gathering) can be made. It is the help of just neighbors and relatives.

A home was chosen at which people gathered. The brother of a Muslim victim of assault explained, “When a problem like this occurs, truly relatives, family, friends, neighbors are

Table 1. Study Characteristics of Homicide Victims and their Informants in Dar es Salaam, Tanzania

Victims (N = 30)

Informants (N = 31)

n % n %

Gender Male 29 97 30 97 Female 1 3 1 3Age (years) Mean 30.4 48.9 Range 17-47 26-71 Religion Christian 18 60 Muslim 12 40 Causes of death Mob 16 54 Assault 12 40 Legal 1 3 Unintentional 1 3 Relationship to victims Uncle 12 39 Sibling 7 23 Father 5 16 Ndugu-Jirani/friend 4 13 Cousin 1 3 Stepfather 1 3 Brother-in-law 1 3

Note. Ndugu-jirani literally means relative-neighbor, meaning a neighbor with whom one lives with the closeness of a relative.

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drawn together to the place of the sorrow . . . We are sitting together—relatives, friends and neighbors—3 days and nights.”

People gathered at the home over a period of several days—from when the body was identified until it was buried or transported to a home village for burial. After official identification by relatives, the police, and the pathologist together, the corpse was (a) washed and dressed at the mor-tuary if the victim was Christian, (b) at the nearby mosque if Muslim, or (c) more rarely, at home. The body was carried out of the mortuary in a coffin by Christians, a shroud (sanda) by Muslims to the nearby mosque, or a mat brought by the family. A waiting motor vehicle then took the body to the home, where prayers were said to help the soul of the deceased.

Care as caring for each other (kutunzana). Among adults, kutunza is often interchangeable with kutunzana. The Swa-hili verb ending “-na” changes the unidirectionality of kutunza to the bidirectional kutunzana, which means “caring for each other.” Community is built by people caring for each other. Kutunzana often occurs in times of troubles. “People caring for each other is a result of our culture. Peo-ple help each other in calamities . . . even if it is hunger,” explained the brother of 27-year-old male killed by mob violence.

In almost all cases, on receiving the news of the death until the burial was completed, the close bereaved of the deceased were surrounded by relatives and neighbors caring for them, day and night. Discussions to solve immediate and long-term problems took place during this time. Topics addressed included the following: the burial site, how to meet funeral expenses and pay debts of the deceased, regret, continuation of the family despite the loss, care of depen-dents, and prayers to God for the deceased. Strengthening of relationships between relatives (undugu) was reported to occur through accomplishing these tasks together.

Kutunzana implies obligation. If a person accepts help, that person must in turn give help when it is needed, as was described by the stepfather of a 42-year-old man who was accidentally killed:

Life is difficult; therefore we live by helping each other. The salary is very low. The cost of living has climbed; everything—clothes, food—has become expensive. If I awoke without money I could go to his place and he would help me. Now he is dead and there is no more help from his place. He has left a child . . . now it is my responsibility to educate that child—and to provide clothes, and other things.

Informants were usually interviewed 3 days after the death. The difference in demeanor from the first day to the third was usually profound. Often calm radiated from them on the third day, a very different state from the first. Being

surrounded by relatives and neighbors appeared to be heal-ing for the bereaved. At that point Christians and Muslims alike accepted the death: “I am sorry. I leave it to the police. Then, I praise God. There is no other way.”

Differences Between Traditional and Modern PracticesWhen informants were asked to describe the traditional and modern practices used to console themselves, most said there were no differences between current practices in the city and traditional customs in the village. However, a few differences were reported. The most commonly reported was economic. Traditionally, and still, in villages, care is expressed through contributions of labor and time. Mats are woven, firewood collected, food donated and prepared, cof-fins constructed, graves dug, presencing conducted, and songs sung without monetary cost. It was reported that cash-poor villagers express caring by contributing through these respected lifeways; in the city, these activities necessitate money. Being able to help is highly valued, but the urban poor can help little, which can lead to a loss of group and self-respect.

Meeting cash requirements for a funeral is accomplished through gathering small monetary contributions from many people. A basic funeral with the body being buried in DSM costs about TZS250,000 (US$220). The amount of the expected contribution (mchango) depended on the relation-ship with the deceased and the ability of the donor. Frequently reported amounts were TZS200 (US$0.17), 500 (US$0.44), and 1,000 (US$0.88).

Another difference was legal. If a person were murdered in a village without police, the assailant would be followed and the murder solved by the people themselves. The brother of an 18-year-old victim of assault explained,” It is very seri-ous, a quarrel of such intensity [ugomvi] that it confuses your head. There is no love at all.” They cooperate in solving that ugomvi. In the city, the informants followed the “modern way.” The brother further explained,

But right now, if you fight each other, there are no bad feelings. We endure, put up with it [tumestahamili], we calm down about this question. We follow the law, everywhere. We are patient, we go inside our religion, and let the law take its course.

The other reported difference was that the music is different—in the village native songs are sung, whereas in the city the Christians sing hymns, and the Muslims do not sing.

Nursing Care Concerns and ActionsThe mortuary is an emotionally charged and important con-fluence of legal, kinship and social, and philosophical and

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religious factors in which nurses can have profound impact. Nursing is responsible for the coordination of postmortem care (Luckmann, 1997). Informants were asked what strate-gies nurses can use to help. Unprompted, many informants defined nurses in terms of caring, especially through the culture care themes of (a) providing basic needs and (b) pay-ing attention. “Nurses!” exclaimed the brother of an assault victim. “A nurse . . . is any person who ministers to human beings. He or she has gone to the classroom in order to offer service for this kind of work. He or she cares for hurts.”

After a violent death occurs, the immediate nursing role is to care for the body and the relatives of the deceased, and to help stabilize and strengthen the family within community as it moves through this traumatic passage. Remembrance and efforts toward prevention of such incidents should follow.

Nursing Modes and ActionsCulture care preservation/maintenance. Most of the bereaved

were unfamiliar with the procedures and legalities of the mortuary. Providing basic needs included guiding them as to their monetary and legal obligations. A smoothly running office, simplified procedures, and expediting the release of the body were perceived as caring. A place to eat, toilet, and wait comfortably, in the shade, would facilitate further acts of caring.

Culture care accommodation/negotiation. Nurses were judged as to whether their verbal and nonverbal communications were caring or not. The brother of an assault victim said,

Many have compassion . . . Nurses can heal . . If you arrive, they care for you like a nurse, as if you were their own child . . . But sometimes others cause despair. They have words to embarrass people . . . Then, others have words of humanism (utu). Truly they are pleasing. They comfort you.

The bereaved sometimes viewed themselves as patients. Respondents explained that the first thing the nurse should do to demonstrate care is to pay attention to them by greeting them with soothing words. The bereaved need to be sup-ported emotionally while identifying their relative. There-fore, for example, body lockers should not be flung open all at once.

The act of consoling by gathering is very important, but large groups of relatives congregated for hours at the mortu-ary impede its smooth running. The nursing role should be to speed the process to ease congestion and facilitate gathering within their close community.

Culture care repatterning/restructuring. The cultural expec-tation and desire of people is to show caring for each other. For nurses, this would fall into the categories of remem-brance and prevention. According to several informants, accurate and appropriate records should be kept because they are a way of remembering the deceased as well as useful in

designing prevention strategies. Using such research data to repattern the future, nurses were urged by the brother of an assault victim to “give good advice inside the family or com-munity.” This included educating the public about human rights, that when trouble arrives to follow the law in order to ensure rights for both the accused and the complainant. To decrease violent death it was suggested that the lack of sec-ondary school education and employment opportunities for young men needs to be addressed.

Discussion and ConclusionsThe general profile of the victims in this sample was similar to all murders in DSM in 2005. Most youth in DSM, because of lack of education and employment opportunities, are part of a vulnerable group with significant potential for destabi-lizing society. The relatives of many of these young men, especially those killed by community mobs, felt the youth had failed to respond appropriately to family care. Ultimately, however, the youth had not been disowned or abandoned at their death. They remained as members of the family. Manifestations of caring and obligation after his death held possibilities for strengthening the family unit.

Although the overall culture, language, and history of TZ are shared by its citizens (wananchi), each tribe has specific traditions and life ways. In the cities, however, cultures are merging, and although the overall meanings of “caring” are probably stable, ways of expressing them are changing. The universalities between the cultures are driving a coherent approach to the death of an individual within a family and community.

The findings confirm what other scholars have found. In Africa, demanding caregiving responsibilities are commonly coupled with difficult economic straits (Tarimo, Kohi, Outwater, & Blystad, 2009). Reliance on reciprocal extended family support networks, informal credit arrangements, and informal support networks among households and at the community level are well-documented household strategies in much of Africa (Ayittey, 1991) and in TZ (Moser, 1996). “Bonds of amity are forged through participation in commu-nity events, visiting and sharing food” (Ayittey, 1991, p. 19). In the aftermath of a death, gathering together is a way of expressing caring for the bereaved as well as enhancing the prevailing network of mutual obligations and interdepen-dence. In TZ, funeral rites simultaneously mourn for the dead and celebrate life in all its abundance (Magesa, 1997). Funerals are a time for the family and community to build solidarity and to regain its identity.

The respondents said that funeral arrangements were the same for their assaulted relative as for others who had died a natural death. For those whose relative died as an alleged thief, the response was more subdued. This may be partially because death is seen as a departure and not a complete anni-hilation of a person (Anderson, 2011, Magesa, 1997, Mbiti, 1990). The deceased moves on to join the company of the

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departed, and the only major change is the decay of the phys-ical body. Debtors, thieves, witches, murderers, and those who denied something to others face the greatest difficulties (Mbiti, 1990). However, if a person who dies is not given a “correct” funeral, the deceased may come back to trouble the living relatives. In that way, it can be argued that “proper” death rites are more a guarantee of protection for the living than to secure a safe passage for the dying (Anderson, 2011). In TZ, mutual assistance is a highly developed and valued cultural tradition (Askew, 2002). Therefore, neighbors and relatives will help avert trouble by participating in the funeral of even someone who has been killed by the community for having transgressed societal norms.

Within ongoing patterns, specific ways to show care are changing and dynamic. Ayittey (1991) reports that most lin-eages in traditional Africa have a general welfare fund. “A minimum\regular payment may be made by the contributor in some cases. In other cases, the contribution may be irregu-lar and based upon financial ability” (pp. 23-24). Mchango is a manifestation of that practice.

Juntunen, Nikkonen, and Janhonen (2002) found that among the Bena people in rural TZ, providing basic needs such as food, clothes, and bedside support; polite greetings; sharing the hardships of life through meetings with extended family; assistance to members of the extended family; and attending funerals confirmed family unity and were evidence of care. Similarly, in DSM, care as perceived by men in the aftermath of a relative’s homicide death was (a) providing basic needs, (b) paying attention, (c) consoling through gath-ering, and (d) caring for each other over time. To ease the trauma of the relatives of the deceased, culture care nursing at the mortuary, should address these themes.

Numerous studies—particularly in the context of HIV and AIDS—have described caring in the family as mainly conducted by women, who are primarily responsible for domestic activities (e.g., Aga & Kylma, 2009; MacNeil, 1996; Tarimo et al., 2009). The present study is one of the few that explicate the important role that men have in stabi-lizing and building relationships within family and commu-nity through acts of caring in the public realm. The mortuary was part of the government infrastructure and the staff inter-acted with the bereaved on its behalf. The distance between the domestic and public realms was bridged by men through acts of lay caring as they identified and claimed the body as part of a larger set of interlocking activities. Through facili-tating the tasks that men undertake, appropriate culture care nursing could ease families’ trauma as well as help the mor-tuary run smoothly.

Mortuaries are important settings in which to deliver competent culture care nursing. This ethnonursing study found evidence of immediate and appropriate acts of lay cul-ture care in DSM among the male relatives of a homicide death. Traditional ways of caring have not been lost but rather adapted to current circumstances. Care posthomicide is targeted by the family to the family for present and future

safety. Competent nursing care at the mortuary, supporting these positive cultural norms, can enhance positive culture care among families.

Although it may not be possible to decrease violent death directly through working at the mortuary, implementing the four culture care themes would increase efficiency at the mortuary and ease the families’ burden of grief. Beneficial effects would ripple into communities most at risk for vio-lent death.

Limitations of the StudyThe informants were experiencing the shock of the murder of a close family member, which would influence their reports. For example, if farmers had been interviewed, more would have been learned about the meaning of kutunza as “renting land.”

Swahili was not the principal investigator’s first lan-guage. Misunderstandings were minimized by constant veri-fication with the second author, the mortuary manager and attendants, the police, and the pathologists, all of whom were native Swahili speakers. Having researchers with different cultural backgrounds was useful in contrasting emic and etic views and values.

Most homicide victims were men and all their informants were men. The informant of the one woman victim in this study was the only female (a nurse). Research about how women express caring before and after a homicide death would be useful.

This study focused on one multicultural region of TZ. Since most Tanzanians live in rural areas, specific details may be transferable only to other large cities in TZ. Although the focus was on homicide victims and their relatives, the implications for nursing practice are broadly generalizable to all deceased and their bereaved in TZ.

Implications for Research and PracticeSince this study was conducted, most of the actions listed in Table 2 have been implemented at the Muhimbili National Hospital mortuary, as part of a major upgrading. An evalua-tion of the present care, based on the respondents’ themes, would be enlightening.

Political and legal factors are important at a mortuary, as much of the work there is done on behalf of the govern-ment: for example, registration, storage of bodies, burial of unclaimed bodies, legal identification, and autopsy proce-dures. Research to understand this evidence of caring by government and its intersection with nursing would further inform nursing’s role.

Islam and Christianity are significant religions among this population, and death practices vary. Research is needed to clarify the diversities, universalities, and amalgamations of DSM lay religious practice, both Christian and Islam, with African philosophies and religions.

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404 Journal of Transcultural Nursing 23(4)

Table 2. Nursing Concerns and Actions, Based on Respondents’ Themes (N = 31)

Leininger’s modes of action Application of mode of action

Respondents’ themes

Nursing area of concern Specific actions

Preservation and maintenance

Actions that would help the homicide bereaved retain and maintain healthy meaningful care values and lifeways for their well-being and to deal with the death in beneficial ways

Caring as providing basic needs

Caring for the body of the deceased

Create a respectful atmosphereEnsure proper identificationStore body in a cold lockerWash and prepare skillfullyFacilitate transport of Muslim

bodies to the mosque for ritual cleaning

Provide appropriate disposition of patients’ belongings

Ensure sensitive viewing

Caring for the relatives of the deceased

Provide guidance to relatives about their financial/legal obligations at the mortuary

Provide clean adequate places to eat and for use of latrines

Plant trees to provide shade

Accommodation/negotiation

Assistive, supportive, facilitative, or enabling creative professional actions and decisions for meaningful, beneficial, and congruent health outcomes

Caring as “paying attention to,” including to protect and conserve

Help stabilize and strengthen the family through verbal and nonverbal communication

Greet the bereaved with comforting words.

Provide emotional support to relatives during identification of the deceased

Caring as consoling through gathering together

Facilitate gathering within their close community

Integrate procedures to avoid duplication

Expedite the release of the body Provide adequate waiting areas

for the bereaved and policeRepatterning/

restructuringTo enable actions that help the

bereaved reorder, change, or modify their lifeways to beneficial health outcomes

Caring for each other

RemembrancePrevention

Maintain complete and accurate vital statistics.

Inform the family or community, for example, educate the public about human rights and the law

Advocate for increased opportunities for secondary school education and employment especially for young males

At the mortuary, providing basic needs includes proper identification, storage, and preparation of the body for burial. Psychological support can be provided to the bereaved, who often viewed themselves as patients, by paying attention to them with comforting words when greeting and during identification of the deceased. Supporting acts of consoling through gathering should include provision of a clean, shady place for the bereaved to wait with food and latrines nearby and procedures that expedite release of the body. Respondents urged nurses to practice caring for each other by educating the public about human rights and advocating for increased education and employment opportunities for young men. Accurate mortality records allow the deceased continued

remembrance and a chance to inform future interventions to decrease homicide loss.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was partially supported through the 2004 Transcultural Nursing Society Graduate Research Award.

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